Navigating Difficult Decisions: End of Life Nutrition

1. Navigating Difficult Decisions: End of Life Nutrition Marilyn Graves, MSN, RN, CHPN Gilchrist Hospice Care

2. Navigating Difficult Decisions: End of Life Nutrition End of life care involves many different kinds of courageous conversations. One of these conversations may center on nutrition- tube/enteral feeding or not or IV/parenteral feeding or not. This session will examine some of these challenges and offer ways to navigate the issue with positive outcomes for patients and families.

3. OBJECTIVES At the completion of this session, the participant will be able to: Define the philosophy and principles of hospice and palliative care that can be integrated across settings to effect quality care at the end of life. Identify common symptoms that are experienced at the end-of-life. Discuss the concepts of burden versus benefit in nutritional goals in end of life care.

4. Gilchrist Hospice Care Largest hospice in the state of Maryland A not-for-profit organization An affiliate of GBMC Healthcare Hospice of Baltimore serves clients in Baltimore, Harford, Howard Counties Parts of Carroll County and Pennsylvania Baltimore City

5. What is Hospice Care? A special way of caring for patients at end of life Focus of care is the patient and family Focus on comfort care, not aggressive treatment Goal is peaceful, comfortable, pain free end of life

6. �What is Hospice Care? Hospice: Views death as a natural part of life Does not hasten death nor prolong life Provides spiritual and emotional care for the patient and family Continues to care for the family after the death through bereavement services

7. What Does Hospice Do? Supports the patient�s dignity Encourages patients to remain as independent as possible Encourages patients to remain in control of their lives Involves patients and families in every decision

8. Hospice Medicare Benefit Eligibility Criteria: The patient�s doctor and the hospice medical director use their best clinical judgment to certify that the patient is terminally ill with life expectancy of six months or less, if the disease runs its normal course The patient chooses to receive hospice care rather than curative treatments for his/her illness The patient enrolls in a Medicare-approved hospice program http://www.nhpco.org

9. Symptoms and Suffering Symptoms create suffering and distress Psychosocial intervention is key to complement pharmacologic strategies Need for interdisciplinary care Similar to pain, other physical and psychological symptoms create suffering and distress. Psychosocial intervention is key to complement pharmacologic strategies. � Use of chaplains, social workers and psychologists are necessary to address suffering. For the purposes of this presentation, I will focus on nutritional related symptoms. Similar to pain, other physical and psychological symptoms create suffering and distress. Psychosocial intervention is key to complement pharmacologic strategies. � Use of chaplains, social workers and psychologists are necessary to address suffering. For the purposes of this presentation, I will focus on nutritional related symptoms.

10. Anorexia and Cachexia Anorexia - loss of appetite, usually with decreased intake Cachexia - lack of nutrition and wasting Kemp, 2006 �������� Anorexia and cachexia are commonly found in advanced disease and palliative care services must be prepared for these symptoms. � �������� Anorexia is: ؠ���� A loss of desire to eat or a loss of appetite associated with a decrease in food intake (Kemp, 2006). � �������� Cachexia is: ؠ���� A general lack of nutrition and wasting occurring in the course of a chronic disease. ؠ���� A result of metabolic abnormalities. ؠ���� Increases distress, impacts negatively on self-concept and body imagine, is associated with decreased survival, and serves as a constant reminder of the disease process and impending death. ؠ���� Etiology is rarely reversible in advanced disease. � �������� Weight loss is present in both conditions. Decreased appetite can occur very early in some diseases. In some institutions the leading referral to palliative care consulting teams is related to the issues surrounding nutrition. Unfortunately aggressive nutritional treatment does not improve survival or quality of life and may actually create more discomfort for the patient. Artificial nutrition is a medical procedure requiring serious consideration as it can incur significant morbidity and financial cost. Artificial nutrition can lead to nausea, vomiting, or diarrhea. This therapy can sometimes provide a false sense of hope to the patient/family, that this therapy will allow them to �get better.� Caring for the patient and family as they deal with the real and symbolic meaning attributed to feeding, requires much reassurance and support. �������� Anorexia and cachexia are commonly found in advanced disease and palliative care services must be prepared for these symptoms. � �������� Anorexia is: ؠ���� A loss of desire to eat or a loss of appetite associated with a decrease in food intake (Kemp, 2006). � �������� Cachexia is: ؠ���� A general lack of nutrition and wasting occurring in the course of a chronic disease. ؠ���� A result of metabolic abnormalities. ؠ���� Increases distress, impacts negatively on self-concept and body imagine, is associated with decreased survival, and serves as a constant reminder of the disease process and impending death. ؠ���� Etiology is rarely reversible in advanced disease. � �������� Weight loss is present in both conditions. Decreased appetite can occur very early in some diseases. In some institutions the leading referral to palliative care consulting teams is related to the issues surrounding nutrition. Unfortunately aggressive nutritional treatment does not improve survival or quality of life and may actually create more discomfort for the patient. Artificial nutrition is a medical procedure requiring serious consideration as it can incur significant morbidity and financial cost. Artificial nutrition can lead to nausea, vomiting, or diarrhea. This therapy can sometimes provide a false sense of hope to the patient/family, that this therapy will allow them to �get better.� Caring for the patient and family as they deal with the real and symbolic meaning attributed to feeding, requires much reassurance and support.

11. Causes of Anorexia and Cachexia Disease related Psychological Treatment related Bistrian, 1999; Fainsinger & Periera, 2004; Meyer et al., 2003 �������� There are multiple causes of anorexia/cachexia in terminally ill patients including: ؠ���� Disease related: w������� Oral or systemic infection, such as candidiasis, may cause discomfort when eating. w������� Pain associated with eating can occur in certain disease states, such as pancreatitis. w������� Chronic nausea and vomiting can be caused by treatment, medications, or disease progression. w������� Constipation may be caused by medications, decreased fluid intake, and inactivity. w������� Metabolic alterations may be due in a large part to systemic inflammatory response and the stimulation of cytokine production (Bistrian, 1999). w������� Delayed gastric emptying and ulcers may decrease a person�s desire to consume food. w������� Diarrhea causes increased weakness and food intake may worsen the symptom. w������� Malabsorption may be a result of medications or disease process. w������� Bowel obstruction may be a result of tumor/disease process. w������� Raised intracranial pressure can be a frequent cause of chronic nausea in terminal illness (Fainsinger & Periera, 2004). ؠ���� Psychological: w������� Depression exhibits many somatic symptoms which includes anorexia (Meyer et al., 2003). ؠ���� Treatment related: w������� Taste changes are often a result of treatments such as chemotherapy. Radiation therapy effects, including bowel strictures and fistulas, can be problematic for patients long after radiation has been completed. �������� There are multiple causes of anorexia/cachexia in terminally ill patients including: ؠ���� Disease related: w������� Oral or systemic infection, such as candidiasis, may cause discomfort when eating. w������� Pain associated with eating can occur in certain disease states, such as pancreatitis. w������� Chronic nausea and vomiting can be caused by treatment, medications, or disease progression. w������� Constipation may be caused by medications, decreased fluid intake, and inactivity. w������� Metabolic alterations may be due in a large part to systemic inflammatory response and the stimulation of cytokine production (Bistrian, 1999). w������� Delayed gastric emptying and ulcers may decrease a person�s desire to consume food. w������� Diarrhea causes increased weakness and food intake may worsen the symptom. w������� Malabsorption may be a result of medications or disease process. w������� Bowel obstruction may be a result of tumor/disease process. w������� Raised intracranial pressure can be a frequent cause of chronic nausea in terminal illness (Fainsinger & Periera, 2004). ؠ���� Psychological: w������� Depression exhibits many somatic symptoms which includes anorexia (Meyer et al., 2003). ؠ���� Treatment related: w������� Taste changes are often a result of treatments such as chemotherapy. Radiation therapy effects, including bowel strictures and fistulas, can be problematic for patients long after radiation has been completed.

12. Assessment of Anorexia and Cachexia Physical findings Impact on function and QOL Calorie counts/daily weights Lab tests Skin breakdown Kemp, 2006 �������� Proper assessment of anorexia and cachexia is vital (Kemp, 2006). � �������� Physical findings � Physical exam includes assessment of weight loss, muscle wasting, gastric stasis, loss of strength and decreased fat. Note that edema may mask some wasting � �������� Impact on function ؠ���� Evaluate if there is an increase in weakness and/or fatigue. ؠ���� Evaluate for signs and symptoms related to depression or confusion. � �������� Impact on self/family � Discuss the patient�s/family�s perception of and response to this symptom and on quality of life. � �������� Calorie counts/daily weights ؠ���� Evaluate if the patient has experienced decreased food/fluid intake. ؠ���� A calorie count is of value along with daily weights. ؠ���� The use of these assessments will need to be continuously evaluated as late in disease they may be unnecessary and may create burden and distress. � �������� Laboratory tests � Serum albumin concentration decreases as nutrition status decreases; however, this laboratory value is a last marker. Hence, if low albumin is noted, this problem has existed at least 2 to 3 weeks. � �������� Pain that is associated with eating. � �������� The risk or presence of skin breakdown. � Suggested Supplemental Teaching Materials: Table 14: Anorexia Assessment �������� Proper assessment of anorexia and cachexia is vital (Kemp, 2006). � �������� Physical findings � Physical exam includes assessment of weight loss, muscle wasting, gastric stasis, loss of strength and decreased fat. Note that edema may mask some wasting � �������� Impact on function ؠ���� Evaluate if there is an increase in weakness and/or fatigue. ؠ���� Evaluate for signs and symptoms related to depression or confusion. � �������� Impact on self/family � Discuss the patient�s/family�s perception of and response to this symptom and on quality of life. � �������� Calorie counts/daily weights ؠ���� Evaluate if the patient has experienced decreased food/fluid intake. ؠ���� A calorie count is of value along with daily weights. ؠ���� The use of these assessments will need to be continuously evaluated as late in disease they may be unnecessary and may create burden and distress. � �������� Laboratory tests � Serum albumin concentration decreases as nutrition status decreases; however, this laboratory value is a last marker. Hence, if low albumin is noted, this problem has existed at least 2 to 3 weeks. � �������� Pain that is associated with eating. � �������� The risk or presence of skin breakdown. � Suggested Supplemental Teaching Materials: Table 14: Anorexia Assessment

13. Treatment of Anorexia and Cachexia Dietary consultation Medications Parenteral/enteral nutrition Odor control Counseling Earthman, 2002; Kemp, 2006; MacDonald, 2003 �������� Interventions regarding anorexia and cachexia must be individualized. Eating for pleasure should always be the goal. Referrals to a dietician may be appropriate. � �������� Patients should be encouraged to: ؠ���� Eat favorite foods. ؠ���� Dietary restrictions should be eliminated. ؠ���� High calorie foods, in small frequent meals, may improve intake. ؠ���� Food presentation is important - small quantity; small frequent meals. � �������� Medications ؠ���� Appetite stimulants, particularly megestrol acetate ؠ���� Olanzapine or mirtazapine may be helpful in increasing intake. ؠ���� Prokinetics (e.g., metoclopramide) may be helpful in increasing gastric emptying. ؠ���� Other agents may prove useful such as alcohol (e.g., wine before mealtime), dronabinol, corticosteroids, thalidomide, ARP (adenosine triphosphate), EPA (omega 3 fatty acids), TNF inhibitor (tumor necrosis factor inhibitor) or oxandralone (Earthman et al., 2002; MacDonald, 2003). � �������� Parenteral or enteral nutrition � In some cases parenteral or enteral nutrition may prove useful in patients who cannot swallow but continue to have an appetite, such as in esophageal cancer. � �������� Problem odors that inhibit eating can be addressed by separating cooking times from eating times or moving the patient away from the kitchen. � �������� Counseling Overall the problem of cachexia may prove to be one of the most distressing symptoms for patients and families. Constant evaluation is appropriate with support and guidance regarding this symptom. �������� Interventions regarding anorexia and cachexia must be individualized. Eating for pleasure should always be the goal. Referrals to a dietician may be appropriate. � �������� Patients should be encouraged to: ؠ���� Eat favorite foods. ؠ���� Dietary restrictions should be eliminated. ؠ���� High calorie foods, in small frequent meals, may improve intake. ؠ���� Food presentation is important - small quantity; small frequent meals. � �������� Medications ؠ���� Appetite stimulants, particularly megestrol acetate ؠ���� Olanzapine or mirtazapine may be helpful in increasing intake. ؠ���� Prokinetics (e.g., metoclopramide) may be helpful in increasing gastric emptying. ؠ���� Other agents may prove useful such as alcohol (e.g., wine before mealtime), dronabinol, corticosteroids, thalidomide, ARP (adenosine triphosphate), EPA (omega 3 fatty acids), TNF inhibitor (tumor necrosis factor inhibitor) or oxandralone (Earthman et al., 2002; MacDonald, 2003). � �������� Parenteral or enteral nutrition � In some cases parenteral or enteral nutrition may prove useful in patients who cannot swallow but continue to have an appetite, such as in esophageal cancer. � �������� Problem odors that inhibit eating can be addressed by separating cooking times from eating times or moving the patient away from the kitchen. � �������� Counseling Overall the problem of cachexia may prove to be one of the most distressing symptoms for patients and families. Constant evaluation is appropriate with support and guidance regarding this symptom.

14. Nausea and Vomiting Common in advanced disease Assessment of etiology is important Acute, anticipatory or delayed Mannix, 1998 � �������� The incidence of nausea is quite common in advanced disease; occurring in up to 70 percent of terminally ill patients (Mannix, 2004). Vomiting occurs in approximately 30 percent of patients; but unfortunately, this symptom has not been well-researched in those with advanced disease. � �������� The pathophysiology of nausea and vomiting is extremely complex, requiring careful assessment of etiology, and therefore, appropriate treatment. ؠ���� Nausea/vomiting can be acute, anticipatory or delayed. ؠ���� Nausea and vomiting can be exceptionally frustrating, painful and exhausting for the patient and family/caregivers. These symptoms clearly increase suffering and require immediate intervention in insuring patient comfort (Glare et al., 2004). � �������� The incidence of nausea is quite common in advanced disease; occurring in up to 70 percent of terminally ill patients (Mannix, 2004). Vomiting occurs in approximately 30 percent of patients; but unfortunately, this symptom has not been well-researched in those with advanced disease. � �������� The pathophysiology of nausea and vomiting is extremely complex, requiring careful assessment of etiology, and therefore, appropriate treatment. ؠ���� Nausea/vomiting can be acute, anticipatory or delayed. ؠ���� Nausea and vomiting can be exceptionally frustrating, painful and exhausting for the patient and family/caregivers. These symptoms clearly increase suffering and require immediate intervention in insuring patient comfort (Glare et al., 2004).

15. Causes of Nausea and Vomiting Physiological (GI, metabolic, CNS) Psychological Disease related Treatment related Other �������� There are numerous causes of nausea and vomiting in the terminally ill. � �������� Physiological: ؠ���� Gastrointestinal causes � The following causes of nausea and vomiting include gastric irritation and stasis, constipation, intestinal obstruction, pancreatitis, ascites, liver failure, intractable cough, and radiation effects. All cause visceral disturbances by stimulating vagal and sympathetic pathways. ؠ���� Metabolic causes � Hypercalcemia, uremia, infection and drugs cause stimulation of the chemoreceptor zone within the brain, causing nausea, with or without vomiting. ؠ���� Central nervous system causes � Raised intracranial pressure, pain � �������� Psychological: ؠ���� Emotional factors can lead to nausea and vomiting as a result of stimulation of emetic receptors in the brain. � �������� Disease related � �������� Treatment related: ؠ���� Radiation ؠ���� Chemotherapy � �������� Other: ؠ���� Vestibular disturbances, including motion sickness, toxic action of certain drugs (i.e., aspirin and opiates) ؠ���� Local tumors within the brain, stimulate the vestibular apparatus causing nausea/vomiting (Glare et al., 2004). �������� There are numerous causes of nausea and vomiting in the terminally ill. � �������� Physiological: ؠ���� Gastrointestinal causes � The following causes of nausea and vomiting include gastric irritation and stasis, constipation, intestinal obstruction, pancreatitis, ascites, liver failure, intractable cough, and radiation effects. All cause visceral disturbances by stimulating vagal and sympathetic pathways. ؠ���� Metabolic causes � Hypercalcemia, uremia, infection and drugs cause stimulation of the chemoreceptor zone within the brain, causing nausea, with or without vomiting. ؠ���� Central nervous system causes � Raised intracranial pressure, pain � �������� Psychological: ؠ���� Emotional factors can lead to nausea and vomiting as a result of stimulation of emetic receptors in the brain. � �������� Disease related � �������� Treatment related: ؠ���� Radiation ؠ���� Chemotherapy � �������� Other: ؠ���� Vestibular disturbances, including motion sickness, toxic action of certain drugs (i.e., aspirin and opiates) ؠ���� Local tumors within the brain, stimulate the vestibular apparatus causing nausea/vomiting (Glare et al., 2004).

16. Assessment of Nausea and Vomiting Physical exam History Lab values �������� Clinical assessment of nausea and vomiting should include past history and effectiveness of treatment of nausea/vomiting, medication history, frequency of episodes of nausea and any correlation with vomiting, identification of those activities that may precipitate or alleviate nausea/vomiting. � �������� Physical assessment should include: ؠ���� Abdominal examination and evaluation to include bowel sounds ؠ���� Possible assessment of the rectal vault. � �������� History: ؠ���� Consistency, frequency and volume of emesis, ؠ���� Emesis associated with position changes ؠ���� Presence of contributing factors (i.e. vertigo, blood sugar levels, and medications) ؠ���� Relationship to food intake ؠ���� Evaluation of the presence of constipation or impaction ؠ���� Presence of uncontrolled pain or infection ؠ���� Presence of anxiety and other emotional symptoms � �������� Lab values: ؠ���� Renal and liver function tests ؠ���� Electrolytes, calcium, serum drug levels ؠ���� Radiologic tests to include abdominal X-rays and/or head CT or MRI �������� Clinical assessment of nausea and vomiting should include past history and effectiveness of treatment of nausea/vomiting, medication history, frequency of episodes of nausea and any correlation with vomiting, identification of those activities that may precipitate or alleviate nausea/vomiting. � �������� Physical assessment should include: ؠ���� Abdominal examination and evaluation to include bowel sounds ؠ���� Possible assessment of the rectal vault. � �������� History: ؠ���� Consistency, frequency and volume of emesis, ؠ���� Emesis associated with position changes ؠ���� Presence of contributing factors (i.e. vertigo, blood sugar levels, and medications) ؠ���� Relationship to food intake ؠ���� Evaluation of the presence of constipation or impaction ؠ���� Presence of uncontrolled pain or infection ؠ���� Presence of anxiety and other emotional symptoms � �������� Lab values: ؠ���� Renal and liver function tests ؠ���� Electrolytes, calcium, serum drug levels ؠ���� Radiologic tests to include abdominal X-rays and/or head CT or MRI

17. Pharmacologic Treatment of Nausea and Vomiting Anticholinergics Antihistamines Steroids Prokinetic agents Other � �������� Treatment of nausea is dictated by the presumed cause so treat any underlying cause if possible and try interventions that have worked in the past. � �������� Medications include: ؠ���� Anticholinergics, such as hyoscine hydrobromide, treat motion sickness, intractable vomiting, or small bowel obstruction. ؠ���� Antihistamines are commonly used in intestinal obstruction, increased intracranial pressure, or peritoneal irritation, and when vestibular causes exist (e.g. cyclizine). ؠ���� Steroids, given alone or with other agents for nausea and vomiting, are appropriate for cytotoxic-induced emesis (e.g. dexamethasone). ؠ���� Prokinetic agents, such as metoclopramide, can treat gastric stasis or ileus. ؠ���� Benzodiazepines, such as lorazepam, are most effective in treating nausea exacerbated by anxiety. ؠ���� 5-HT3 receptor agonists are used for post-operative nausea and vomiting and chemotherapy-related emesis. These include ondansetron and granisetron. ؠ���� Neurokinin �1- receptor antagonists inhibit postoperative and post-chemotherapy nausea and vomiting, but their role in chronic nausea and vomiting is not yet known. � � � Suggested Supplemental Teaching Materials: Table 10: Antiemetic Drugs in Palliative Care � �������� Treatment of nausea is dictated by the presumed cause so treat any underlying cause if possible and try interventions that have worked in the past. � �������� Medications include: ؠ���� Anticholinergics, such as hyoscine hydrobromide, treat motion sickness, intractable vomiting, or small bowel obstruction. ؠ���� Antihistamines are commonly used in intestinal obstruction, increased intracranial pressure, or peritoneal irritation, and when vestibular causes exist (e.g. cyclizine). ؠ���� Steroids, given alone or with other agents for nausea and vomiting, are appropriate for cytotoxic-induced emesis (e.g. dexamethasone). ؠ���� Prokinetic agents, such as metoclopramide, can treat gastric stasis or ileus. ؠ���� Benzodiazepines, such as lorazepam, are most effective in treating nausea exacerbated by anxiety. ؠ���� 5-HT3 receptor agonists are used for post-operative nausea and vomiting and chemotherapy-related emesis. These include ondansetron and granisetron. ؠ���� Neurokinin �1- receptor antagonists inhibit postoperative and post-chemotherapy nausea and vomiting, but their role in chronic nausea and vomiting is not yet known. � � � Suggested Supplemental Teaching Materials: Table 10: Antiemetic Drugs in Palliative Care

18. Non-Drug Treatment of Nausea and Vomiting Distraction/relaxation Dietary Small/slow feeding Invasive therapies �������� Several non-drug treatments are recommended to treat nausea and vomiting. � �������� Non-pharmacologic techniques (Berenson, 2006) ؠ���� Anticipatory nausea can be treated by the use of distraction or relaxation techniques, acupuncture, music therapy and hypnosis. � �������� Serving meals at room temperature with clear fluids while avoiding strong smells may be beneficial. � �������� Encourage the patient to eat slowly, avoiding large, high bulk meals. ؠ���� Patients who are weak should be positioned to avoid aspiration. � �������� Invasive therapies ؠ���� A nasogastric tube may need to be inserted to relieve pressure for comfort. ؠ���� In rare cases, such as unresectable obstruction, a draining peg tube may be placed or octreotide given. ؠ���� IV hydration in severe nausea/vomiting needs to be carefully considered. TPN and peripheral nutrition have a very limited role in palliative care. Some may argue it has no role in end-stage disease. Be aware of patient�s goal. ؠ���� Surgery to remove obstructions if patient�s life expectancy permits. � � � Suggested Supplemental Teaching Materials: Table 11: Non-pharmacological Interventions for Nausea and Vomiting Table 12: Non-pharmacological Self-Care Activities for Nausea and Vomiting �������� Several non-drug treatments are recommended to treat nausea and vomiting. � �������� Non-pharmacologic techniques (Berenson, 2006) ؠ���� Anticipatory nausea can be treated by the use of distraction or relaxation techniques, acupuncture, music therapy and hypnosis. � �������� Serving meals at room temperature with clear fluids while avoiding strong smells may be beneficial. � �������� Encourage the patient to eat slowly, avoiding large, high bulk meals. ؠ���� Patients who are weak should be positioned to avoid aspiration. � �������� Invasive therapies ؠ���� A nasogastric tube may need to be inserted to relieve pressure for comfort. ؠ���� In rare cases, such as unresectable obstruction, a draining peg tube may be placed or octreotide given. ؠ���� IV hydration in severe nausea/vomiting needs to be carefully considered. TPN and peripheral nutrition have a very limited role in palliative care. Some may argue it has no role in end-stage disease. Be aware of patient�s goal. ؠ���� Surgery to remove obstructions if patient�s life expectancy permits. � � � Suggested Supplemental Teaching Materials: Table 11: Non-pharmacological Interventions for Nausea and Vomiting Table 12: Non-pharmacological Self-Care Activities for Nausea and Vomiting �������� Several non-drug treatments are recommended to treat nausea and vomiting. � �������� Non-pharmacologic techniques (Berenson, 2006) ؠ���� Anticipatory nausea can be treated by the use of distraction or relaxation techniques, acupuncture, music therapy and hypnosis. � �������� Serving meals at room temperature with clear fluids while avoiding strong smells may be beneficial. � �������� Encourage the patient to eat slowly, avoiding large, high bulk meals. ؠ���� Patients who are weak should be positioned to avoid aspiration. � �������� Invasive therapies ؠ���� A nasogastric tube may need to be inserted to relieve pressure for comfort. ؠ���� In rare cases, such as unresectable obstruction, a draining peg tube may be placed or octreotide given. ؠ���� IV hydration in severe nausea/vomiting needs to be carefully considered. TPN and peripheral nutrition have a very limited role in palliative care. Some may argue it has no role in end-stage disease. Be aware of patient�s goal. ؠ���� Surgery to remove obstructions if patient�s life expectancy permits. � � � Suggested Supplemental Teaching Materials: Table 11: Non-pharmacological Interventions for Nausea and Vomiting Table 12: Non-pharmacological Self-Care Activities for Nausea and Vomiting

19. Concepts of Burden versus Benefit Ethical Principles Autonomy Beneficence Nonmaleficence Justice �������� Respect for Autonomy is the moral attitude that disposes one to refrain from interference with the autonomous beliefs and actions of others in the pursuit of their goals (Jonsen et al., 2002). � �������� Beneficence is the duty to assist persons in need by asking, �How can a medical intervention help this patient?� (Jonsen et al., 2002). � �������� Non-maleficence is the duty to refrain from causing harm (Jonsen et al., 2002). � Justice - concerns the fair and equitable distribution of burdens and benefits to the participants in social institutions. Many of the clinical problems encountered by patients and physicians arise from inequities in the institutions of health care and society at large (Jonsen et al., 2002). �������� Respect for Autonomy is the moral attitude that disposes one to refrain from interference with the autonomous beliefs and actions of others in the pursuit of their goals (Jonsen et al., 2002). � �������� Beneficence is the duty to assist persons in need by asking, �How can a medical intervention help this patient?� (Jonsen et al., 2002). � �������� Non-maleficence is the duty to refrain from causing harm (Jonsen et al., 2002). � Justice - concerns the fair and equitable distribution of burdens and benefits to the participants in social institutions. Many of the clinical problems encountered by patients and physicians arise from inequities in the institutions of health care and society at large (Jonsen et al., 2002).

20. Ethical Issues in Palliative Care Prolongation of life: balancing benefits and burdens Withholding/withdrawing medical interventions DNR �������� Prolongation of life: Balancing benefits and burdens (Aulisio et al., 2004; Manima, 2003; Stanley & Zoloth-Dorfman, 2006) ؠ���� Curative Intent - interventions aimed at ameliorating the disease process ؠ���� Acute therapeutic care -- this term suggests an ethical dilemma that may arise as to whether or not a patient should be treated for a secondary problem, such as an infection, if death is imminent. For example, antibiotic therapy may clear up an infection, but it may also prolong the life. ؠ���� Life sustaining treatments (LST) -- may, in some cases, be very appropriate to relieve symptoms, but in other cases, it may be seen as prolonging suffering of a patient who is dying. There may be physical benefits of life-sustaining as well as psychosocial benefits for both the patient and family. Life-sustaining procedures may allow time for the patient and family to become prepared and able to say their good-byes before death, or for a patient to get his/her affairs in order, to complete their emotional and spiritual tasks of dying. � �������� Withholding/withdrawing of medical interventions ؠ���� Common reasons why withholding/withdrawing interventions are considered: burdens outweigh benefits; prolongation of dying/suffering; patient and/or family choice; and undesirable quality of life (Faber-Langendoen & Lanken, 2000; Neely & Roxe, 2000; Quill & Byock, 2000; Rubenfeld & Crawford, 2001). � �������� DNR - Three considerations to be assessed to write a DNR order: ؠ���� Judgment that CPR would be futile, that is, that the resuscitation would be very unlikely to succeed or, if it did, the patient would not survive to be discharged from the hospital. ؠ���� Consideration of patient preferences. Expected quality of life for the patient if CPR succeeds. �������� Prolongation of life: Balancing benefits and burdens (Aulisio et al., 2004; Manima, 2003; Stanley & Zoloth-Dorfman, 2006) ؠ���� Curative Intent - interventions aimed at ameliorating the disease process ؠ���� Acute therapeutic care -- this term suggests an ethical dilemma that may arise as to whether or not a patient should be treated for a secondary problem, such as an infection, if death is imminent. For example, antibiotic therapy may clear up an infection, but it may also prolong the life. ؠ���� Life sustaining treatments (LST) -- may, in some cases, be very appropriate to relieve symptoms, but in other cases, it may be seen as prolonging suffering of a patient who is dying. There may be physical benefits of life-sustaining as well as psychosocial benefits for both the patient and family. Life-sustaining procedures may allow time for the patient and family to become prepared and able to say their good-byes before death, or for a patient to get his/her affairs in order, to complete their emotional and spiritual tasks of dying. � �������� Withholding/withdrawing of medical interventions ؠ���� Common reasons why withholding/withdrawing interventions are considered: burdens outweigh benefits; prolongation of dying/suffering; patient and/or family choice; and undesirable quality of life (Faber-Langendoen & Lanken, 2000; Neely & Roxe, 2000; Quill & Byock, 2000; Rubenfeld & Crawford, 2001). � �������� DNR - Three considerations to be assessed to write a DNR order: ؠ���� Judgment that CPR would be futile, that is, that the resuscitation would be very unlikely to succeed or, if it did, the patient would not survive to be discharged from the hospital. ؠ���� Consideration of patient preferences. Expected quality of life for the patient if CPR succeeds.

21. Ethical Issues in Palliative Care (cont.) Medical futility Assisted suicide Euthanasia �������� Medical Futility - designates an effort to provide a benefit to a patient, which reason and experience suggest is highly likely to fail and whose rare exceptions cannot be systematically produced. The judgment of futility is probabilistic, and its accuracy depends on empirical data drawn from clinical trails and from clinical experience (Jonsen et al., 2002). � �������� Assisted Suicide - the public, medical community, and medical ethicists are divided about the ethical propriety of physician-assisted suicide. ؠ���� Nurses may not deliberately act to terminate the life of any person; and nursing has a social contract with society based on trust. Nurses must provide realistic alternatives � (ANA, 1994; Stanley & Zoloth-Dorfman, 2006; Volker, 2006). � �������� Euthanasia - Deliberately causing the death of another constitutes a criminal act, as does cooperating in the causing of another�s death. Although suicide is not itself illegal, nearly all the states have specific statutes against assisting someone to commit suicide. Thus, the nurse who administers or provides a lethal agent is liable to a criminal charge of homicide or assisting suicide (Jonsen et al., 2002) �������� Medical Futility - designates an effort to provide a benefit to a patient, which reason and experience suggest is highly likely to fail and whose rare exceptions cannot be systematically produced. The judgment of futility is probabilistic, and its accuracy depends on empirical data drawn from clinical trails and from clinical experience (Jonsen et al., 2002). � �������� Assisted Suicide - the public, medical community, and medical ethicists are divided about the ethical propriety of physician-assisted suicide. ؠ���� Nurses may not deliberately act to terminate the life of any person; and nursing has a social contract with society based on trust. Nurses must provide realistic alternatives � (ANA, 1994; Stanley & Zoloth-Dorfman, 2006; Volker, 2006). � �������� Euthanasia - Deliberately causing the death of another constitutes a criminal act, as does cooperating in the causing of another�s death. Although suicide is not itself illegal, nearly all the states have specific statutes against assisting someone to commit suicide. Thus, the nurse who administers or provides a lethal agent is liable to a criminal charge of homicide or assisting suicide (Jonsen et al., 2002)

22. Ethical Issues in Palliative Care (cont.) Principle of double effect - �Last Dose Syndrome� Research �������� The principle of double effect recognizes that, occasionally, clinicians are faced with a decision that cannot be avoided and, in these circumstances; the decision may cause both a desirable and undesirable effect (Jonsen et al., 2002). Often nurses are concerned about how their actions will affect the timing and circumstances of a patient�s death. Nurses worry that they will �cause� the patient�s death if they administer adequate opioid doses at the end of life. This can be reflected in a hesitancy to give doses that may be temporally related to the death. The principle states: ؠ���� An ethically permissible effect can be allowed, even if the ethically undesirable one will inevitably follow, when the following conditions are met (Jonsen et al., 2002): w������� The action itself is ethically good or at least indifferent, that is neither good nor evil in itself (e.g. the action is the administration of a drug, a morally indifferent act); w������� The agent must intend the good effects, not the evil effects, even though these are foreseen (in this case, the intention is to relieve pain, not to compromise respiration); and w������� The morally objectionable effect cannot be a means to the morally permissible one (in this case, respiratory compromise is not the means to relief of pain). If this intention becomes primary, the action would be judged unethical. � �������� Research - regulations: ؠ���� Review of proposed research by an institutional review board (IRB); ؠ���� Informed consent by any competent participant or permission by surrogates for incapacitated persons without decision-making capability; Fair selection of subjects �������� The principle of double effect recognizes that, occasionally, clinicians are faced with a decision that cannot be avoided and, in these circumstances; the decision may cause both a desirable and undesirable effect (Jonsen et al., 2002). Often nurses are concerned about how their actions will affect the timing and circumstances of a patient�s death. Nurses worry that they will �cause� the patient�s death if they administer adequate opioid doses at the end of life. This can be reflected in a hesitancy to give doses that may be temporally related to the death. The principle states: ؠ���� An ethically permissible effect can be allowed, even if the ethically undesirable one will inevitably follow, when the following conditions are met (Jonsen et al., 2002): w������� The action itself is ethically good or at least indifferent, that is neither good nor evil in itself (e.g. the action is the administration of a drug, a morally indifferent act); w������� The agent must intend the good effects, not the evil effects, even though these are foreseen (in this case, the intention is to relieve pain, not to compromise respiration); and w������� The morally objectionable effect cannot be a means to the morally permissible one (in this case, respiratory compromise is not the means to relief of pain). If this intention becomes primary, the action would be judged unethical. � �������� Research - regulations: ؠ���� Review of proposed research by an institutional review board (IRB); ؠ���� Informed consent by any competent participant or permission by surrogates for incapacitated persons without decision-making capability; Fair selection of subjects

23. � Beyond the mastering of decision-making skills to identify values in conflict and develop actions for conflict resolution and mediation, nurses should focus efforts on preventing the occurrence of ethical dilemmas (Dubler, 2004; Reigle & Boyle, 2000). � Beyond the mastering of decision-making skills to identify values in conflict and develop actions for conflict resolution and mediation, nurses should focus efforts on preventing the occurrence of ethical dilemmas (Dubler, 2004; Reigle & Boyle, 2000).

24. Preventive Ethics Nurses should focus efforts on preventing the occurrence of conflicts Early identification of issues Knowledge of the natural history of many illnesses Reigle & Boyle, 2000 �������� Preventive ethics promotes an environment where early identification of issues and anticipation of possible dilemmas may serve to proactively avert potential areas of conflict (Reigle & Boyle, 2000). � Knowledge of the natural history of many illnesses allows the palliative care nurse to assess patient/family concerns and wishes long before a crisis situation develops. �������� Preventive ethics promotes an environment where early identification of issues and anticipation of possible dilemmas may serve to proactively avert potential areas of conflict (Reigle & Boyle, 2000). � Knowledge of the natural history of many illnesses allows the palliative care nurse to assess patient/family concerns and wishes long before a crisis situation develops.

25. Preventive Ethics (cont.) Understanding of patient/family wishes Cultural and spiritual assessment Communication skills �������� A better understanding of values of each individual (patient, family, caregiver, professional) will allow a proactive method of anticipating where values may differ and address issues before the conflict arises. � �������� Cultural and spiritual assessments are completed as a matter of routine for all patients, regardless of the stage of illness. ؠ���� When considering different approaches to health care decision-making and advance care planning, generalizations should not be made. It is important to determine how each patient and family wants medical information to be shared and decisions to be made early in the therapeutic relationship (Emmott et al., 2001). ؠ���� Consider cultural, ethnic and age-related differences (Hallenbeck, 2002). Consider ethnocentric biases - When faced with ethical decisions, it is important to note that the ethical principles (autonomy, beneficence, nonmaleficence and justice) that are utilized in practice are derived from a Western philosophical viewpoint. Conflicts may arise when a patient and/or family beliefs, values, or cultural norms clash with those of the health care team. �������� A better understanding of values of each individual (patient, family, caregiver, professional) will allow a proactive method of anticipating where values may differ and address issues before the conflict arises. � �������� Cultural and spiritual assessments are completed as a matter of routine for all patients, regardless of the stage of illness. ؠ���� When considering different approaches to health care decision-making and advance care planning, generalizations should not be made. It is important to determine how each patient and family wants medical information to be shared and decisions to be made early in the therapeutic relationship (Emmott et al., 2001). ؠ���� Consider cultural, ethnic and age-related differences (Hallenbeck, 2002). Consider ethnocentric biases - When faced with ethical decisions, it is important to note that the ethical principles (autonomy, beneficence, nonmaleficence and justice) that are utilized in practice are derived from a Western philosophical viewpoint. Conflicts may arise when a patient and/or family beliefs, values, or cultural norms clash with those of the health care team.

26. Facilitating Ethical and Legal Practice The 4 Box Method �������� The following approach is a straightforward method of sorting out the pertinent facts and values of any case into an orderly pattern that facilitates the discussion and resolution of ethical problems. This approach brings together principles and circumstances that comprise a method to facilitate the analysis of the case involving ethical issues (Jonsen et al., 2002). � �������� Every clinical case, especially those raising an ethical problem, should be analyzed by means of the following four topics: ؠ���� Clinical indications; ؠ���� Patient preferences; ؠ���� Quality of life; and Contextual features, defined as the social, economic, legal, and administrative context in which the case occurs. �������� The following approach is a straightforward method of sorting out the pertinent facts and values of any case into an orderly pattern that facilitates the discussion and resolution of ethical problems. This approach brings together principles and circumstances that comprise a method to facilitate the analysis of the case involving ethical issues (Jonsen et al., 2002). � �������� Every clinical case, especially those raising an ethical problem, should be analyzed by means of the following four topics: ؠ���� Clinical indications; ؠ���� Patient preferences; ؠ���� Quality of life; and Contextual features, defined as the social, economic, legal, and administrative context in which the case occurs.

27. Clinical Indications Indications for and against the intervention Reflects the goals of care Common ethical dilemmas �������� Clinical indications ؠ���� This box addresses the first topic relevant to any ethical problem in clinical medicine, namely, the indications for or against clinical intervention. These indications imply the overall goals of medicine: prevention, cure, and care of illness and injury. Every discussion of an ethical problem in clinical medicine should begin with a statement of the medical facts. Cardiopulmonary resuscitation (CPR) falls under the category of medical interventions (Jonsen et al., 2002). � �������� These indications must reflect the goals of care and the responsibilities of clinicians. The responsibilities are to benefit the patient (principle of beneficence) and to refrain from harm (non-malificence). ؠ���� The healthcare team should ask the following questions to determine the medical indications of a case: w������� What is the medical problem? History? Diagnosis? Prognosis? w������� Is the problem acute? Chronic? Critical? Emergent? Reversible? w������� What are the probabilities of success? What are the plans in case of therapeutic failure? (Jonsen et al., 2002) � �������� Common ethical dilemmas addressed by this area (clinical indications) include (Jonsen et al., 2002): ؠ���� Medical futility; Withholding/withdrawing of medical interventions; ؠ���� Do Not Attempt Resuscitation (DNAR)/No Code orders; ؠ���� Care of the dying patient; and Determination of death (e.g. death by brain criteria). �������� Clinical indications ؠ���� This box addresses the first topic relevant to any ethical problem in clinical medicine, namely, the indications for or against clinical intervention. These indications imply the overall goals of medicine: prevention, cure, and care of illness and injury. Every discussion of an ethical problem in clinical medicine should begin with a statement of the medical facts. Cardiopulmonary resuscitation (CPR) falls under the category of medical interventions (Jonsen et al., 2002). � �������� These indications must reflect the goals of care and the responsibilities of clinicians. The responsibilities are to benefit the patient (principle of beneficence) and to refrain from harm (non-malificence). ؠ���� The healthcare team should ask the following questions to determine the medical indications of a case: w������� What is the medical problem? History? Diagnosis? Prognosis? w������� Is the problem acute? Chronic? Critical? Emergent? Reversible? w������� What are the probabilities of success? What are the plans in case of therapeutic failure? (Jonsen et al., 2002) � �������� Common ethical dilemmas addressed by this area (clinical indications) include (Jonsen et al., 2002): ؠ���� Medical futility; Withholding/withdrawing of medical interventions; ؠ���� Do Not Attempt Resuscitation (DNAR)/No Code orders; ؠ���� Care of the dying patient; and Determination of death (e.g. death by brain criteria).

28. Patient Preferences An ongoing, dynamic process of assessment that decreases chance of conflict Cultural, ethnic and age related differences Common ethical dilemmas �������� Assessing patient preferences is an ongoing, dynamic process of assessment that decreases the chance of conflict. ؠ���� This box addresses the principle of �Respect for Persons� which is a fundamental component in the first provision in the Code of Ethics for Nurses (ANA, 2001), which states that nurses are to �provide services with respect for human dignity and the uniqueness of clients� (p.1) above all else. The concept of respect for persons assumes that each and every person has an inherent value. � �������� Process of ascertaining patient preferences ؠ���� Assess mental capacity. If competent, determine what the patient is stating about preferences for treatment. If incapacitated, who is the appropriate surrogate? ؠ���� Has the patient been informed of benefits & risks, understood this information, and given consent? ؠ���� Has the patient expressed prior preferences, e.g., Advance Directives? ؠ���� Is the patient unwilling or unable to cooperate with medical treatment? � �������� Cultural, ethnic and age related differences must be taken into consideration when assessing patient preferences ؠ���� Nurses will be faced with the problem of reconciling a clinical judgment that seems reasonable to them, and even an ethical judgment that seems obligatory, with a patient�s preference for a different course of action. The appropriate response involves: truthful disclosure, competent refusal of treatment& the role of family in making decisions � �������� Common ethical dilemmas addressed by this topic include (Jonsen et al., 2002): ؠ���� Conflicts related to beliefs due to religious and cultural diversity; ؠ���� Truthful communication and disclosure; Refusal of treatment; Advance planning and advance directives. �������� Assessing patient preferences is an ongoing, dynamic process of assessment that decreases the chance of conflict. ؠ���� This box addresses the principle of �Respect for Persons� which is a fundamental component in the first provision in the Code of Ethics for Nurses (ANA, 2001), which states that nurses are to �provide services with respect for human dignity and the uniqueness of clients� (p.1) above all else. The concept of respect for persons assumes that each and every person has an inherent value. � �������� Process of ascertaining patient preferences ؠ���� Assess mental capacity. If competent, determine what the patient is stating about preferences for treatment. If incapacitated, who is the appropriate surrogate? ؠ���� Has the patient been informed of benefits & risks, understood this information, and given consent? ؠ���� Has the patient expressed prior preferences, e.g., Advance Directives? ؠ���� Is the patient unwilling or unable to cooperate with medical treatment? � �������� Cultural, ethnic and age related differences must be taken into consideration when assessing patient preferences ؠ���� Nurses will be faced with the problem of reconciling a clinical judgment that seems reasonable to them, and even an ethical judgment that seems obligatory, with a patient�s preference for a different course of action. The appropriate response involves: truthful disclosure, competent refusal of treatment& the role of family in making decisions � �������� Common ethical dilemmas addressed by this topic include (Jonsen et al., 2002): ؠ���� Conflicts related to beliefs due to religious and cultural diversity; ؠ���� Truthful communication and disclosure; Refusal of treatment; Advance planning and advance directives.

29. Quality of Life Evaluation of prior QOL Expected QOL with and without treatment Common ethical dilemmas addressing QOL �������� Quality of life must be reviewed to analyze a problem in clinical ethics. After reviewing medical indications and patient values and preferences, the patient�s quality of life before the current illness and expected quality of life with or without treatment should be described (Jonsen et al., 2002). � �������� The evaluation of quality of life is always relevant to appropriate medical care. Healthcare teams must work with patients and families to determine what level of quality is desirable, how it is to be attained, and what risks and disadvantages are associated with the desired level (Jonsen et al., 2002). � �������� Quality of life addresses the principles of beneficence (to do good) and non-maleficence (to avoid harm) as well as respect for autonomy (Jonsen et al., 2002). Quality of life measures have become important indicators of clinical benefit and therefore important in measuring the efficacy of new treatments (Field & Cassel, 1997). � �������� The healthcare team should ask the following questions to assess a patient�s quality of life with and without treatment: ؠ���� What are the prospects, with or without treatment, for a return to normal life? What physical, mental, and social deficits is the patient likely to experience if treatment succeeds? ؠ���� Are there biases that might prejudice the provider�s evaluation of the patient�s quality of life? Is the patient�s present or future condition such that his or her continued life might be judged undesirable? ؠ���� Is there any plan and rationale to forgo treatment? Are there plans for comfort and palliative care? � �������� Common ethical dilemmas addressed by this topic include (Jonsen et al., 2002): Nutrition and hydration; withhold/withdrawal of life support interventions; euthanasia; suicide; and principle of double effect. �������� Quality of life must be reviewed to analyze a problem in clinical ethics. After reviewing medical indications and patient values and preferences, the patient�s quality of life before the current illness and expected quality of life with or without treatment should be described (Jonsen et al., 2002). � �������� The evaluation of quality of life is always relevant to appropriate medical care. Healthcare teams must work with patients and families to determine what level of quality is desirable, how it is to be attained, and what risks and disadvantages are associated with the desired level (Jonsen et al., 2002). � �������� Quality of life addresses the principles of beneficence (to do good) and non-maleficence (to avoid harm) as well as respect for autonomy (Jonsen et al., 2002). Quality of life measures have become important indicators of clinical benefit and therefore important in measuring the efficacy of new treatments (Field & Cassel, 1997). � �������� The healthcare team should ask the following questions to assess a patient�s quality of life with and without treatment: ؠ���� What are the prospects, with or without treatment, for a return to normal life? What physical, mental, and social deficits is the patient likely to experience if treatment succeeds? ؠ���� Are there biases that might prejudice the provider�s evaluation of the patient�s quality of life? Is the patient�s present or future condition such that his or her continued life might be judged undesirable? ؠ���� Is there any plan and rationale to forgo treatment? Are there plans for comfort and palliative care? � �������� Common ethical dilemmas addressed by this topic include (Jonsen et al., 2002): Nutrition and hydration; withhold/withdrawal of life support interventions; euthanasia; suicide; and principle of double effect.

30. Contextual Features Social, legal, economic and institutional circumstances Context features must be determined and assessed Common ethical dilemmas � �������� The fourth area (contextual features) that is essential to the adequate description and resolution of a case in clinical ethics is contextual features: the social, legal, economic, and institutional circumstances under which a particular case of patient care occurs (Jonsen et al., 2002). � Nurses and patients have various responsibilities and obligations to the larger world. Nurses stand in multiple relationships with other allied health professionals, health care administrators, third-party payers, professional organizations, and state and federal agencies, in addition to patients and their families. Similarly, patients stand in relationships with family and friends, other health professionals, health care institutions, and third-party payers. Nurses and patients are also subject to the varying influence of community and professional standards, legal rules, governmental and institutional policies, research regulations, teaching concerns, economic considerations, religious beliefs, and other factors (Jonsen et al., 2002). � �������� The fourth area (contextual features) that is essential to the adequate description and resolution of a case in clinical ethics is contextual features: the social, legal, economic, and institutional circumstances under which a particular case of patient care occurs (Jonsen et al., 2002). � Nurses and patients have various responsibilities and obligations to the larger world. Nurses stand in multiple relationships with other allied health professionals, health care administrators, third-party payers, professional organizations, and state and federal agencies, in addition to patients and their families. Similarly, patients stand in relationships with family and friends, other health professionals, health care institutions, and third-party payers. Nurses and patients are also subject to the varying influence of community and professional standards, legal rules, governmental and institutional policies, research regulations, teaching concerns, economic considerations, religious beliefs, and other factors (Jonsen et al., 2002).

31. � �������� The healthcare team should ask the following questions to determine contextual features of a clinical case: ؠ���� Are there family or provider issues that might influence treatment decisions? Are there financial and economic factors? Are there religious or cultural factors? Are there problems of allocation of resources? How does the law affect treatment decisions? Is there any conflict of interest on the part of the providers or the institution? � �������� Common ethical dilemmas addressed by this topic include (Jonsen et al., 2002): ؠ���� Research; justice and allocation of scarce resources (e.g. transplantation); Economic issues; confidentiality; and legal issues. � �������� The healthcare team should ask the following questions to determine contextual features of a clinical case: ؠ���� Are there family or provider issues that might influence treatment decisions? Are there financial and economic factors? Are there religious or cultural factors? Are there problems of allocation of resources? How does the law affect treatment decisions? Is there any conflict of interest on the part of the providers or the institution? � �������� Common ethical dilemmas addressed by this topic include (Jonsen et al., 2002): ؠ���� Research; justice and allocation of scarce resources (e.g. transplantation); Economic issues; confidentiality; and legal issues.

32. Reasons FOR placing a feeding tube:

33. Reasons AGAINST placing a feeding tube:

34. American Academy of Hospice and Palliative MedicineStatement on Artificial Nutrition and Hydration Near the End of Life Key Elements Recognize that ANH is a form of medical therapy which, like other medical interventions, should be evaluated by weighing its benefits and burdens in light of the patient's goals of care and clinical circumstances Acknowledge that ANH, like other medical interventions, can ethically be withheld or withdrawn, consistent with the patient's wishes and the clinical situation Establish open communication between patients/families and caregivers, to assure that their concerns are heard and that the natural history of advanced illness is clarified Respect patient's preferences for treatment, once the prognosis and anticipated trajectory with and without ANH have been explained

36. Considerations for Withholding or Withdrawing Treatment: 8 Step Protocol to Discuss Treatment Preferences Be familiar with policies and statutes. Create an appropriate setting for the discussion. Ask the patient and family what they understand. Discuss the general goals of care. Establish context for the discussion. Discuss specific treatment preferences. Respond to emotions. Establish and implement the plan.

37. Case #2: Eight-months ago Joan was diagnosed with ovarian cancer and recently with lung mets. TPN was started several months ago when Joan was too nauseated to eat. Two nights ago, Joan had acute shortness of breath and collapsed on the living room floor. Davey, her 12-year old son who was the only person at home at the time, called 911. When the paramedics arrived, they found her awake and oriented to person and place, though very dyspneic and drowsy. She is admitted to the hospital where tests revealed the lung metastases are increasing in size and number. Joan has resisted signing an advance directive or bringing closure to the DNR discussion. She is to be discharged tomorrow and agrees to a family meeting to discuss hospice and palliative care options.

38. Conclusion Ethical discernment, discourse, decision-making Address values and understanding of needs Advocate for patient/family rights Work closely with other disciplines � �������� Nurses in palliative care need to engage in a process of ethical discernment, discourse and decision-making. � �������� Application of principles of ethics can assist in a search for best solutions to complex ethical dilemmas at the end of life. � �������� An ethical process is a way to seek balance in decision making by addressing values and understanding the needs of those involved. � �������� Nurses in palliative care have a responsibility to patients and families to advocate for their rights to pursue choices and make informed decisions. � Palliative care nurses work closely with other disciplines to address ethical issues in end-of-life/palliative care (O�Keefe & Crawford, 2002). � �������� Nurses in palliative care need to engage in a process of ethical discernment, discourse and decision-making. � �������� Application of principles of ethics can assist in a search for best solutions to complex ethical dilemmas at the end of life. � �������� An ethical process is a way to seek balance in decision making by addressing values and understanding the needs of those involved. � �������� Nurses in palliative care have a responsibility to patients and families to advocate for their rights to pursue choices and make informed decisions. � Palliative care nurses work closely with other disciplines to address ethical issues in end-of-life/palliative care (O�Keefe & Crawford, 2002).