Overcoming Ethical Barriers to Improved EOL Patient Outcomes

Ethics in EOL Decisions

Finding Common Ground in EOL Care Decisions

Churchill (2014) presents to readers a case study to highlight some of the ethical and moral issues that will occur during end-of-life (EOL) decisions. The case study is not a factual event, but represents the mean severity and complexity of the EOL struggles experienced by the typical stakeholders. In this example, the treating physician has unsuccessfully tried to convince the adult daughter that her father will never recover from a coma and would benefit the most by palliative care, while the daughter refused to give up on the hope that her father would recover. Churchill (2014) spent time with clinicians and family member to try and understand their perspectives, thereby fulfilling his duties as a clinical ethics consultant. He discovers the patient has a living will and durable power of attorney, which prevented the use life-sustaining interventions in circumstances just like this; however, the patient was suffering from progressed Alzheimer's when the forms were signed, thereby limiting the validity of the documents. The surrogate named in the power of attorney likewise could no longer fulfill their role. A compromise was eventually reached and the patient received a percutaneous feeding tube and was transferred to a long-term acute care facility.

The message Churchill (2014) was trying to communicate is that EOL decisions typically involve multiple narratives. In the example he presents, individual narratives are provided by the daughter, the clinicians responsible for the care of the patient, the living will/durable power of attorney, and from Churchill himself as an experienced ethics consultant. When the goal is providing the best patient outcome from the perspective of the patient, Churchill (2014) recommends avoiding the trap of believing ethics consultants will know what is best for the patient and family members, both clinically and ethically. Instead, a successful ethical consultation is one which helps the stakeholders understand their own narratives at a deeper level and communicate better with each other. If successful, the consultation will provide an imperfect, but effective mechanism for making difficult EOL decisions in most situations. Churchill (2014) also cautions readers to avoid the other trap of mistaking decisiveness with being definitive.

The effectiveness of increasing communications between EOL decision-making stakeholders was revealed in a study by Shuman and colleagues (2013). They examined 208 oncology cases retrospectively where the family or clinicians requested an ethics consultation. Physicians were most likely to request a consult (61%), followed by physician assistants and nurse practitioners (13%). Nurses (9%), physicians in training (4%), family members (2%), and social workers (1%) also made requests for ethics consults. The main events triggering a request were a change in code status and advanced directives (25%), followed by family members facing an EOL decision (17%) and medical futility (13%). Communication failures and interpersonal conflict were identified in nearly half of all cases (45% and 51%, respectively). The most common conflicts were between clinicians and family members, followed by between family members, between clinicians and patients, and between critical care team members. Importantly, ethics consultations doubled the number of patients who received a palliative care consultation and nearly tripled the number of do not resuscitate (DNR) orders. Ethics consultations also increased the number of other services being made available to patients and family members, including social workers, medical specialists, pastors, psychiatrists, and attorneys. Based on these findings, it would seem that ethical consultations are an effective way to improve EOL care outcomes for all stakeholders.

In reality, ethical consultations are rarely requested (

Discussion

The ethics involved in EOL decisions depend on the willingness of stakeholders to share their personal and professional narratives with each others. This implies that most stakeholders are primarily concerned with the patient's welfare, including the desire to minimize unnecessary suffering. Despite the good intentions of most stakeholders, however, the EOL decision-making process can often be derailed due to trust issues and communication failures. These barriers can be overcome to a significant extent with the use of ethical consultants and/or and onsite palliative care consultation team, thereby improving patient and family member outcomes.

HANDOUT: Finding Common Ground in EOL Care Decisions

Making EOL decisions is often a messy and imperfect process, but finding common ground among all stakeholders is critical for optimizing care outcomes for everyone involved, especially the patient. Although rarely used, experienced clinical ethics consultants are able to overcome communications failures between stakeholders, thereby improving patient outcomes. What follows is a concise overview of the issues that can arise during EOL decision making and how these barriers to EOL care decisions can be minimized.