E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium

1. E L N E C Geriatric CurriculumEnd-of-Life Nursing Education Consortium Session 6 Ethical Issues in Palliative Care Nursing Fairfield University Quinnipiac University School of Nursing ELDER Project

2. Objectives • Discuss ethical issues that may arise in end-of-life/palliative care. • Describe the role of the palliative care team in ethical decision-making. • Identify the 4 ethical principles for evaluating issues.

3. Responding to Ethical Issues in Palliative Care • Changes in social/family systems have added to the complexity of end-of-life/palliative care • Landmark cases influence legal/ethical history • Palliative care team help patients make fully informed decisions

4. Landmark case • Remember Terri Schiavo?

5. Landmark Case:Terri Schiavo Born December 3, 1963Died March 31, 2005 (age 41) • Terri Schiavocollapsed in her St. Petersburg, Florida home in full cardiac arrest on February 25, 1990. She suffered massive brain damage and, after two and a half months in a coma, her diagnosis was elevated to vegetative state. For the next few years doctors attempted physical therapy and other experimental therapy, hoping to return Terri to a state of awareness. • In 1998 Schiavo's husband, Michael, petitioned the Sixth Circuit Court of Florida (Pinellas County), to remove her feeding tube pursuant to Florida Statutes Section 765.401(3).[1] He was opposed by Terri's parents, Robert and Mary Schindler, who argued that she was conscious. The court determined that she would not wish to continue life-prolonging measures,[2] and on April 24, 2001 Terri's feeding tube was removed for the first time, only to be reinserted several days later. • On February 25, 2005, a Pinellas County judge ordered the removal of Terri Schiavo's feeding tube. Several appeals and federal government intervention followed, which included U.S. PresidentGeorge W. Bush returning to Washington D.C. to sign legislation designed to keep her alive. After all attempts at appeals through the federal court system upheld the original decision to remove the feeding tube, staff at the Pinellas Park hospice facility where Terri was being cared for disconnected the feeding tube on March 18, 2005 and she died on March 31. • http://en.wikipedia.org/wiki/Terri_Schiavo_case

6. Ethical Principles • Autonomy • Beneficence • Nonmaleficence • Justice

7. Ethical Principles

8. Ethical Issues in Palliative Care • Prolongation of life: balancing benefits and burdens • Withholding/withdrawing medical interventions • DNR

9. Ethical Issues in Palliative Care-artificial feeding • D.W. is an 82-year-old widowed retired secretary with advanced dementia. She is cared for in the home of her married daughter, who is her power of attorney for health affairs. She requires assistance in all her domestic activities of bathing, feeding, toileting, ambulation, etc. She spends most of the day in bed, or lying on the sofa. She speaks very little, and not very intelligibly. • She has recently stopped eating almost everything. She bites the spoon when it is brought to her mouth and/or pockets food in her cheeks without swallowing. She was admitted to the hospital several months ago for the treatment of aspiration pneumonia. • The possibility of a feeding tube has been raised.

10. Mr. E.: Discussing Life-Sustaining Treatments- DNR? • Mr. E is a 68 year-old truck driver with advanced COPD and CHF who was recently diagnosed with esophageal cancer. Despite surgical resection and combination chemotherapy and radiotherapy, the disease has progressed. • He is admitted for shortness of breath. He is on BIPAP. Recent studies have demonstrated malignant pleural effusion and liver metastases. He knows these results. Life-sustaining treatments (LST) will need to be discussed with him.

11. Case Study - What do you think? • Mr. Butler is a hospice patient living in an adult living facility. He has a living will expressing his desire to not have any further emergency interventions. • The patient experiences a medical crisis and the staff calls the Emergency Response System. The patient is transported to the hospital emergency room and treated.

12. Ethical Issues in Palliative Care • Medical futility • Assisted suicide • Euthanasia

13. Wired for Life

14. Preventive Ethics • Palliative care team should focus efforts on preventing the occurrence of conflicts • Early identification of issues • Knowledge of the natural history of many illnesses

15. Preventive Ethics (cont.) • Understanding of patient/family wishes • Cultural and spiritual assessment • Communication skills

16. Case study • Mrs. Rose is a hospice patient in the nursing home. She has gangrene of her foot. Surgical removal of the foot was recommended to treat the gangrenous infection. • Mrs. Rose does not want the surgery. She would prefer to just "let it go." • The nursing home is concerned about surveyors coming in with a patient that has an "untreated infection" and is trying to convince Mrs. Rose to have the surgery.

17. Question 1 • An 84-year-old widow with diabetes and end-stage kidney disease has been sent to the hospital from a nursing home. She has gangrene of the left foot. Surgery is recommended but the client is refusing. She wants to go back to the nursing home. She is alert, oriented, and has good judgment. However, her children say, “We want to do everything that can be done and we want her to have the surgery.” What should the healthcare worker do first? • Make sure the client and family understand the treatment options and risks. • Ask the hospital ethics committee to consider this case as soon as possible. • Offer to discuss the children’s preferences with the doctors. • Encourage the children to talk their mother into having the surgery.

18. Question 2 • The hospice team is caring for a dying patient whose family disagrees with the patient’s decisions about end-of-life care. Which of the following actions should the team take first? • Present the case to the agency’s ethics committee for a resolution. • Ask the healthcare team to make decisions regarding end-of-life care. • Initiate a referral to social services and request a home visit. • Encourage the family and client to discuss the conflict.

19. Question 3 • Which of the following statements most accurately describes the healthcare team’s role in addressing ethical issues in palliative care? • Consider client decisions according to the health care workers own values and beliefs. • Help the client/family understand all options and their consequences. • Refer client care ethical issues to ethics experts within the health care system. • Determine when clients are no longer competent to make their own decisions.

20. Question 4 • The healthcare team can contribute to ethical practice in end-of-life care by doing all of the following Except: • Working closely with doctors to meet the needs of patients and their families. • Ensuring that clients/families are aware of treatment options and consequences of those options. • Participate in creating systems of care that specifically meet end-of-life needs for clients/families. • Using personal values and morals to determine best courses of actions for clients/families.

21. Question 5 • The palliative care team is caring for a man hospitalized with advanced cancer. He has refused further treatment, and he is aware that he may die sooner. The client is considered to have good judgment. Who should make the decision to end treatment, and what ethical principle applies? • The client refuses treatment for himself based on the right to self-determination. • The doctor decides to withdraw treatment based on the principle of medical futility. • The family declines further treatment, based on their option to claim surrogacy or proxy. • The executive board determines the patient’s competence based on hospital policies.

23. References City of Hope & the American Association of Colleges of Nursing, 2007; Revised, 2010. TheEnd-of-Life Nursing Education Consortium (ELNEC)- Geriatric Training Program and Curriculum is a project of the City of Hope (Betty R. Ferrell, PhD, FAAN, Principal Investigator) in collaboration with the American Association of Colleges of Nursing (Pam Malloy, RN, MN, OCN, Co-Investigator). “Supported by DHHS/HRSA/BHPR/Division of Nursing Grant # D62HP06858”