Monthly Archives: August 2015

End of Life Care

End-of-life care

End of life care is a healthcare delivery concept that aims at providing interdisciplinary and supportive services to critically-ill patients and their family members. It focuses on alleviating suffering, facilitating end-of-life wishes, and providing support to the bereaved (Callahan, 2009). It is an emerging concept that moves away from the traditional school of thought that suggests that the primary objective of medicine is to sustain lives to a new school of thought, which sees the primary goal of medicine as that of improving the quality of life. In this care delivery model, medical practitioners change their paradigm from trying to postpone the death of the terminally-ill patients to improving the quality of life of these patients during the final moments of their lives. This care delivery model extends beyond the death of the patient as it also entails helping family members to go through the grieving process.
Principles in End of Life Care
1. Medical Futility
There are several principles that have inspired the development of the end-of-life care concept. Medical futility is one of these principles. Today, there are medical interventions and technologies that can sustain human life even in situations where there is little hope of recovery or little meaning for existence. Ventilators and artificial feeding technology can prolong patient’s life for years. However, it reaches a point where these interventions and technology cannot change the patient condition or improve the quality of life of the patient. Any intervention that does not have a reasonable chance of improving the patient condition tis referred to as futile treatment. For instance, while a CPR procedure may help keep a patient who is suffering from an advanced stage of cancer alive, the CPR cannot change the patient’s underlying condition. This treatment only prolongs the patient’s life and, consequently, prolongs the suffering of the patients. Therefore, the treatment is termed as a medical futility. A given medical procedure can be futile to one patient and very beneficial to another patient. Therefore, the principle of medical futility largely depends on the prognosis of the patient.
2. Respect for Patient Autonomy
Another principle that has shaped the concept of end of life care is the principle of respect for patients’ autonomy. This principle suggests that all patients have the right to determine the direction of their lives including determining the kind of treatment that they should receive whenever they fall sick. This principle became popular after a series of landmark cases where patients who were terminally-ill were kept on life support for years against their families’ wishes to have the life support withdrawn. Karen Ann Quinlan, Nancy Cruzan, and Terry Schiavo are among the most common cases where futile treatment were administered to patient against their family’s wishes despite the fact that these patients were in a permanent vegetative state. These cases shaped the concept of end-of-life care by prompting the creation of laws that protect terminally-ill patient from being subjected to medical treatment that they do not want.
3. Death with dignity
Death with dignity is another principle that has informed the concept of end-of-life care. This principle suggests that all people have the right to die with dignity. It was informed by the recognition of the fact that terminally-ill patients undergo immense suffering during the end-of-life stage of their illness, which strips them off their dignity (Plaisted, 2013). Most of these patients cannot do anything on their own; they have to depend on other even in basic tasks such as cleaning themselves. The dependency and social isolation that comes with terminal disease strips the patient their dignity. The physical pain also damages the dignity of the patient. The end-of-life care concept is founded on the premise that it does not make sense to prolong the patient life in a way that strip-off their dignity and subject them to miserable conditions. The patient should be allowed to die with dignity rather than go in an inhumane and torturous way.
4. Compassion
The concept of end-of-life care is also founded on the principle of compassion. Showing compassion to patients is a duty for all healthcare practitioners. Compassion is more than pity and sympathy; it is the capacity to connect and share what the patient is going through (Comte-Sponville, 2002). It also goes beyond feelings and becomes a willingness to help the patient and the family to overcome their suffering. Since it is not possible for medical practitioner to cure the illness of terminally-ill patients, the only way to show compassion is by improving their quality of life during their final days. Instead of subjected the patients to painful and invasive procedures, medical practitioners focus on reducing the patient’s physical pain, emotional anxiety, spiritual, and psychological concerns.
5. Efficiency
Another principle that inspired the development of the concept of end-of-life care is efficiency. The end-of-life care concept seeks to promote the efficient utilization of medical resources. Medical resources such as ventilators, ICU space, and artificial feeding equipment are very scarce (Sharma, 2004). It is therefore prudent to ensure that these resources are applied to cases where they will give meaningful and optimal benefits. It is not prudent to spend these resources in cases that have minimal chances of success at the expense of cases that have reasonable survival chances.
End-of-life care practices
1. Advance Care Planning
Advance care planning is one of the practices that are common in end-of-life care. Advance care planning is the process of making arrangements regarding own future health and personal care (Detering, Hancock, Reade, & Silvester, 2010). This practice is informed by recognition that a patient with a terminal-illness may reach a stage where he or she will not be able to make or communicate decisions regarding the type of care that he or she wants to get. For instance, some patients at the terminal-stage of cancer lose the ability to speak or fall into a comma reducing their capacity to make decisions. Consequently, advance care planning give the terminally-ill patient the opportunity to prepare and communicate his or her directives, preferences, values and beliefs in advance so as to ensure that his or her wishes will be carried out in the event that he or she becomes unable to make decisions in the future. The patient may also appoint a surrogate or substitute decision-maker who will call the shot when the patient becomes incompetent.
2. Intensive Care
Intensive care is a critical component of end-of-life care. Many terminally-ill patients spend the final days of their lives in intensive care units because their illnesses interfere with critical life functions such as breathing and feeding (Curtis & Vincent, 2010). The end-of-life care concept emphasizes the use of a family-centered approach when providing intensive care for patients at the terminal-stage of their illness. It also calls for the application of ethical aspects such as respect for patient’s autonomy, efficiency, honest communication, and compassion. Medical practitioners are expected to continually engage the patient and family members through open communication. They are expected to consult patients and their families before making major decisions and provide them with sufficient information to decide on the fate of the patient.
3. Withholding and Withdrawing Treatment
There are several practices that are common in end-of-life care. Withholding and withdrawing treatments are among the common practices. The concept of end-of-life care distinguishes between killing and allowing a person to die (Rietjens, Van der Maas, Philipsen, van Delden, & van der Heide, 2009). Consequently, this concept allows medical practitioners to withhold or withdraw any treatment that has been proven to be futile. For instance, a patient’s cancer can grow to a stage where it becomes incurable. In this case, the physician is allowed to withhold or withdraw treatments such as chemotherapy because they are no longer useful to the patient. However, patients should be the ones to make the decision to withhold or withdraw treatment by themselves or through advance directives or surrogates. Withholding or withdrawing treatment is different from assisted suicide and Euthanasia in that in the former no active step is taken to end the patient’s life. Treatment is withdrawn and the patient is allowed to die naturally. Today, many deaths in the intensive care are preceded by the withdrawal of life support (Curtis & Vincent, 2010). Similarly, many patients who receive negative prognosis especially in cancer opt not to commence treatment.
4. Palliative Care
Palliative care is another important component that defines end-of-life care. Palliative care is form of specialized care that focuses on relieving pain, symptoms, mental stress, and physical strain that are caused by the patient’s illness. Since patient at the end-of-life stage have little chances of having the underlying illness cured, medical practitioners shift their attention towards reducing symptoms, managing pain, and psychological distress. However, palliative care can also be provided to patients who are not terminally-ill. For end-of-life patients, this type of care is often provided in the home or hospice environment by a multidisciplinary medical team.
5. Comprehensive Bereavement Programs
Bereavement support is also a critical component of end-of-life care. This component focuses on preparing and supporting the patient’s family to deal with the loss of their loved one. Medical practitioners are expected to assess the family’s level of resilient and use the assessment’s findings to establish ways of helping family members to get through the grieving process. During the resilient assessment, practitioners are required to pay attention to risk factors such as the bereaved gender, economic hardship, ethnic background, family conflict, and religious beliefs so as to identify family members who are at risk of experiencing a complicated bereavement. Bereavement support may apply strategies such as holding bereavement information session where the medical practitioner and family members review and reflect on the loss, counseling, meditation, art groups, support groups, and music.
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Callahan, D. (2009). Death, mourning, and medical progress. Perspectives in Biology and Medicine. 52 (1), 103-115
Comte-Sponville, A., (2002). A Small Treatise on the Great Virtues: Compassion. New York; Holt Paperbacks Publishers
Curtis, R., & Vincent, J. (2010). Ethics and end-of-life care for adults in the intensive care unit. The Lancet, 376 (9749), 1347- 1353
Detering, K., Hancock, A., Reade, M., & Silvester, W. (2010). The impact of advance care planning on end-of-life care in elderly patients: Randomized controlled trial. British Medical Journal, 340 doi:
Plaisted D., (2013). An undignified side of death with dignity legislations. Kennedy Institute of Ethics Journal. 23 (3), 201- 228
Rietjens, J., Van der Maas, P., Philipsen, B., van Delden, J. and van der Heide, A., (2009). Two decades of research on euthanasia from Netherland. Bioethical Inquiry. 6 (1), 271- 283
Sharma, B. (2004). Withholding and withdrawing of life support. The American Journal of Forensic Medicine and Pathology. 25 (2), 150- 155