Ethical dilemmas and team strategies in palliative care

Ethical Analysis: Strategy for Palliative Care

The alternatives that are available today to take care of dying patients are numerous. These alternatives have increased as technology has evolved. Ethical dilemmas arise when one is faced with the decision of the best possible care for a patient who is dying. One of these decisions is on sustaining a patient's life through machines or terminating it through the switching off of the life supporting machines. These are decisions that create ethical dilemmas for all who are involved. Unlike in the past, when death could easily be defined as the cessation of life, today, things are different. This is because in today's world, there exist machines that can sustain the functions of various organs such as the lungs and this leads the definition of death to be more complex. Thus as Shaughnessy (2004) says, in the twentieth century a new patient has emerged whose heart and lungs are alive but the brain is essentially dead as it does not function. Technologies such as the cardiopulmonary resuscitation (CPR) have made this possible where a patient whose heart and lungs have ceased to work, but are restarted using machines. This care of dying patients as well as the ethical dilemmas imposed lead many healthcare workers to burnout because of the emotional exertion, the physical as well as psychological demands made on them. Periera, et.al, (2011) state that this suffering is as a result of facing death everyday by the palliative care workers. Some of the issues that confront these workers are the decision to comply with the advance requests of patients, the decision to assist in suicide or euthanasia, the decision to withhold or withdraw treatments that one knows are necessary to sustain life, the decision to withhold resuscitation techniques.

Intraprofessional Team to Formulate Strategies

Palliative care delivery is difficult and often requires a whole team; the team includes medical and nursing staff, physiotherapist, social worker, and spiritual caregiver. Communication and coordination of a team is very important and during meetings of the team, detailed information should be shared and every member should be on the same page. A stronger team requires common understanding and ideal of the contribution and the role of the team that each member makes to achieve successful results (Spruyt, 2011). Inadequate communication, interpersonal conflict, role overload, role ambiguity and conflict issues are some of the challenges within the team. This can be due to external or internal issues, corporate issues or stresses. As the team grows larger in lobby groups, alliances and subgroups, several agendas come up, which distract the team from its actual purpose (Crawford & Price, 2003).

Application of Ethical Standards

Through technological developments new ethical dilemmas have emerged. The patients, health workers, and families must now make decisions on whether to adopt procedures that will prolong the life of the patient, even though not curing them, or not. Some of these techniques to prolong life may also prolong the suffering of the patient and by extension the family and caregivers involved. There are principles that can guide those involved in making a decision that would be agreeable and morally right.

Hinshaw (2008) highlights four of these principles as the modern principles of autonomy and justice as well as the Hippocratic principles of non-malfeasance and beneficence. All who are involved in patient care must have adequate knowledge so that their care is preemptive and accommodates the inclinations of the patient. It can be a difficult thing to be truthful to patients in cases of terminal illness or advanced stages of cancer. Sometimes informed consent must be sought from the families of patients who are not in a conducive mental state for this. Thus a family caregiver will be in communication with the palliative care team so that during the patient's final stages, their dignity is preserved and confidentiality is maintained. In this case, the communication will serve two purposes as far as ethics is concerned. Mohanti (2009), states that one of these is to clarify what a good death would be and the other is try and resolve the needs of the patient and his/her family which are mostly in conflict.

Pain is a present factor in many terminal illnesses including cancer in its advanced stages. It causes the patient discomfort and agitation and is difficult to bear for their families. In palliative care, it is relieved through the scientific principles of the analgesic ladder. However much as it is an ethical duty to relieve pain, it has not been given priority in medical care. Mohanti (2009) explains the reasons for this as inadequacy of skills and knowledge to evaluate pain, poor medication, lack of morphine, and myths surrounding opioid addictions and sedation.

The World Health Organization has made efforts to improve these situations especially in palliative care. These efforts by WHO and other bodies has caused the relief of pain to be designated an ethical duty of medicine and made it the responsibility of society to avail morphine. Pain should actually be viewed as a public health crisis for ethical reasons and this will ensure that measures are put into place to give it priority. The palliative care principles and the preferences of the patients should try as much as possible to be balanced. Autonomy of the patient through the receiving of his or his family's consent should be encouraged. Through this numerous tests, prolonged hospitalization, and unnecessary procedures can be avoided. Many nations around the world have incorporated the DNR (do not resuscitate) policy into their palliative care (Mohanti, 2009).

Palliative care strategies

Baker, et.al, (2008) proposes various strategies when dealing with ethics in palliative care. One of these is the formation of ethics committees whose input is imperative when conflicts arise in resolving complex situations with regard to patients, the communication required with their families and healthcare providers and all the ethical issues arising from this.

Another strategy proposed by Baker, et.al, (2008) is that where pediatric oncology programs foster partnerships with health and hospice agencies so that the patient receives the palliative care that is better as a result of the partnership than it would have been without it.

Another strategy is by combating the fragmentation of care through coordinating the care process so that there is adequate communication and collaboration between health care providers as the disease progresses. This will ensure that the quality of life of the patient is improved while the healthcare is provided (Baker et.al, 2008).

Another strategy is to have a symptom control process (Baker et.al, 2008). This is the process by which attention is given, right from the point of diagnosis, to expected and unexpected symptoms with the aim of incorporating palliative care with oncology programs.

Lastly Baker et.al, (2008) state that special attention needs to be given to the patient's preferences as well as those of their families. The patient and their family's preferences and priorities are bound to change as the condition changes or the treatment is altered.

Team Member Conflict

Legal elements as well as human rights offer protection of rights that permit not only equal participation but also individual fairness in any functional society. This implies that individual life, health, freedom and property are protected by law. In this century, healthcare rights are well documented, including delivery of fundamental clinical services and an society that permits optimum and thriving health. Within this framework, a patient with terminal illness might seek to commit suicide assisted by a physician. This phenomenon is referred to as Euthanasia and this practice has been authorized by law in a few countries including Holland, Belgium, some states within the U.S. along with Australia). Nonetheless, euthanasia raises moral issues in palliative care. Since the staff is not trained for this act, stress and conflict tends to arise in such situations (Mohanti, 2009). The Physician in the team was against using euthanasia, while the rest of the team had no issue with it, in the palliative strategy because of several reasons he presented to the team; (1) he stated that euthanasia is wrong in its pure essence, violates professional integrity while also endangers the relationship between the patient and the physician; (2) this sends mixed messages to the public who are already misinformed about the issue; (3) it is a source of distress for both the family of the patient and the patient itself; (4) it is also a source of moral and emotional stress for the staff members; (5) and it places the entire team on the position of a gatekeeper between the family who disagrees with using euthanasia and the patient who wants to end his life through assisted suicide (Bigler, Jean-Michel, et al., 2006).

Conclusion

In cases of terminal illnesses or advanced stages of cancer, palliative care is required. Ethics must be adhered to when dealing with pain, controlling symptoms, giving psychosocial attention and even dealing with end of life. Modern and Hippocratic principles of justice, autonomy, beneficence and non-malfeasance must be the guide in this care. It is the responsibility of the healthcare providers to ensure dignity and honesty is maintained. Accessing relief from pain through alternatives such as morphine is a human right. Palliative care can be improved through studies and research. Ethics and palliative care should go hand-in-hand and in this way the patient can be well taken care of as well as ease the mind of his family (Mohanti, 2009).

H. no. 7, Bl. No. 3, New Island, Washington D.C.

Ted Williams

Minister for Health

Downing House

Downing Street

Washington D.C.

27th November, 2015

Dear Minister,

I am writing to express my disappointment over the Palliative Team organized this year to form out strategies to carry out ethical measurements during end of life care. Several strategies were formed, which were accepted by the team members, however, at one point, the physician in the team, Dr. Robert Blank, proposed his opposition for Euthanasia. Dr. Blank presented a detailed presentation on his opposition for Euthanasia, and I would like to present some factual information that clearly describes the use of Euthanasia in Palliative care as positive and useful.

Possible Negative Consequences of Excluding Assisted Suicide

Considering the negative outcomes of not allowing euthanasia is important;

(1) Providing care to the patients who request euthanasia would become difficult if it is not allowed. The units would prevent the patients from getting admitted and receiving the care that would basically result in changing the decision of the patient. These patients would have to be transferred to other units time and again, which would be equal to abandonment. The families and the patients might feel that they are a burden to the healthcare facility (Bigler, Jean-Michel, et al., 2006).

(2) Allowing a person who is terminally ill, to end their life is a compassionate, rational and humane choice as they continue to suffer endlessly against their wish. The right to private life gives a choice to every person to end their life when they cannot suffer any further (Chand, 2009).

(3) Several arguments have come in place that euthanasia shortens life, but according to a Dutch report in 1991, it was found out in eighty six percent of the cases that the life of the patients who opted for euthanasia was only shortened by maximum of a week or a few hours. It was their last escape from pain that was unbearable (Morris, 2013).

(4) Many doctors end the lives of their patients one way or the other without telling them. In a 2012 study in Britain, it was discovered that fifty seven thousand patients die every year without being informed that efforts to keep them alive are not being carried out anymore (Morris, 2013).

(5) When you look at it economically, euthanasia helps the patient and his family in the economic sense. According to CNN, the families have been swallowed under debts because, one in every four Medicare money that is spent, goes to the beneficiaries and forty percent of the families exceed their bills (Morris, 2013).

(6) The Hippocratic Oath itself means that a patient should not be kept alive artificially when death is preferable and there is more harm in allowing him to suffer and die from suffering (Morris, 2013).

In order for a team to work effectively and properly, it requires good communication and networking so there is a larger benefit, and a serious case like this needs a strong team. The facts presented clearly state the need for Euthanasia, however, in order to resolve the conflict between the team, I as one of the leader of the team, would like you to assist in the negotiations between the team members and Dr. Blank, so that the conflicts can be resolved and the strategies can be carried out without any further delay.

Looking forward to hear from you

Yours sincerely,

Dr. Wood Green