palliative care ethics Flashcards
Concepts that fall under autonomy
- Informed consent
- Freedom from interference/control by others
- Freedom from unwanted bodily intrusion
- Advance directives and designated surrogate decision makers
how to help your pt maintain autonomy
- You must know their goals, values, and preferences
- You must ensure the patient (or their proxies) understand their medical options, along with the benefits and consequences of each
Providers have a fiduciary duty to
provide care that is in the best interest of the patient
Guidelines that forbid providers from providing care that:
does more harm than good
is ineffective
stems from malicious or selfish acts
Principles of Medical Ethics
autonomy - A person’s right to make their own decisions
Nonmaleficence - do no harm
Beneficence - The duty to promote what is best for others
justice - Fair treatment; Distribute resources fairly
the ability of a patient to understand the benefits and risks of, and the alternatives to, a proposed treatment or intervention
Decision making capacity
Determined based upon the specific decision at hand - Is the decision straightforward (when to eat) or complex (safety in home)?
decision making capacity can be determined by who?
how?
general clinician
Cognitive assessments can help in determining cognitive dysfunction that might interfere with decision making - Clock draw is most reliable
a person’s ability to act reasonably after understanding the nature of the situation being faced
competence
Consider consulting who if you feel a patient’s mental condition is interfering with their decision-making ability
psychiatrist
competence is determined by who?
Determined by a court of law
Assessing a patient’s decision making capacity:
- must make a decision.
- explain the reasons behind the decision.
- cannot result from delusions or hallucinations.
- demonstrate understanding of the medical situation and the risks, benefits, and alternatives to the decision - If possible, reassess understanding on more than one occasion
- The decision must be consistent with the patient’s values and preferences over time.
Principles of Informed Consent
- The patient has right to choose among medically feasible options and the right to refuse unwanted interventions and treatments
What is included in an informed consent?
- Nature of the proposed intervention
- Potential benefits, risks, and longer-term consequences of intervention
- Alternative interventions or treatments
- Option of not going forth with a treatment along with risks and long-term consequences
Having the Conversation about Informed Decision Making
- Avoid medical jargon
- Determine if pt knows/wants to know prognosis
- Offer to discuss prognosis routinely throughout a patient’s care; As the prognosis changes the patient’s decisions may change -
Be cautious as to how you present
- avoid bias inflection; avoid unequal presentation of information (risks vs benefits) - Disclosure of info does not equal understanding
- assess understanding using a teach-back method
The process of a patient talking with the their loved ones, often in conjunction with a healthcare clinician, about plans and preferences for future care
- Requires competence
- Patient needs to consider goals for life
Advanced Care Planning
parts of Advance Directives
- Contains a Living Will and designation of a Medical Power of Attorney (MPOA)
-
Official doc of goals and end of life wishes
- Should be signed by a witness (other than the designated MPOA), preferably a notary
- Forms vary from state to state - Federal law requires that all entering a hospital or long-term care facility be offered opportunity to indicate ADs
- Patient Self-Determination Act (1990)
what is a Living Will
-
Life saving measures
- CPR, respiratory assistance, IV hydration, artificial nutrition, blood transfusions, or medical devices
- Valid across all settings - Transfer to acute care setting for more aggressive interventions
- Use of abx
- Organ or tissue donation
- Type of funeral/memorial services; cremation vs burial
- aka: surrogate decision maker, a proxy, durable power of attorney
- A person elected by the patient, in advance, who has extensive knowledge of the patient’s values, preferences, and goals
- Determine level of decision making allowed by HCPOA
medical power of attorney
If a MPOA is not designated, is determined by ?
law in a default order
- Spouse → then adult children → siblings → parents → health care team
- Conservators are court-appointed surrogates
Medical care focused on improving quality of life for people living with serious illness regardless of prognosis
Palliative Care
a condition that carries a high risk of mortality, negatively impacts quality of life and daily function, and/or is burdensome in symptoms, treatments or caregiver stress.
serious illness
Focuses of palliative care
- addresses and treats symptoms
- support for patients’ families and loved ones
- through clear communication helps ensure that care aligns with patients’ preferences, values, and goals
Palliative care can be delivered along with cure-focused treatments
A form of palliative care when there is a limited life expectancy
Hospice Care
eligibility for Hospice Care
- Part A Medicare coverage
- Two clinicians have determined the patient has ≤ 6 months to live if disease runs its expected course
- Patients must forgo curative tx for a terminal disease
Can hospice care be provided in home or institutional setting?
yes
Hospice covers what?
- physician and nursing visits
- palliative medications
- medical equipment and supplies (bedside commode, wheelchair etc.)
- psychological and spiritual support to patient and family
Patients and families express a wide variety of psychological, spiritual, and social needs during serious illness, what are these needs?
- Preserving control and independence
- Accessing information (eg, regarding disease progression and expectations)
- Managing anxiety and depression
- Dealing with financial burdens
- Spiritual support
Coordinate the care for every patient, provide direct patient care, education and check symptoms and medication.
This healthcare worker is the link between the patient and his or her family and the clinician.
what service is this
Nursing
provides advice and counseling to the patient and all family members during the crisis period. assists other care team members in understanding the family dynamics and acts as an advocate for the patient and the family in making use of community resources.
what service is this
social work
The patient’s primary care clinician approves the plan of care and works with the hospice team.
what service is this
Clinician services
Clergy and other counselors are available to visit and provide spiritual support to the terminally ill at home.
Programs also use churches and congregations to aid the patient and family as requested.
what service is this
Spiritual/counseling
Home care aides provide personal care for the patient, such as bathing, shampooing, shaving, and nail care, and homemakers may be available for light housekeeping or meal preparation.
what service is this
Home health care/homemaker
If the patient’s needs require it or if the family can no longer manage the level of care required around the clock, hospice staff will provide care for 8- to 24-hour periods on a short-term basis.
what service is this
Continuous home health care
Daily living tasks such as walking, dressing, or feeding oneself can become frustrating and impossible during an illness. Therapists help the patient develop new ways to accomplish these tasks.
what service is this
Therapy/rehabilitation services
A hospice team member is on call 24 hours a day, 7 days a week. If a problem should arise, the team member may offer advice over the phone and, if necessary, make a visit.
what service is this
On-call team support
To provide relief for family members, the hospice may arrange a brief period of in-patient care for the patient.
what service is this
Respite care
The hospice care team works with surviving family members to help them through the grieving process. Support may include a trained volunteer or counselor visiting the survivors at specific periods during the first year, or phone calls and/or letter contact and the opportunity for family members to participate in support groups. The hospice will refer survivors to medical or other professional care if necessary.
what service is this
Bereavement counseling
how to provide good communication with shared decision making with the pt and family when dealing with pallative care?
- Review decisions
- Exchange info about pt/family values, pt’s current status, and risks/benefits of available tx
- Ensure that all parties understand info
- Discuss preferred roles in decision making
- Reach an agreement about tx that is congruent with patient/family values and preferences
Keys to Providing High Quality Palliative Care
- All pertinent preferences and decisions should be documented in advance directives
- discussions should occur early
pain management in palliative care
Goal: treat pain proactively and find the minimal dose of medication that can prevent pain
Reassure them that their pain will be managed
Use both pharm and nonpharm
nonpharm options for pain management in palliative care
positioning changes
heat or ice
music or other types of distractions
acupuncture and massage
pharm options for pain management in palliative care
- Acetaminophen (Tylenol) - 1st line for mild pain
- not to exceed a total daily dose of 3g - NSAIDs
- oral NSAIDS - caution in older adults because of the high risk of SE (renal failure, GI irritation, and worsening HF) - Opioids - moderate to severe pain
- SE: N/V/C, sedation, respiratory distress - Corticosteroids - nerve compression, neuropathic and bone pain
- SE: abdominal pain, N/V, hyperglycemia, or psychosis - benzo - anxiety associated with pain
- SE: sedation, confusion, delirium - Anticonvulsants - neuropathic pain
- SE: confusion, sedation - Muscle relaxants - muscle spasms
- SE: sedation, muscle weakness, falls
Dyspnea is a common sx among older palliative care pt, particularly those with these conditions:
COPD, CHF, end-stage pulmonary disease, and lung cancer
management for dyspnea in palliative care
- Treatment focuses on underlying cause
- opiates relieve the sensation of breathlessness
- opioid-naive patients: start low doses of opioids (2 mg IR morphine) and titrate up prn - Supplemental oxygen if hypoxemic
- Environmental changes - elevate head of bed, use a fan to blow air into patients face
- Avoid lengthy conversions with patient as these can exacerbate breathlessness
management for Excessive Secretions and Cough in palliative care
- may not be able to expectorate
- Suctioning can be traumatic and uncomfortable
- Anticholinergics: hyoscyamine or atropine - Trans Derm Scopolamine patches are very helpful for “the death rattle” - Cough related to CHF - diuretics
- URI related cough - abx, dextromethorphan, codeine
common meds that cause N/V
opioids, antibiotics, antineoplastic agents, vitamins (zinc, iron), and acetylcholinesterase inhibitors
a common symptom that often needs to be managed during palliative care treatment.
Constipation
management for Constipation
- laxative, enema, manual disimpaction if needed
- Preventative measures esp if at risk due to medication profile - increasing fluid, fiber and physical activity as tolerable
medication for Gut inflammation
ondansetron (Zofran)
medications for Chemotherapy induced N/V
ondansetron (Zofran)
meds for Motion-induced/labyrinthitis N/V
Scopolamine patch
promethazine (Phenergan)
meds for N/V from increase ICP
Dexamethasone (Decadron)
management for diarrhea in palliative care
Bulking agents (fiber)
OTC loperamide (Imodium)
an adaptive, universal, and highly personalized emotional response to loss that occurs throughout life
Often intense early on after a loss, but the impact of grief on daily life generally decreases over time without clinical intervention
Grief
neither universal nor adaptive, although it is common among persons with advanced illness
Feelings of hopelessness, helplessness, worthlessness, guilt, lack of pleasure, and suicidal ideation are key in distinguishing depression from grief
major depression
what txs are effective treatments in reducing distressing symptoms and improving quality of life for those with depression
Both cognitive therapy and antidepressant
management for delirium in palliative care
- Similar to those who are not at the end of life
- Focus on reversible causes (pain, med SE, urine retention, or fecal impaction)
- nonpharm to prevent delirium - frequent reorientation, promoting daytime activity and a quiet nighttime environment, avoid agents that may precipitate delirium (anticholinergics)
- Small doses of antipsychotics (haloperidol) - decreases agitation at the end of life
Hospice care can improve patient and caregiver outcomes how?
- better sx management
- fewer unmet needs
- decreased hospitalizations during last 30 d of life
- higher caregiver satisfaction w/ end-of-life care
how often is hospice used in advanced dementia?
Hospice is often underutilized in advanced dementia
Difficulty of predicting death within 6 months using current hospice eligibility criteria
Hospice should be considered in any advance dementia case complicated by what conditions?
pneumonia, febrile episode or eating problems
These are markers of a poor 6-month prognosis
Decreased Appetite and Weight Loss occur how?
palliative care
dysphagia, GI discomfort, dry mouth, medication SE, imminent death
tx options for Decreased Appetite and Weight Loss in palliative care if NOT in AD?
- PEG tube
- hand feeding
- appetite stimulants
- corticosteroids
- dronabinol (Syndros) a synthetic THC cannabinoid
- megestrol (Megase) a synthetic progestin
- antidepressants with a SE of weight gain or increased appetite - focus on food preferences
- pleasant eating experience
things to do for palliative care
- Have an open and frank discussion with the patient and family.
- You may have to repeat yourself or rephrase your statements for them to understand. - Have the conversation early on, do not wait until decisions have to be made emergently.
- Consider palliative care as a part of your overall treatment in the elderly.
- Do not delay the treatment of pain, nausea, secretions and cough.
- Show the patient and family that you care.
- You are allowed to express your emotions.
- Lastly, CARE. Families will only lose a particular family member once, so it is your responsibility to ensure that they feel that “things are done right.”
things NOT to do in palliative care
- Forget to treat both the patient and family
- Consider palliative care and Hospice too late
- Fail to aggressively treat pain, nausea, dyspnea, constipation, secretions, and psychiatric issues
- Give false hope
- Fail to involve clergy and other spiritual management
- Fail to consider palliative sedation
- Delay death when it is inevitable
