Ethics and Palliative Care: an Umbrella Effect Kathleen Benton, DrPH, MA CEO / President Hospice Savannah, Inc. Savannah, Georgia, USA Bachelor of Arts, Political Science and Communications Furman University Master of Arts, Medical Ethics Case Western Reserve University Doctoral Student, Doctorate of Public Health Georgia Southern University ‘10

Many of the most common ethical consults are THE ISSUES Many of the most common ethical consults are rendered at the end-of-life. A family cannot consent to withdrawal. A patient cannot give up hope and pushes for futile, inappropriate and burdensome treatment. A patient is suffering unnecessarily because a family does not want their loved one sedated. The question presents itself: Are these dilemmas purely ethical, or is there another discipline that may seem more appropriate?

BACKGROUND

ETHICS?? We know…

Ethics Appropriate Case 52 yr old male. Past MVA, had blood transfusion (10 yrs ago) Patient presents to hospital with infection/sepsis, put on vent. Wife is surrogate and a Jehovah’s Witness, agreed to all aggressive treatments but will not consent to blood products. No longer a surgical candidate because of no consent for blood. Patient’s health is deteriorating. Patient is a practicing Baptist, a leader in the church Patient’s mother and brother disagree with wife’s choice.. Ethics recommends deferring consent Wife disagrees and patient becomes sicker This is an ethics issue. Surrogate must speak for the patient, honoring their beliefs and values…

What is Palliative Care? “Palliative Care is interdisciplinary care to relieve suffering and improve quality of life for patients and families…they need not be imminently dying or even certain to die of the illness, for this care to be appropriate and beneficial. Nor is palliative care a mutually exclusive alternative to curative care” (Griffin et al., 2007, p.405)

The Umbrella Quality of life Good Communication and Semantics To embrace end-of-life To uphold the patient’s wishes

How is Palliative Care Beneficial in Resolving Ethical Dilemmas? Focuses on quality of life - important in making ethical decisions Symptom management and goal setting may alleviate ethical dilemmas within treatment Provides better communication between the patient, family, and health care providers Palliative Care can provide important information in helping patients and family members make decisions

Palliative Care Appropriate Case 60 yr old female. Past diagnoses of Hepatitis C, in remission Recently diagnosed with cancer, underwent chemo Chemo may have exacerbated Hepatitis C Patient expressed desire to live, but refuses to eat Patient and family refused hospice, wants aggressive care Patient did not want NG tube placed Patient seemed very depressed

Crossover Consults 52 year old, end stage cancer 61 yr old end stage diabetes Responsive at times Diseases has progressed = 3 amputations and present blindness Resistant STAFF in stage 4 sacral wound No longer surgical candidate for further amputation or PEG Surrogates want everything done Ethics consulted, recommend palliative care Patient and hospital held hostage to continued aggressive care and family abandonment. Patient states “stop pricking and poking me” Ethics is re-consulted 52 year old, end stage cancer Patient alert and oriented Family wants full aggressive care Concern that patient is continuing with care so that family is not disappointed MDs believe full code status and continued chemo is burdensome and inappropriate Ethics is consulted Ethics speaks with patient about Advance Directive Ethics recommends Palliative Consultation

THE TOOLS

Palliative Care Screening Tool Does the patient have: Unacceptable symptoms Life threatening disease process Failure of one or more organs Is there a need for: Assistance to the family understanding prognosis Evaluation to determine appropriate referral to Hospice

ETHICS CONSULT TRIGGERS: The Ethics Tool ETHICS CONSULT TRIGGERS: a very ill, non-responsive person who does not have any known surrogate The possibility of over-treatment or under-treatment guided by a physician who does not consider beneficence or non-maleficence Continued Medically Inappropriate / Ineffective care after palliative consultation Surrogate decision making that represents a disregard for patient beliefs, convictions and overall wishes (documented or past verbalized)

THE CROSSOVER TOOL: GO WISH CARDS “To have a doctor who knows me as a whole person To be free from pain To be mentally aware To maintain my dignity To die at home Not being connected to machines To have an advocate who knows my values and priorities” (Menkin, 2007)

Back to the Basics: Proactive Ethics is Communication Listening to patient needs Be unafraid. Be uncomfortable. Be ok to read the notes. Understanding patient barriers: language, literacy, home support, surrogate appointment and understanding, knowing hospice concepts Scripting the discussion within reason and keeping value based ethics Losing fear of offering opinions at end of life Losing fear that everything is a liability Understanding the ethics may be in giving options which are unrealistic and futile

Clear strategies for improving communication LEARNING SKILLS (Can be even more difficult than surgical interventions and mediation management) Clear strategies for improving communication

Think These Through… Compassion is learned Remove Personal Guilt Let them salvage control Don’t ignore suffering of any kind Things are not black and white at the end

Ethics and Palliative Care will continue to develop Through the continued success of ethics and palliative care, diagnosis of a terminal and and/or chronic illness will no longer be considered the end of an acceptable quality of life, but simply the beginning of goal setting aimed at the institution of wellness. This is the author’s hope.

REFERENCES THIS POWERPOINT HAS BEEN AN ADAPTATION OF THE PAPER Ethics and Palliative Care: The Umbrella Effect (n.p.) BY: Kathleen DeLoach Griffin, P., Koch, K., Nelson, J., & Cooley, M. (2007). Palliative Care Consultation, Quality-of –Life Care in Patients With Lung Cancer. ACCP Evidence Based Grimaldo, D., Kronish, J., Jurson, T., Shaughnessy, T., Curtis, J., & Liu, L. (2001). A Randomized, Controlled Trial of Advance Care Planning Discussions during Preoperative Evaluations. Anesthesiology, 95, 45-50. Menkin, E., (2007). Go Wish: A Tool for End-of-Life Care Conversations. Journal Of Palliative Medicine, 10(2), 297-303. Palliative Screening Tool DRAFT: St. Joseph’s / Candler Hospital, Savannah, GA * cases and theories presented in this power point are a direct reflection of referenced practical cases and experience via the author