End-Of-Life Cancer Incidence: A Case Study
Abstract
When a patient is ordered to move from curative to palliative care, it can really take a toll on the patient, his or her family, as well as the physician. This can be due to the fact that end-of-life care is usually seen as the end. To make this worse, the healthcare providers do not always relay such information in a way that the family will completely understand. Sometimes, the healthcare professional will not let the family know that end-of-life care is necessary; he or she will just continue to give the patient medications that are futile to their well-being. In order to prevent this, there should be a set guideline for healthcare professionals to learn and follow when telling patients and their families that end-of-life …show more content…
care will be the necessity from that point on.
Keywords: palliative, end-of-life care
Introduction
When dealing with ethical behavior in the healthcare setting, it should be a known fact that not every situation will be handled the way they should be. An example of this would be the way end-of-life issues are addressed. While the decision-making process is in the hands of the family in most cases, it is up to the healthcare professional to discuss all possible options as well as his or her opinion of what may be best for the patient. Because the life expectancy of Americans has made great progress, this is the trade-off. The Hastings Center states:
When it comes to the final phase of life, there has been great progress. We now have good evidence of how best to relieve suffering, provide good palliative care, resolve conflicts, and honor the individual preferences of dying patients, but our health system is slow to incorporate this knowledge. Health care professionals are seldom reimbursed for discussing the end of life with patients, have limited time to address the subject, and often are poorly prepared to talk about such sensitive matters. They may also be unaware of what is ethically and legally permissible or confused by continuing ethical debates on issues like physician-assisted suicide or determining death in the context of organ transplantation.
As the 21st century progresses and the massive baby boom generation ages, health care professionals, patients, and families face unprecedented challenges. There will be hard choices to make requiring careful ethical analysis, balancing stakeholder interests, health care professional accountability, and the need for civil discourse in the public square.
To better deal with this issue, there should be set guidelines and training for professionals in order to have better conversations regarding end-of-life problems among themselves and with other professionals as well. This is not only a problem in the United States, but also in other countries around the world. Ryu (2013) states the following:
In October 2009, the Korean Medical Association also responded and proposed guidelines regarding EOL treatments. The guidelines classify terminally-ill patients into four categories depending on their ability to make decisions and their neurologic state and the range of EOL treatments that should be discussed and decided. However, there are still no guidelines with authority or legislature regarding EOL treatments.
Main Body According to Chan and Webster (2010), “Obstacles to quality end-of-life care have also been identified and may include failure to recognize treatment futility, lack of communication among decision makers, and no agreement on a course of end-of-life care and failure to implement a timely end-of-life plan of care.” Sometimes, healthcare professionals tend to give families false hope that the treatment they will provide to the patient will work, or even that continuing said treatment will at some point improve the patient’s condition. This could be due to physicians getting too emotionally connected with the family or the patient, causing the physician not to want to be the bearer of bad news. A study conducted by M. Daher (2013) states the following:
Cancer incidence will increase as the population ages; there will be a 50% increase in new cancer cases over the next 20 years, and the biggest rates of increase will occur in the developing world.
Owing to technical advances in the care of critical illness, as it is the case in elderly people with advanced cancer, physicians, patients and families are often confronted with ambiguous circumstances in which medical advances may inadvertently prolong suffering and the dying process rather than bring healing and recovery.
False promises actually are worse than being upfront about the fact that in some cases, further treatment is useless. Because I want to eventually own a hospice facility, I believe that all healthcare professionals, regardless of their rank in the hospital, should be trained on the correct form of delivery when informing patients and family members of end-of-life issues. According to Lewis (2013), “Healthcare providers should recognize and understand that interventionist care may not be best for patients who are terminally ill” (p. 2). This is exactly why such training is …show more content…
necessary.
Ethical issues concerning end-of-life treatment typically exist because of concerns with the nature and amount of care that would be considered appropriate for someone who is terminally ill. This especially exists among those who are elderly. There tends to be conflict mainly between the family of the patient and the physician about the type of care that the patient should receive. These conflicts could be easily avoided by the family making it clear amongst themselves who will make the decision in the worst case scenario. Tejwani (2013) states the following in his article:
A futility dispute occurs when physicians and the patient’s family or surrogate have opposite views on what kind of care is appropriate for the patient; typically, the physicians consider aggressive care to be futile and comfort care appropriate, while the patient’s family or surrogate disagree. Futility disputes touch upon multiple aspects of care-related issues. They involve moral judgments on what constitutes ethical care, the obligation to preserve both the patient’s and physician’s autonomy, and distinguishing an effect in an organ from an actual improvement in patient outcome. Understanding the ethical and legal outline in which such decisions are made can also convert what appear to be challenging questions into direct answers. In his article, Ramalingam states “Several studies from the United States and Europe showed that physicians ' religiosity is associated with their approach to end-of-life care beliefs.” Different religions have different beliefs relating to end-of-life care, therefore, healthcare professionals should be aware of these beliefs and alter their methods of care based on that. In his article, Televantos (2013) relayed the following:
To our knowledge this is the first study in Cyprus examining population beliefs and attitudes with respect to end-of-life decisions about euthanasia and cremation. Our survey showed that Greek Cypriots are opposed to euthanasia for themselves even if they are terminally ill or suffer from dementia and they are also opposed to euthanasia for their close relatives who have similar conditions. In addition Greek Cypriots, in their vast majority, are opposed to cremation.
It is the responsibility of the physician to assess whether or not the patient is able to make decisions properly before ultimately deciding that the patient is incapable of speaking for himself or herself. Patients with early-onset Alzheimer’s, for example, may have the mental capacity to understand the extents of a certain surgery and make the decision of whether or not he or she wants to move forward with it.
Potential objections to extra training when it comes to end-of-life issues and care include lack of funding as well as potential instructors. It would be difficult to get federal funds to support an issue like this because it is not considered to be huge, but from my personal experiences, I have seen it break families down to the core. The uncertainty can become too much for some people to handle. If funding was not an issue, the next problem would be finding a team of healthcare professionals who have experience delivering life-altering news and would have no problems relaying how to do this to others. There is a great lack of knowledge among ranks of healthcare professionals. Lee (2013) found the following results:
End-of-life care (EOLC) knowledge differed significantly between the grades of frontline workers: registered nurses, enrolled nurses, health workers, and personal care workers. Workers with more health education were more likely to overestimated the proportion of cancer deaths and underestimate that of dementia-related deaths.
Another potential issue would be the fact that it would be extremely difficult to train every healthcare professional on a certain tactic related to communicating terminal illness, especially when the physician has adapted his or her own way of doing so and has been using that method for a certain amount of time. To support my stance on this issue, I have a paragraph from an article about a family who could not agree to withdraw life support from a patient for whom death was inevitable. Hyde (2003) states the following:
We advocate training for ICU nurses in ways to help families with spiritual and psychological needs, communication before death, care at death, and the family’s initial bereavement. Nurses also need training to help families from other cultures, so that they do not create mistrust, and they provide culturally sensitive end-of-life care. Nurses also need training in conflict management and ways to help families communicate when members disagree about a course of action. This is especially true when dealing with family members who have been estranged from each other but now are forced to work together to make a decision about a family member’s end-of-life care. A solution that would solve the problem of delivering the news of a terminal illness and also counter the issue of funding as well as instructors would be to start small. First, Joint Commission would set guidelines on how such news should be delivered as well as who should deliver it. Next, having a “training day”, if you will, to have a group of healthcare professionals who work in one organization and are familiar with ethical ways to deliver such news to families train their peers. It would be a time consuming effort, but I do believe that it would be well worth it. It could be a normal day, that way no extra funding would have to be set aside for it. Also, the process could be split throughout the week, with each day having different workshops. In her article, Kerai (2013) states the following:
The second session begins with a listening exercise. Each participant is asked to speak with a partner for 5 minutes about a loss they have experienced. In order to provide a safe environment, they are instructed to discuss any loss, be it minor or very personal. The listener is instructed to be attentive, but to refrain from speaking, during the 5 minute period. After 5 minutes, the roles are reversed. At the conclusion of the exercise, the facilitators review the experience. Next, the participants introduce a challenging end-of-life case and the group decides which one to role-play. Roles are assigned and the resident is given the opportunity to lead the conversation. During this exercise, the observers pay attention to language, listening, whether the resident utilized the SPIKES techniques. Depending upon the case, the resident may be given suggestions and the role-play may be repeated using new strategies. At the end, the trainee would be given a certificate to confirm that he or she is trained and knows how to deliver the news of terminal illnesses per the guidelines of the Joint Commission.
Conclusion
In conclusion, end-of-life issues create an ethical dilemma that can completely be avoided. If there were guidelines set forth for all healthcare professionals to follow, it would make things much easier. It is not only the responsibility of the healthcare professional; however, families must also be prepared for the worst case scenario, as nothing in this world is guaranteed. It is considered unethical for physicians to withhold information from patients or their families, as well as to continue care when they know that the efforts may be futile. It is best for every healthcare professional to understand and follow rules when it comes to such a sensitive subject.
References
Daher, M.
(2013). Ethical issues in the geriatric patient with advanced cancer ‘living to the end’. Retrieved October 31, 2013, from http://annonc.oxfordjournals.org.ezproxy3.lhl.uab.edu/content/24/suppl_7/vii55
Hyde, Y., & Kautz, D. (2010). What to Do When the Family Cannot Agree to Withdraw Life Support. Retrieved October 31, 2013, from http://ovidsp.tx.ovid.com.ezproxy3.lhl.uab.edu/sp-3.10.0b/ovidweb.cgi?QS2=
Kerai, S. M., & Wheeler, M. (2013). The Forgotten Educational Needs of the House Staff: Training Internal Medicine Residents to Address End-of-Life Issues. Retrieved October 29, 2013, from http://web.ebscohost.com.ezproxy3.lhl.uab.edu/ehost/detail?sid=8752da98-533d-4102-b0d8-39a4cbcb76b2%40sessionmgr114&vid=1&hid=118&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=tfh&AN=88230741
Lee, J., & Cheng, J. (2013, October 7). Improving the Quality of End-of-Life Care in Long-Term Care Institutions. Retrieved October 29, 2013, from
http://online.liebertpub.com.ezproxy3.lhl.uab.edu/doi/abs/10.1089/jpm.2013.0190
Lewis, K. (2013, June 25). How Nurses Can Help Ease Patient Transition to End-of-Life Care. Retrieved November 18, 2013, from http://web.ebscohost.com.fetch.mhsl.uab.edu/ehost/pdfviewer/pdfviewer?sid=ab386523-9d6d-4099-8b4e-6723327cdecd%40sessionmgr113&vid=4&hid=127
Ramalingam, V. S., & Saeed, F. (2013, September 19). End-of-Life Care Beliefs Among Hindu Physicians in the United States. Retrieved October 29, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/24052431
Ryu, H. G., & Choi, J. (2013, October 4). Critical Care. Retrieved October 30, 2013, from http://ccforum.com.ezproxy3.lhl.uab.edu/content/17/5/R221
Tejwani, V., & Wu, Y. (2013, August 9). Issues surrounding end-of-life decision-making. Retrieved October 31, 2013, from http://www-ncbi-nlm-nih-gov.ezproxy3.lhl.uab.edu/pmc/articles/PMC3749083/
Televantos, A., & Talias, M. (2013, September 23). Attitudes towards euthanasia in severely ill and dementia patients and cremation in Cyprus: a population-based survey. Retrieved October 30, 2013, from http://www.biomedcentral.com.ezproxy3.lhl.uab.edu/1471-2458/13/878
When a patient is ordered to move from curative to palliative care, it can really take a toll on the patient, his or her family, as well as the physician. This can be due to the fact that end-of-life care is usually seen as the end. To make this worse, the healthcare providers do not always relay such information in a way that the family will completely understand. Sometimes, the healthcare professional will not let the family know that end-of-life care is necessary; he or she will just continue to give the patient medications that are futile to their well-being. In order to prevent this, there should be a set guideline for healthcare professionals to learn and follow when telling patients and their families that end-of-life …show more content…
care will be the necessity from that point on.
Keywords: palliative, end-of-life care
Introduction
When dealing with ethical behavior in the healthcare setting, it should be a known fact that not every situation will be handled the way they should be. An example of this would be the way end-of-life issues are addressed. While the decision-making process is in the hands of the family in most cases, it is up to the healthcare professional to discuss all possible options as well as his or her opinion of what may be best for the patient. Because the life expectancy of Americans has made great progress, this is the trade-off. The Hastings Center states:
When it comes to the final phase of life, there has been great progress. We now have good evidence of how best to relieve suffering, provide good palliative care, resolve conflicts, and honor the individual preferences of dying patients, but our health system is slow to incorporate this knowledge. Health care professionals are seldom reimbursed for discussing the end of life with patients, have limited time to address the subject, and often are poorly prepared to talk about such sensitive matters. They may also be unaware of what is ethically and legally permissible or confused by continuing ethical debates on issues like physician-assisted suicide or determining death in the context of organ transplantation.
As the 21st century progresses and the massive baby boom generation ages, health care professionals, patients, and families face unprecedented challenges. There will be hard choices to make requiring careful ethical analysis, balancing stakeholder interests, health care professional accountability, and the need for civil discourse in the public square.
To better deal with this issue, there should be set guidelines and training for professionals in order to have better conversations regarding end-of-life problems among themselves and with other professionals as well. This is not only a problem in the United States, but also in other countries around the world. Ryu (2013) states the following:
In October 2009, the Korean Medical Association also responded and proposed guidelines regarding EOL treatments. The guidelines classify terminally-ill patients into four categories depending on their ability to make decisions and their neurologic state and the range of EOL treatments that should be discussed and decided. However, there are still no guidelines with authority or legislature regarding EOL treatments.
Main Body According to Chan and Webster (2010), “Obstacles to quality end-of-life care have also been identified and may include failure to recognize treatment futility, lack of communication among decision makers, and no agreement on a course of end-of-life care and failure to implement a timely end-of-life plan of care.” Sometimes, healthcare professionals tend to give families false hope that the treatment they will provide to the patient will work, or even that continuing said treatment will at some point improve the patient’s condition. This could be due to physicians getting too emotionally connected with the family or the patient, causing the physician not to want to be the bearer of bad news. A study conducted by M. Daher (2013) states the following:
Cancer incidence will increase as the population ages; there will be a 50% increase in new cancer cases over the next 20 years, and the biggest rates of increase will occur in the developing world.
Owing to technical advances in the care of critical illness, as it is the case in elderly people with advanced cancer, physicians, patients and families are often confronted with ambiguous circumstances in which medical advances may inadvertently prolong suffering and the dying process rather than bring healing and recovery.
False promises actually are worse than being upfront about the fact that in some cases, further treatment is useless. Because I want to eventually own a hospice facility, I believe that all healthcare professionals, regardless of their rank in the hospital, should be trained on the correct form of delivery when informing patients and family members of end-of-life issues. According to Lewis (2013), “Healthcare providers should recognize and understand that interventionist care may not be best for patients who are terminally ill” (p. 2). This is exactly why such training is …show more content…
necessary.
Ethical issues concerning end-of-life treatment typically exist because of concerns with the nature and amount of care that would be considered appropriate for someone who is terminally ill. This especially exists among those who are elderly. There tends to be conflict mainly between the family of the patient and the physician about the type of care that the patient should receive. These conflicts could be easily avoided by the family making it clear amongst themselves who will make the decision in the worst case scenario. Tejwani (2013) states the following in his article:
A futility dispute occurs when physicians and the patient’s family or surrogate have opposite views on what kind of care is appropriate for the patient; typically, the physicians consider aggressive care to be futile and comfort care appropriate, while the patient’s family or surrogate disagree. Futility disputes touch upon multiple aspects of care-related issues. They involve moral judgments on what constitutes ethical care, the obligation to preserve both the patient’s and physician’s autonomy, and distinguishing an effect in an organ from an actual improvement in patient outcome. Understanding the ethical and legal outline in which such decisions are made can also convert what appear to be challenging questions into direct answers. In his article, Ramalingam states “Several studies from the United States and Europe showed that physicians ' religiosity is associated with their approach to end-of-life care beliefs.” Different religions have different beliefs relating to end-of-life care, therefore, healthcare professionals should be aware of these beliefs and alter their methods of care based on that. In his article, Televantos (2013) relayed the following:
To our knowledge this is the first study in Cyprus examining population beliefs and attitudes with respect to end-of-life decisions about euthanasia and cremation. Our survey showed that Greek Cypriots are opposed to euthanasia for themselves even if they are terminally ill or suffer from dementia and they are also opposed to euthanasia for their close relatives who have similar conditions. In addition Greek Cypriots, in their vast majority, are opposed to cremation.
It is the responsibility of the physician to assess whether or not the patient is able to make decisions properly before ultimately deciding that the patient is incapable of speaking for himself or herself. Patients with early-onset Alzheimer’s, for example, may have the mental capacity to understand the extents of a certain surgery and make the decision of whether or not he or she wants to move forward with it.
Potential objections to extra training when it comes to end-of-life issues and care include lack of funding as well as potential instructors. It would be difficult to get federal funds to support an issue like this because it is not considered to be huge, but from my personal experiences, I have seen it break families down to the core. The uncertainty can become too much for some people to handle. If funding was not an issue, the next problem would be finding a team of healthcare professionals who have experience delivering life-altering news and would have no problems relaying how to do this to others. There is a great lack of knowledge among ranks of healthcare professionals. Lee (2013) found the following results:
End-of-life care (EOLC) knowledge differed significantly between the grades of frontline workers: registered nurses, enrolled nurses, health workers, and personal care workers. Workers with more health education were more likely to overestimated the proportion of cancer deaths and underestimate that of dementia-related deaths.
Another potential issue would be the fact that it would be extremely difficult to train every healthcare professional on a certain tactic related to communicating terminal illness, especially when the physician has adapted his or her own way of doing so and has been using that method for a certain amount of time. To support my stance on this issue, I have a paragraph from an article about a family who could not agree to withdraw life support from a patient for whom death was inevitable. Hyde (2003) states the following:
We advocate training for ICU nurses in ways to help families with spiritual and psychological needs, communication before death, care at death, and the family’s initial bereavement. Nurses also need training to help families from other cultures, so that they do not create mistrust, and they provide culturally sensitive end-of-life care. Nurses also need training in conflict management and ways to help families communicate when members disagree about a course of action. This is especially true when dealing with family members who have been estranged from each other but now are forced to work together to make a decision about a family member’s end-of-life care. A solution that would solve the problem of delivering the news of a terminal illness and also counter the issue of funding as well as instructors would be to start small. First, Joint Commission would set guidelines on how such news should be delivered as well as who should deliver it. Next, having a “training day”, if you will, to have a group of healthcare professionals who work in one organization and are familiar with ethical ways to deliver such news to families train their peers. It would be a time consuming effort, but I do believe that it would be well worth it. It could be a normal day, that way no extra funding would have to be set aside for it. Also, the process could be split throughout the week, with each day having different workshops. In her article, Kerai (2013) states the following:
The second session begins with a listening exercise. Each participant is asked to speak with a partner for 5 minutes about a loss they have experienced. In order to provide a safe environment, they are instructed to discuss any loss, be it minor or very personal. The listener is instructed to be attentive, but to refrain from speaking, during the 5 minute period. After 5 minutes, the roles are reversed. At the conclusion of the exercise, the facilitators review the experience. Next, the participants introduce a challenging end-of-life case and the group decides which one to role-play. Roles are assigned and the resident is given the opportunity to lead the conversation. During this exercise, the observers pay attention to language, listening, whether the resident utilized the SPIKES techniques. Depending upon the case, the resident may be given suggestions and the role-play may be repeated using new strategies. At the end, the trainee would be given a certificate to confirm that he or she is trained and knows how to deliver the news of terminal illnesses per the guidelines of the Joint Commission.
Conclusion
In conclusion, end-of-life issues create an ethical dilemma that can completely be avoided. If there were guidelines set forth for all healthcare professionals to follow, it would make things much easier. It is not only the responsibility of the healthcare professional; however, families must also be prepared for the worst case scenario, as nothing in this world is guaranteed. It is considered unethical for physicians to withhold information from patients or their families, as well as to continue care when they know that the efforts may be futile. It is best for every healthcare professional to understand and follow rules when it comes to such a sensitive subject.
References
Daher, M.
(2013). Ethical issues in the geriatric patient with advanced cancer ‘living to the end’. Retrieved October 31, 2013, from http://annonc.oxfordjournals.org.ezproxy3.lhl.uab.edu/content/24/suppl_7/vii55
Hyde, Y., & Kautz, D. (2010). What to Do When the Family Cannot Agree to Withdraw Life Support. Retrieved October 31, 2013, from http://ovidsp.tx.ovid.com.ezproxy3.lhl.uab.edu/sp-3.10.0b/ovidweb.cgi?QS2=
Kerai, S. M., & Wheeler, M. (2013). The Forgotten Educational Needs of the House Staff: Training Internal Medicine Residents to Address End-of-Life Issues. Retrieved October 29, 2013, from http://web.ebscohost.com.ezproxy3.lhl.uab.edu/ehost/detail?sid=8752da98-533d-4102-b0d8-39a4cbcb76b2%40sessionmgr114&vid=1&hid=118&bdata=JnNpdGU9ZWhvc3QtbGl2ZQ%3d%3d#db=tfh&AN=88230741
Lee, J., & Cheng, J. (2013, October 7). Improving the Quality of End-of-Life Care in Long-Term Care Institutions. Retrieved October 29, 2013, from
http://online.liebertpub.com.ezproxy3.lhl.uab.edu/doi/abs/10.1089/jpm.2013.0190
Lewis, K. (2013, June 25). How Nurses Can Help Ease Patient Transition to End-of-Life Care. Retrieved November 18, 2013, from http://web.ebscohost.com.fetch.mhsl.uab.edu/ehost/pdfviewer/pdfviewer?sid=ab386523-9d6d-4099-8b4e-6723327cdecd%40sessionmgr113&vid=4&hid=127
Ramalingam, V. S., & Saeed, F. (2013, September 19). End-of-Life Care Beliefs Among Hindu Physicians in the United States. Retrieved October 29, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/24052431
Ryu, H. G., & Choi, J. (2013, October 4). Critical Care. Retrieved October 30, 2013, from http://ccforum.com.ezproxy3.lhl.uab.edu/content/17/5/R221
Tejwani, V., & Wu, Y. (2013, August 9). Issues surrounding end-of-life decision-making. Retrieved October 31, 2013, from http://www-ncbi-nlm-nih-gov.ezproxy3.lhl.uab.edu/pmc/articles/PMC3749083/
Televantos, A., & Talias, M. (2013, September 23). Attitudes towards euthanasia in severely ill and dementia patients and cremation in Cyprus: a population-based survey. Retrieved October 30, 2013, from http://www.biomedcentral.com.ezproxy3.lhl.uab.edu/1471-2458/13/878