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Table of Contents
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
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35. Palliative Care
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How people die remains in the memory of those who live.
~ Cicely Saunders
Palliative Betrayal
The Importance of Palliative Care and Medication Management in Healthcare
Dr. Jane Smith had always prided herself on being a compassionate and skilled physician. She had built a reputation for her expertise in treating patients with serious illnesses, including cancer. When she was approached by a patient named Mr. Johnson, who had been recently diagnosed with advanced-stage lung cancer, she was eager to offer her help.
Mr. Johnson was a 65-year-old retired mechanic who had never smoked a day in his life. He had been feeling ill for several months, but he had put off seeing a doctor until his symptoms became unbearable. When he finally went to see Dr. Smith, he was shocked to hear that he had stage 4 lung cancer.
Dr. Smith knew that there was no cure for Mr. Johnson’s cancer, but she was confident that she could help him manage his symptoms and maintain his quality of life through palliative care. She explained the principles of palliative care to Mr. Johnson and his family, and they agreed to begin treatment.
Over the next several weeks, Dr. Smith worked closely with Mr. Johnson and his family to manage his pain and other symptoms. She prescribed medications, recommended lifestyle changes, and provided emotional support to both Mr. Johnson and his family.
But as the weeks went on, Dr. Smith began to notice that Mr. Johnson’s condition was not improving. His pain seemed to be getting worse, and he was becoming increasingly weak and fatigued. Dr. Smith tried adjusting his medications and treatment plan, but nothing seemed to help.
Then, one day, Dr. Smith received a call from Mr. Johnson’s daughter. She told Dr. Smith that her father had died suddenly the night before. She said that he had been in a lot of pain and that his condition had deteriorated rapidly in the hours leading up to his death.
Dr. Smith was devastated. She had worked so hard to help Mr. Johnson manage his symptoms and maintain his quality of life, but it seemed like everything she had done had been for nothing. She wondered if there was something she could have done differently, some way she could have saved Mr. Johnson’s life.
As she began to investigate what had happened, Dr. Smith discovered that Mr. Johnson had not been taking his medications as prescribed. His daughter told her that he had been complaining of side effects and had stopped taking the medications on his own.
Dr. Smith was horrified. She realized that she had not done enough to ensure that Mr. Johnson was adhering to his treatment plan. She had assumed that he was taking his medications and following her recommendations, but she had never actually confirmed it.
As she dug deeper, Dr. Smith discovered something even more troubling. Mr. Johnson’s medical records indicated that he had been prescribed a much higher dose of pain medication than she had prescribed. It appeared that someone had altered his records to make it look like he was taking less medication than he actually was.
Dr. Smith knew that something was very wrong. She reported her findings to the hospital administration and to the authorities, and an investigation was launched.
It turned out that one of the nurses on Mr. Johnson’s care team had been stealing his medication and selling it on the black market. She had altered his medical records to cover up the theft, and Mr. Johnson had been suffering needlessly as a result.
Dr. Smith was devastated by the news. She had always trusted her team to provide the best possible care to her patients, but now she realized that she couldn’t take anything for granted. She redoubled her efforts to ensure that her patients were receiving the care they needed, and she became an advocate for stricter controls on medication management in hospitals.
The case of Mr. Johnson was a wake-up call for Dr. Smith and for the healthcare community as a whole.
Abstract
Palliative care is a medical approach that focuses on improving the quality of life and reducing suffering of patients and families facing life-threatening illnesses. It is a recognized subspecialty of the medical profession and involves interprofessional collaboration and advanced care planning. The core principles of palliative care include patient autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair). The aim of palliative care is to provide patient-centered care that maximizes the patient’s best interests in accordance with the patient’s goals, values, and priorities. Palliative care provides a solution to the challenge of end-of-life care and helps address health disparities caused by technological advancements in the medical field.
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Think
[35:1] The word “palliative” comes from the Latin root “palliare,” which means “to cloak.” Palliative care includes an interprofessional medical care team that focuses on the quality of life and the mitigation of suffering of the patient and family. Although palliative care grew out of the hospice movement, it is now much broader in its practice but still focuses on patients with serious illnesses. Unlike hospice, which requires the terminal patient to have less than six months to live, there are no specific qualifications for palliative care.
[35:2] The World Health Organization defines palliative care as:
Palliative care is an approach that improves the quality of life of patients (adults and children) and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.
[35:3] In 2006, the American Board of Medical Specialties recognized hospice and palliative care as a medical subspecialty. Central to hospice and palliative care is advanced care planning for providing a forum for the patient to express their healthcare goals, values, and priorities, communicate their treatment preferences, and identify who will make medical decisions on their behalf if they are no longer able to do so.
Assess
Patient: 1) Autonomy
[35:4] Palliative care respects, promotes, and supports patient end-of-life planning as a reflection of patient autonomy (informed consent). Medicine’s success in extending life through medication and technology has had the unintended consequence of diminishing the patient’s autonomous control of where, how, and with whom the patient will die. As a subspecialty, palliative care directly addresses these concerns without violating or weakening the traditional patient-practitioner relationship.
[35:5] In the past, there was no need for advanced care planning because people generally lived their lives and died in the home environment. This changed when technologies started to fill hospital wards, and patients started to die on ventilators and other medical equipment, alone and isolated in intensive care units (ICU). Medical care adaptation was essential if the principles of patient autonomy (informed consent) were to continue to have decisional importance for those with life-threatening illnesses.
[35:6] Palliative care filled this newly created niche, maximizing the patient’s autonomy (informed consent) by incorporating advance care planning and interprofessional collaboration with hospice teams. Living wills determine what treatment options are permissible for the practitioner to provide to the patient under various circumstances. If the patient no longer has decisional capacity, then the durable power of attorney (POA) determines who will make medical decisions on the patient’s behalf.
Practitioner: 2) Beneficence & 3) Nonmaleficence
[35:7] The medical profession is a patient-centered healing art. However, a problem arises when healing is no longer possible, and abandoning the patient in their time of highest need is unacceptable.
[35:8] Palliative care is the medical profession’s interprofessional attempt to address this issue by having the team focus on the maximization of the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. Although the practitioner’s professional maxim of healing may in some cases be no longer possible, that is not equivalent to being part of an activity of harming, a violation of the professional principle of nonmaleficence (do no harm). Palliative care, therefore, is not a violation of nonmaleficence (do no harm), and the palliation of pain and suffering is in accordance with beneficence (do good).
Public Policy: 4) Justice
[35:9] Justice (be fair) is the implementation of public policy to address various types of health disparities. Technologically laden hospitals have created unanticipated health disparities. In the attempt to heal, there are times in which the patient and the practitioner need to accept that any further treatment is futile, and that death is unavoidable and imminent. In such circumstances, the only just or fair thing to do is to palliate any accompanied pain and suffering without violating the patient-practitioner relationship, patient autonomy (informed consent), and the practitioner’s duty of nonmaleficence (do no harm).
Conclude
[35:10] Palliative care is a recognized subspecialty available to anyone with serious illness, whereas hospice care is only available for those who are thought to have six months or less to live. Patients with serious illnesses find it desirable to maximize the quantity of their lives and the quality of their lives, and palliative care provides those services without violating the patient-practitioner relationship.
[35:11] In summary, palliative care, as a recognized subspecialty, plays a crucial role in the healthcare system by addressing the needs of patients with serious illnesses. Unlike hospice care, which is reserved for patients with less than six months to live, palliative care is accessible to anyone with a serious illness. It ensures that patients can maximize both the quantity and quality of their lives without violating the patient-practitioner relationship or compromising core medical principles. By prioritizing patient autonomy and providing comprehensive, compassionate care, palliative care serves as a valuable solution to the challenges of end-of-life care.
(See also: 23. Hospice)
**
35. Review Questions
1. Palliative care requires that the patient has less than six months to live.
2. In 2006, the American Board of Medical Specialties recognized hospice and palliative care as a medical subspecialty.
3. Palliative care maximizes patient’s autonomy (informed consent) by incorporating advance care planning and interprofessional collaboration.
4. Palliative care is a violation of nonmaleficence (do no harm), and therefore should not be a recognized specialty.
5. In the attempt to heal, there are times in which the patient and the practitioner need to accept that any further treatment is futile and death is unavoidable and imminent.
**
CORRECT! 🙂
[35:1] The word “palliative” comes from the Latin root “palliare,” which means “to cloak.” Palliative care includes an interprofessional medical care team that focuses on the quality of life and the mitigation of suffering of the patient and family. Although palliative care grew out of the hospice movement, it is now much broader in its practice but still focuses on patients with serious illnesses. Unlike hospice, which requires the terminal patient to have less than six months to live, there are no specific qualifications for palliative care.
Wrong 😕
[35:1] The word “palliative” comes from the Latin root “palliare,” which means “to cloak.” Palliative care includes an interprofessional medical care team that focuses on the quality of life and the mitigation of suffering of the patient and family. Although palliative care grew out of the hospice movement, it is now much broader in its practice but still focuses on patients with serious illnesses. Unlike hospice, which requires the terminal patient to have less than six months to live, there are no specific qualifications for palliative care.
CORRECT! 🙂
[35:3] In 2006, the American Board of Medical Specialties recognized hospice and palliative care as a medical subspecialty. Central to hospice and palliative care is advanced care planning for providing a forum for the patient to express their healthcare goals, values, and priorities, communicate their treatment preferences, and identify who will make medical decisions on their behalf if they are no longer able to do so.
Wrong 😕
[35:3] In 2006, the American Board of Medical Specialties recognized hospice and palliative care as a medical subspecialty. Central to hospice and palliative care is advanced care planning for providing a forum for the patient to express their healthcare goals, values, and priorities, communicate their treatment preferences, and identify who will make medical decisions on their behalf if they are no longer able to do so.
CORRECT! 🙂
[35:6] Palliative care filled this newly created niche, maximizing the patient’s autonomy (informed consent) by incorporating advance care planning and interprofessional collaboration with hospice teams. Living-wills determine what treatment options are permissible for the practitioner to provide to the patient under various circumstances. If the patient no longer has decisional capacity, then the durable power of attorney (POA) determines who will make medical decisions on the patient’s behalf.
Wrong 😕
[35:6] Palliative care filled this newly created niche, maximizing the patient’s autonomy (informed consent) by incorporating advance care planning and interprofessional collaboration with hospice teams. Living-wills determine what treatment options are permissible for the practitioner to provide to the patient under various circumstances. If the patient no longer has decisional capacity, then the durable power of attorney (POA) determines who will make medical decisions on the patient’s behalf.
CORRECT! 🙂
[35:8] Palliative care is the medical profession’s interprofessional attempt to address this issue by having the team focus on the maximization of the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. Although the practitioner’s professional maxim of healing is no longer possible, that is not equivalent to being part of an activity of harming, a violation of the professional principle of nonmaleficence (do no harm). Palliative care, therefore, is not a violation of nonmaleficence (do no harm), and the palliation of pain and suffering is in accordance with beneficence (do good).
Wrong 😕
[35:8] Palliative care is the medical profession’s interprofessional attempt to address this issue by having the team focus on the maximization of the patient’s best interests in accordance with the patient’s reasonable goals, values, and priorities. Although the practitioner’s professional maxim of healing is no longer possible, that is not equivalent to being part of an activity of harming, a violation of the professional principle of nonmaleficence (do no harm). Palliative care, therefore, is not a violation of nonmaleficence (do no harm), and the palliation of pain and suffering is in accordance with beneficence (do good).
CORRECT! 🙂
[35:9] Justice (be fair) is the implementation of public policy to address various types of health disparities. Technologically laden hospitals have created unanticipated health disparities. In the attempt to heal, there are times in which the patient and the practitioner need to accept that any further treatment is futile and death is unavoidable and imminent. In such circumstances, the only just or fair thing to do is to palliate any accompanied pain and suffering without violating the patient-practitioner relationship, patient autonomy (informed consent), and the practitioner’s duty of nonmaleficence (do no harm).
Wrong 😕
[35:9] Justice (be fair) is the implementation of public policy to address various types of health disparities. Technologically laden hospitals have created unanticipated health disparities. In the attempt to heal, there are times in which the patient and the practitioner need to accept that any further treatment is futile and death is unavoidable and imminent. In such circumstances, the only just or fair thing to do is to palliate any accompanied pain and suffering without violating the patient-practitioner relationship, patient autonomy (informed consent), and the practitioner’s duty of nonmaleficence (do no harm).
35. Clinical Vignettes
1. Mr. Joshua William Ortiz is a 65-year-old retired carpenter who presents to the palliative care clinic with complaints of worsening shortness of breath and fatigue over the past few weeks. He was diagnosed with lung cancer six months ago and had been undergoing chemotherapy. On examination, he is found to have tachypnea, decreased breath sounds in the left lung base, and oxygen saturation of 88% on room air. His differential diagnosis includes pulmonary embolism, pneumonia, and progression of the underlying lung cancer. The ethical question in this scenario is whether to provide palliative care and manage the patient's symptoms or pursue further aggressive treatment to manage the underlying disease.
2. Mr. James Lee is a 68-year-old retired accountant who has been diagnosed with pancreatic cancer. He has undergone chemotherapy but has experienced severe side effects, including nausea, vomiting, and loss of appetite. He also suffers from significant pain in his abdomen, which is affecting his ability to perform activities of daily living. His differential diagnosis includes pancreatic cancer, chemotherapy-induced nausea and vomiting, and chemotherapy-induced peripheral neuropathy. What is the ethical question in this case?
3. Mr. Nathaniel Harrison, a 65-year-old retired teacher, is admitted to the hospital with a diagnosis of metastatic lung cancer. His primary complaint is severe pain in his chest and difficulty breathing. The patient's daughter, who is his primary caregiver, reports that Mr. Harrison has been increasingly fatigued and has lost his appetite. The clinical team suspects that he may be experiencing other symptoms such as anxiety, depression, and spiritual distress. What is the ethical question that arises in this case?
4. Mr. James Brown is a 65-year-old retired construction worker who has been diagnosed with advanced lung cancer. He is experiencing shortness of breath, pain in his chest and back, and fatigue. His clinical differential diagnosis includes lung cancer, metastatic disease, and pleural effusion. He is considering his treatment options and expresses a desire to maintain his quality of life and minimize his pain and suffering. What is the appropriate approach to Mr. Brown's care?
5. Mr. David Johnson is a 72-year-old retired accountant who has been battling pancreatic cancer for several years. Despite undergoing various treatments, Mr. Johnson's cancer has progressed, and he is now experiencing severe pain and discomfort, which is impacting his quality of life. His clinical symptoms include abdominal pain, loss of appetite, and nausea. The differential diagnosis includes pancreatic cancer-related pain, side effects of cancer treatments, and underlying comorbidities. What ethical question arises when providing palliative care to Mr. Johnson?
CORRECT! 🙂
Explanation: Providing symptom management and palliative care is the best option in this scenario. The core principles of palliative care include patient autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair) [35:1]. In this case, the patient has a life-limiting illness, and the goal of care should shift from curative to palliative. Palliative care aims to improve the quality of life and reduce suffering in patients and families facing life-threatening illnesses [35:2]. The palliative care team can work with the patient and family to manage symptoms, improve comfort, and provide emotional support [35:4]. Starting antibiotics or increasing chemotherapy may not be effective in managing the patient's symptoms and may cause harm, violating the principle of nonmaleficence (do no harm) [35:7]. Ordering imaging studies may delay necessary symptom management and may not be in line with the patient's goals, values, and priorities. Therefore, providing symptom management and palliative care is the most appropriate course of action.
Wrong 😕
Explanation: Providing symptom management and palliative care is the best option in this scenario. The core principles of palliative care include patient autonomy (informed consent), beneficence (do good), nonmaleficence (do no harm), and justice (be fair) [35:1]. In this case, the patient has a life-limiting illness, and the goal of care should shift from curative to palliative. Palliative care aims to improve the quality of life and reduce suffering in patients and families facing life-threatening illnesses [35:2]. The palliative care team can work with the patient and family to manage symptoms, improve comfort, and provide emotional support [35:4]. Starting antibiotics or increasing chemotherapy may not be effective in managing the patient's symptoms and may cause harm, violating the principle of nonmaleficence (do no harm) [35:7]. Ordering imaging studies may delay necessary symptom management and may not be in line with the patient's goals, values, and priorities. Therefore, providing symptom management and palliative care is the most appropriate course of action.
Wrong 😕
Explanation: The core principles of palliative care include beneficence (do good) and nonmaleficence (do no harm) [35:1]. In this case, the ethical question is how to alleviate Mr. Lee's pain and suffering caused by the side effects of chemotherapy, which is in accordance with the principle of beneficence. Palliative care aims to improve the quality of life and reduce suffering in patients with serious illnesses, including those undergoing cancer treatment [35:2]. The primary goal of palliative care is to address the physical, psychosocial, and spiritual needs of the patient, rather than attempting to cure the underlying disease [35:2]. Therefore, increasing the dosage of chemotherapy or persuading Mr. Lee to consider hospice care does not align with the core principles of palliative care. In addition, encouraging Mr. Lee to continue chemotherapy despite the side effects may not be in his best interests and may violate the principle of nonmaleficence.
CORRECT! 🙂
Explanation: The core principles of palliative care include beneficence (do good) and nonmaleficence (do no harm) [35:1]. In this case, the ethical question is how to alleviate Mr. Lee's pain and suffering caused by the side effects of chemotherapy, which is in accordance with the principle of beneficence. Palliative care aims to improve the quality of life and reduce suffering in patients with serious illnesses, including those undergoing cancer treatment [35:2]. The primary goal of palliative care is to address the physical, psychosocial, and spiritual needs of the patient, rather than attempting to cure the underlying disease [35:2]. Therefore, increasing the dosage of chemotherapy or persuading Mr. Lee to consider hospice care does not align with the core principles of palliative care. In addition, encouraging Mr. Lee to continue chemotherapy despite the side effects may not be in his best interests and may violate the principle of nonmaleficence.
CORRECT! 🙂
Explanation: In this case, the ethical question that arises is how to manage Mr. Harrison's severe pain. The core principle of palliative care is to provide patient-centered care that maximizes the patient's best interests in accordance with the patient's goals, values, and priorities. The goal of palliative care is to prevent and relieve suffering, whether physical, psychosocial, or spiritual [35:2]. The use of opioids is an appropriate and ethical approach to managing pain in palliative care, as it falls under the principle of beneficence (do good) [35:8]. However, the use of opioids should also be carefully monitored and managed to avoid the risk of addiction or other negative side effects. The other options are not appropriate as placing the patient on life support, or transferring him to hospice care, may not be appropriate or necessary at this stage, and while the patient's daughter may be involved in the decision-making process, the ultimate decision should be made in accordance with the patient's autonomous wishes and preferences [35:4-6].
Wrong 😕
Explanation: In this case, the ethical question that arises is how to manage Mr. Harrison's severe pain. The core principle of palliative care is to provide patient-centered care that maximizes the patient's best interests in accordance with the patient's goals, values, and priorities. The goal of palliative care is to prevent and relieve suffering, whether physical, psychosocial, or spiritual [35:2]. The use of opioids is an appropriate and ethical approach to managing pain in palliative care, as it falls under the principle of beneficence (do good) [35:8]. However, the use of opioids should also be carefully monitored and managed to avoid the risk of addiction or other negative side effects. The other options are not appropriate as placing the patient on life support, or transferring him to hospice care, may not be appropriate or necessary at this stage, and while the patient's daughter may be involved in the decision-making process, the ultimate decision should be made in accordance with the patient's autonomous wishes and preferences [35:4-6].
Wrong 😕
Explanation: Palliative care is an approach that improves the quality of life of patients facing life-threatening illnesses, with a focus on reducing suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual [35:2]. In Mr. Brown's case, palliative care is the most appropriate approach to care, given his desire to maintain his quality of life and minimize pain and suffering. Referring Mr. Brown to hospice care would only be appropriate if he had less than six months to live, which is not indicated in the clinical vignette. Aggressive chemotherapy would not be effective at this stage of the disease, and it would cause unnecessary harm, violating the principle of nonmaleficence (do no harm) [35:8]. Encouraging Mr. Brown to continue with his current course of treatment and manage his pain with painkillers would not address his desire to maintain his quality of life and minimize suffering, violating the principle of beneficence (do good) [35:8]. Therefore, providing palliative care services to manage symptoms and maximize quality of life, is the most ethical approach to Mr. Brown's care.
CORRECT! 🙂
Explanation: Palliative care is an approach that improves the quality of life of patients facing life-threatening illnesses, with a focus on reducing suffering through the early identification, correct assessment, and treatment of pain and other problems, whether physical, psychosocial, or spiritual [35:2]. In Mr. Brown's case, palliative care is the most appropriate approach to care, given his desire to maintain his quality of life and minimize pain and suffering. Referring Mr. Brown to hospice care would only be appropriate if he had less than six months to live, which is not indicated in the clinical vignette. Aggressive chemotherapy would not be effective at this stage of the disease, and it would cause unnecessary harm, violating the principle of nonmaleficence (do no harm) [35:8]. Encouraging Mr. Brown to continue with his current course of treatment and manage his pain with painkillers would not address his desire to maintain his quality of life and minimize suffering, violating the principle of beneficence (do good) [35:8]. Therefore, providing palliative care services to manage symptoms and maximize quality of life, is the most ethical approach to Mr. Brown's care.
CORRECT! 🙂
Explanation: Palliative care focuses on providing patient-centered care that maximizes the patient's best interests in accordance with their goals, values, and priorities. The core principles of palliative care include patient autonomy, beneficence, nonmaleficence, and justice. Palliative care aims to prevent and relieve suffering, and pain management is a critical aspect of this care. It is essential to prioritize pain management over other aspects of care to improve the patient's quality of life and reduce their suffering. While the other options may have ethical implications in certain situations, prioritizing pain management aligns with the core principles of palliative care [35:1, 35:2, 35:4, 35:8].
Wrong 😕
Explanation: Palliative care focuses on providing patient-centered care that maximizes the patient's best interests in accordance with their goals, values, and priorities. The core principles of palliative care include patient autonomy, beneficence, nonmaleficence, and justice. Palliative care aims to prevent and relieve suffering, and pain management is a critical aspect of this care. It is essential to prioritize pain management over other aspects of care to improve the patient's quality of life and reduce their suffering. While the other options may have ethical implications in certain situations, prioritizing pain management aligns with the core principles of palliative care [35:1, 35:2, 35:4, 35:8].
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35. Reflection Vignettes
1. Ms. Jane Doe is a 60-year-old retired teacher who has been experiencing severe pain and suffering due to a serious illness. Despite her illness, Ms. Doe does not qualify for hospice care, and she is seeking options to improve her quality and quantity of life. The practitioner has recommended several treatment options to alleviate her symptoms, including palliative care and pain management medications. The practitioner has also discussed the potential benefits and risks of each option and involved Ms. Doe in the decision-making process.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
**
2. Dr. Sarah Johnson is a 55-year-old medical practitioner with years of experience in palliative care. She has a patient who is terminally ill and desires to die in the comfort of their own home surrounded by loved ones. However, due to the patient's condition, they require a significant amount of medical attention and care, making it difficult to leave the hospital. Dr. Johnson recognizes the patient's wishes and begins to work with the interprofessional team to make arrangements for the patient to be discharged and receive care at home while continuing to receive palliative treatment.
Think
Assess
Patient: Autonomy
Practitioner: Beneficence & Nonmaleficence
Public Policy: Justice
Conclude
***
