Leadership and ethical challenges in palliative care implementation

Palliative Care: Ethical Analysis / Ethical Analysis in Healthcare Sector

Communication to move strategy forward

The term 'leadership' is defined as a person's behavior when he/she guides a group's activities in pursuit of a common aim. The main elements of a leader's role include managing change and guiding group activities. One challenge concerning leadership in the healthcare context is that a majority of theories were not formulated keeping healthcare in mind. Rather, they were created for mainstream businesses, and later utilized in healthcare settings (Al-Sawai, 2013). The keystones of ethical clinical practice include avoiding patient harm and delivering quality care. Healthcare professionals wish to do what is ethical, however, how they must proceed is not clear to them in some cases. All scenarios differ in some or other way, and ethical issues may appear even if a healthcare institute establishes policies for dealing with them. A few ethical issues include avoiding situations where personal and organizational interests clash, equalizing charity care and organizational profits derived from serving patients, overcoming dilemma with equality in delivering treatment vs. special treatment for influential patients (e.g., donors), taking care of geriatric and pediatric patients incapable of making the right decisions, and dealing with the moral distress of nurses in regard to care delivery with marginal returns (AMN Healthcare, 2010). A specific example in which modern-day leadership and ethical challenges are posed to healthcare leaders is palliative care. Though a majority of healthcare organizations largely appear to be managed well, with advance planning for a majority of scenarios and situations, this is not the case at all times, particularly in regards to specific actions/decisions nurses must take, acts/services they must refrain from doing, and the reasons for these stipulations. A simple example to explain this would be circumstances wherein a palliative approach is perhaps, or certainly, required, but no clear protocol can be found regarding its precise time/situation of onset as well as, what criteria have to be employed. Patients faced with this sort of scenario are, in fact, terminally ill or, at least, no cure exists for their ailment (e.g., an individual suffering from a case of cancer that, according to doctors, has reached an incurable stage). The lack of a leader to handle protocols of palliative care necessitates collaboration by nurses, who must initiate suitable level of care when there is a lack of interest to bear the responsibility of leadership or initiative. Palliative care situations refer to those situations in which patient care is limited to reducing their pain and managing comfort. Patients who qualify for palliative care include those suffering from cancer, those having chronic, incurable pain conditions, etc. It would be ideal and an indication of leadership for hospices, hospitals, and other healthcare facilities to have clear protocols for palliative care initiation and the way it should progress after commencing. Not every healthcare facility, however, pays sufficient attention to the subject. Frequently, nurses are seen making such decisions -- they set patients on a palliative path and make decisions according to the subsequent condition of the patient, to the best of their ability and knowledge. Also, at present, numerous alternatives exist to care for terminally ill patients. The increase in methods and types of palliative care is mainly because of multi-dimensional technological evolution. Ethical issues arise when healthcare workers have to decide on the ideal type of care for dying patients. An example of the decisions they face is concerning using machines to sustain the life of a patient, or terminating his/her life by taking the patient off life support. Such decisions pose an ethical quandary for all involved parties. In older times, one could conveniently define death as the end of life, but in the modern age, conditions are different. There are machines, now, for sustaining vital bodily functions (e.g., breathing), lending increased complexity to definition of death. Shaughnessy (2004) aptly states that in the new age, a new type of patient can be seen, who is brain-dead, but has functional lungs and heart. CPR (cardiopulmonary resuscitation) and other similar technologies have made restarting of the function of vital organs possible, via machines. Such ethical problems, and care of individuals who are at death's doorstep, result in burnout of several healthcare providers, owing to the emotional stress, and psychological and physical demands of their profession. Pereira and coworkers (2011) indicate that this distress of palliative care personnel arises from the fact that they see death on a daily basis. Some issues encountered by them include the decision of complying with advance patient requests, the decision of aiding in euthanasia or suicide, the decision of withholding CPR, or of withdrawing or withholding treatments they know are essential for sustaining life. Thirdly, ethical challenges typically surface in the context of palliative care, on account of concerns pertaining to the amount and type of care suitable for patients with not many days left to live. There is, generally, a conflict between doctors, nurses, other healthcare workers, patient family, and the patients themselves in connection with what constitutes proper care, particularly as those who are terminally ill near the end of their life (EOL). Lastly, EOL care is often complex, and can compel patient care providers to make hard decisions including: Whether the patient should be put on life support, how long it should be continued, when life support must be terminated, whether or not to put the patient on a tracheostomy or feeding tube, whether or not CPR must be administered to a patient in palliative care who suffers a heart attack, etc. Frequently, it is the patient's families who make such key decisions, as the patients themselves are unable to do so. One major difficulty palliative care personnel encounter is prognosis uncertainty -- when they must broach the topic of EOL with the patient's family.

Proposed Strategy

In general, handling ethical quandaries in the healthcare setting entails prioritizing patient needs. Usually, however, this may mean granting precedence to the majority's needs over the needs of few. Healthcare leaders who can voice their opinions concerning ethical decisions (be it to team members, an ethical board, patients, or patient families) can handle the emotional challenges associated with ethically tough decisions more effectively (Lennon-Dearing, Lowry, Ross, & Dyer, 2009). Ethical issues form an integral part of clinical practice and healthcare workers cannot escape them. However, in the present day, healthcare executives are required to manage ethical problems by taking a balanced perspective of the situation they face (McClellan, 2013).

Clear Guidelines by leaders

Palliative care leaders and physicians need to define what has to be done, why and when. Nurses, according to a researcher in the field, must not shoulder the burden of such a critical responsibility. Secondly, in the pain management context, a few key potential downsides exist, which need due consideration as pain relievers, such as narcotics that may prove addictive. This, however, will not be of much significance if the patient is approaching EOL stage. On the other hand, when a patient's situation is characterized by continuous, long-term pain, a very different series of considerations are witnessed. The likely concerns and problems go beyond these considerations. For instance, healthcare is, at times, rather segmented. The term 'silo' is widely used in this context. A fine example is that the practices and rules of pain management followed by emergency room and hospice nurses will probably differ. Saving lives is the primary goal of emergency room personnel, and pain management techniques are adopted only if possible. However, in a hospice care setting, pain reduction is usually one of many tissues, which may be considered, since hospice patients' days are numbered. The important thing is that consistency be maintained in the decisions of all nurses practicing at the same healthcare facility and scenario (such as palliative care). Moreover, a facility's medical experts and leaders must keep learning the subtle lessons from examples and teachable moments to demonstrate to staff what was performed well, where shortfalls were observed, and the rationale for these appraisals. Leaving a gap for nurses to fill is a totally bad idea; consistency is reduced, as is the emphasis on attaining ideal patient outcomes, even if it means experiencing pain just prior to dying (Lennon-Dearing, Lowry, Ross & Dyer, 2009).

Adaptation of authentic leadership by Leaders

Authentic leadership is capable of influencing nurses and the nursing profession as well as healthcare delivery structure and the overall society. Developing a positive workplace atmosphere for nurses is critical for ensuring a sufficient number of nurses. Nursing profession's stressful nature frequently results in burnout and, often, high rate of absenteeism, and disability, and eventually promotes the escalation of nurse shortages. Leaders have a critical part to play in retaining nursing staff by influencing the atmosphere of their respective healthcare facilities in order to bring about quality patient and staff outcomes. However, not many guidelines are present that aid in developing and maintaining the key components of a positive workplace ambience. The AACN (American Association of Critical-Care Nurses), in the year 2005, issued a major publication that outlined six standards (true collaboration, skilled communication, proper staffing, good decision-making, authentic leadership, and meaningful recognition) essential for establishing and maintaining positive workplace atmospheres in healthcare delivery organizations. According to the publication, authentic leadership denotes the adhesive required for holding a positive workplace environment together. Authentic leaders' relationships and roles in a good workplace setting are well-defined. A more comprehensive definition of the authentic style of leadership covers the attributes of kindness, authenticity, honesty, consistency, and credibility. One tactic authentic healthcare leaders can employ for fostering a healthy clinical atmosphere is engaging staff in the workplace environment for promoting positive behaviors. Healthcare organizations need to advance a practical guidebook that details how one can become an effective authentic leader. A research plan for further research into the leadership style termed as authentic nursing leadership via collaboration between business and nursing needs to be developed (Shirey, 2006). This would aid in sustaining a better workplace atmosphere for palliative care workers.

Clarity in code of conduct

The nursing ethical code appears to have scant value in the resource allocation context. Therefore, well-defined guidelines must be formulated for palliative care nursing leaders, and must function as a tool in making ethical decisions concerning resource allocation matters and, further, to integrate economically efficient activities, and superior care quality. Leaders have to ascertain that all employees are familiar with the organization's ethical code (Aitamaa et al., 2010).

Proper Education

Education marks a key element. The aspiration to perform more efficiently, be ethically competent, and create a common, powerful foundation for thinking ethically in overall nursing management and practice is of utmost import. Extensive discourse in connection with healthcare-related values is also required, which has to be held at the organizational as well as societal level. Nurse leader participation in this discourse is imperative. They should be allowed to voice their opinions for solutions that serve themselves, organizational stakeholders, the nurses working under their wing, and society. This is very vital, particularly in scenarios wherein healthcare resources and structures are reassessed owing to societal transformations (Aitamaa et al., 2010).

Conclusion

Most of the work carried out by my coworkers, collaborators, and me, revolves around reforms to healthcare policy and private sector, as well as private-public collaborations for supporting patients and healthcare providers in improved care delivery. As a senior palliative-care nurse leader, I head numerous endeavors connected with bettering healthcare value and innovation. My focus is surmounting the practical barriers encountered in the implementation of quality measures, followed by applying them for care improvement. Formerly, I supervised the application of several reforms concerned with quality, including providers' quality reporting and experience of patient for reducing general realty rate (McClellan, 2013).

In recent times, however, tremendous progress has been made in regards to supporting superior quality care. Medicare has built on Congressional support and bipartisan rules, and instituted systems for care quality reporting for healthcare providers. Never-before-seen activity surrounds quality measure development, owing to public support, private agencies such as the National Committee for Quality Assurance, the Physician Consortium for Performance Improvement of the American Medical Association, and AHRQ (Agency for Healthcare Research and Quality) and CMS (Centers for Medicare and Medicaid Services) initiatives. Significant steps have been taken by the NQF (National Quality Forum), including facilitating prioritization of implementation and development measures and, in particular, ratifying quality measures for supporting consistent application of well-understood, significant measures (McClellan, 2013).

Currently, several different quality improvement programs are underway at local, state, regional, and federal levels of America's healthcare structure, as well as within hospitals and other healthcare facilities, which are applying quality measures. Quality improvement programs across and within healthcare facilities are central in this regard. They necessitate measurement for identifying opportunities to improve, usually by means of registries enabling providers to track and evaluate how patients fare concerning core care components and likely complications for identifying areas to improve. Further, quality measures are being employed in the context of payment reforms as well, which may help healthcare professionals receive more resources for taking steps in the form of establishing registries and putting other changes into practice in patient care delivery, for avoiding needless expenses and improving care. As an example, fee-for-service Medicaid, Medicare, and private sector payments have, in the past, offered little financial assistance for a number of activities that may possibly lower costs and enhance patient care. Examples include: answering patient emails or phone calls for avoiding the time and cost associated with a visit to the office; devoting time to implement care coordination systems for avoiding inappropriate or duplication of services; and devoting more time to complex patients (or establishing a patient care team comprising of non-physician healthcare workers, nurse practitioner, and pharmacist) for improving adherence to medication, lifestyle modifications, or other steps in care management that may allow disease prevention or progressing of patients' health risks. Medicaid, Medicare, private payers, and employers, all agree to a series of reforms in payment for offering enhanced support for these types of activities, often in combination with quality measure application. Lastly, an increasing adoption of quality measures is witnessed in the area of public reporting, because of national Medicare-supported efforts and remarkable regional efforts, like Minnesota Community Measurement, Puget Sound Health Alliance, Pittsburgh Regional Health Initiative, Wisconsin Collaborative for Healthcare Quality, etc. (McClellan, 2013).

USA's healthcare structure still needs to do a lot of work in the area of quality measurement. A number of key, current quality measures have not been implemented reliably or extensively. The health system of USA lacks sound, reliable, extensive quality measures concerning numerous important healthcare elements, like patient care experiences, or outcome-related measures, such as how effectively they can work, function, and carry out everyday activities. Lastly, the nation also lacks consistent, reliable information on care costs and price; all the aforementioned issues have been in existence for quite some time (McClellan, 2013).