Honesty and autonomy in hospice care ethics

¶ … ethical hospice care is that it must be founded upon honesty. "Frank discussions about death and dying, clarifying knowledge of the underlying illness and knowledge of the dying process" is essential (Guido 2010: 35). However, this must be balanced with the patient's desire for confidentiality and his right to die in a way which honors his wishes. In this instance, a private and confidential discussion with Mr. West is essential. The nurse should explain why candor is preferable when dealing with his wife. By communicating the message that it will be less upsetting if Mrs. West is kept aware of his medical condition, Mr. West will be more willing to allow his wife to understand the likely trajectory of his condition. Then, the nurse should have a meeting with the couple and discuss what will occur. However, the hospice principles of honesty vs. autonomy would be in conflict if Mr. West continued to refuse to tell his wife. This could become even more complicated if Mr. West was no longer competent to make decisions about his care as his illness progressed.

Topic 2: Ethical Dilemma

Equitable access to end-of-life care does not override the obligation of the hospice to keep the staff safe. In all decisions, hospice staff safety is a priority. This includes protection against communicable illnesses and hazardous aspects of the job, such as dealing with radiation. The hospice has the ethical obligation to provide police or security escorts if the worker is going to an unsafe neighborhood. While it is not fair to penalize patients in unsafe neighborhoods, it is also unfair to penalize workers who give their time and energy to care for patients in such locals. Adequate security precautions must be provided and included in the hospice's budget. This is not an unusual request: hospitals located in certain areas (such as high-crime urban locals) may require additional security because of their location. For both the security of the employees as well as the security of the workers, this is necessary.

Topic 3: Bad News

Recently, I was with my friend when she brought her elderly dog to the vet and was informed that it would be kinder to put the dog to sleep. This was a very difficult and emotional situation even though the news was not unexpected. The veterinarian kept my friend fully informed of the situation regarding her dog's health, and did not 'sugar coat' things. The vet presented by friend with all available options. The vet told my friend the decision that she would make, if it were her dog, although she gave my friend the ability to make the final decision about her dog's health. Then the vet affirmed my friend's decision, and said that she knew that my friend was acting out a place of love. I believe this approach is a good one regarding approaching 'bad news' with a patient or caregiver, and would obey these same principles myself. I was glad to see the vet minimized any 'guilt' my friend might have felt about not pursuing heroic measures.

O= Orientation

What are the client's ethnic identity, values, orientation and acculturation? Gene's parents were nominally Buddhist. They placed a strong emphasis on family when Gene was growing up and Gene feels a strong sense of family obligations to his surviving mother.

Do they identify with a specific group? Yes. Gene identifies as an Asian-American, specifically a Chinese-American.

Where were they born? Gene is a second-generation Chinese-American, born in the United States

How long have they lived here? 32 years.

N= Nutrition: Although nominally Buddhist, Gene is not a vegetarian. He eats a wide variety traditional and non-traditional Chinese staples. However, he is lactose intolerant.

F= Family Relationships

Family structure is important

How is family defined and who is in the family? Family includes Gene's immediate and extended family.

Who is the head of the household? Gene

Who makes decisions in the family? Gene

What is the role of women and children? Since Gene's father passed away, Gene's mother has lived with him and he has taken care of her.

Is it important to have family present when someone is sick? Yes. Gene would be offended if decisions regarding his mother's health were made without his presence.

H= Health and health beliefs

Not all cultural groups subscribe to the germ theory of disease. Illness may be the result of evil spirits or something being out of balance.

What does the person do to stay healthy? Gene is a member of a gym. He tries to eat less meat than he used to, although he enjoys fast food.

Who do they consult for health problems? A doctor

How do they explain illness? Gene tends to blame himself for health problems, given that he was brought up with a strong sense of personal responsibility.

E= Education

What is the person's learning style and educational level? College level. Gene is a very logical, fact-oriented person in general although he does have some superstitions.

How much formal education did the person complete? Gene completed his B.S. In business.

What is their occupation? Business.

R= Religion

What is that person's preference? Buddhist

Does the client have any religious beliefs or restrictions that have an impact on healthcare?

and illness? No.

Although Gene is fairly assimilated to American culture, his strong sense of what could be called filial piety makes him want to be involved in decisions regarding his mother's care. He has a rather paternalistic attitude towards her, more like a parent to a child than a child to a parent. Gene wishes to be involved in his mother's healthcare decisions, but he does not want her to be burdened with his own healthcare concerns because of his sense of responsibility to others and status as her caregiving, adult son. Gene worries about his own health sometimes because he does not know what would happen to his mother if something happened to him, because she does not speak English well enough to fend for herself. Gene's traditions and emotions are a blend of Chinese and American traditions and he does not necessarily see a contradiction between the two: he is willing to use both acupuncture and pain medications to treat injuries, for example.

Topic 6: Spiritual Assessment

Table 3: Spiritual Assessment: Mnemonics for Interviewing

Spiritual Assessment: Mnemonics for Interviewing

Author

Components (Mnemonic)

Illustrative Questions

Maugens

S (spiritual belief system)

Secular; Jewish

P (personal spirituality)

I am not observant, but I do have respect for the Jewish religion in which I was brought up.

I (integration with a spiritual community)

I am not religious but I consider myself culturally Jewish

R (ritualized practices and restrictions)

No

I (implications for medical care)

Focusing on the spirituality of the hereafter is not important. Heaven is not an important part of my spiritual tradition.

T (terminal evens planning)

I do believe in the idea that minimizing suffering is important

Anandarajah & Hight

H (sources of hope)

My family and friends

O (organized religion)

No, but I am involved in Jewish cultural organizations which give me a strong sense of connection with something larger than myself.

P (personal spirituality or spiritual practices)

When things get overwhelming, I don't formally meditate but I do try to take a moment to 'take a breath' and relax.

E (effects on medical care and/or end-of-life issues)

No.

Puchalski

F (faith)

Do you have a faith belief? What is it that gives your life meaning?

I (importance or influence)

Faith does not have a strong influence on my life, although being a member of the Jewish community does.

C (community)

I strongly identify with Judaism but not in a religious sense.

A (address)

Leading a high-quality life and minimizing suffering is important to me, more so that simply extending life

Spiritual distress in this patient might be indicated by an expressed crisis of meaning; depression or despair; and a lack of a sense of leading a meaningful life. Or it might simply be expressed as a general sense of depression and malaise without a spiritually-articulated component. Even though he is not formally religious, traditions are clearly very important for the subject. Patients without a strong spiritual orientation (although the individual has a strong cultural orientation regarding his faith community) might say things like: "what does it all matter," or "I don't think I care anymore," because they have trouble finding a rationale for dealing with their suffering. Practices such as non-theological meditation and support groups can be helpful for patients in dealing with spiritual distress in a manner that is not openly theological in orientation. The patient might be resistant to expressing higher order concerns because he is worried about being forced into religious practices he does not personally observe or support.