Regardless of the environment, nurses can play an important role in facilitating the shift from vigorous therapy to palliative care. They must be prepared to make ethical and compassionate judgments while avoiding professional liability exposures in order to do so.
Most hospital deaths occur in intensive care units (ICUs), where patients get extensive, high-tech, and expensive treatment. These last days of life are often marked by unnecessary agony, as the landmark SUPPORT study of 9,000 hospitalized patients revealed. Rather than prolonging life, palliative care focuses on providing supportive care that promotes patients’ comfort and dignity.
Who is eligible for palliative care?
Palliative care is defined by the World Health Organization as active, complete care of patients whose illness no longer responds to curative therapy. It affirms life and views death as a natural process. Death neither hastens nor postpones. It also relieves pain and other unpleasant symptoms.
While palliative care has its roots in the Chicago hospice movement, it does not have to be confined to patients who are anticipated to die within six months, as Medicare originally intended. It should also not be restricted to hospice patients.
Obligations as a nurse
If your patient is getting palliative care, you may be a key member of a healthcare team. A social worker, chaplain, pharmacist, dietician, physical and occupational therapists, and other allied health workers may be included in the team, in addition to one or more nurses and the patient’s primary care practitioner (PCP).
Assessing for pain and other unpleasant symptoms, offering evidence-based therapies to alleviate them, and avoiding the beginning of interventions that may not enhance comfort and quality of life are just a few of the nursing responsibilities. Nurses also collaborate with other team members to address the emotional and spiritual aspects of terminal disease. Finally, when nurses shift their focus from treating the patient to palliative care, they must collaborate with family members. After the patient’s death, the commitment to family members should continue, with assistance and, if necessary, referral for therapy.
There are several options for end-of-life care: Should antibiotics be used to treat pneumonia? Is it possible that a ventilator may help with respiratory distress? Is it necessary to begin tube feeding? Is it necessary to continue dialysis? The patient should be at the heart of these decisions, according to palliative care principles. But what if the patient is asleep, unable to communicate, or senile, and hence unable to make these decisions? That’s where Terri Schiavo’s situation comes into play.
Although Ms. Schiavo was a minor, many observers believe that an advanced directive would have made the decision-making process considerably easier. It may have specified her choices for treatments like artificial feeding that kept her alive. Maybe Terri Schiavo had a healthcare proxy (durable power of attorney for healthcare) saying who she wanted to represent her if she couldn’t. There is no guarantee that a patient’s wishes would be honored even if signed and recorded.
Advanced Care Planning (ACP) is a more thorough method.
ACP is a sort of anticipatory advice that involves both family members and the patient early in the patient’s sickness. If we can enhance communication and lifecare planning earlier in the patient’s lifetime, Okun says, “each of us will get more experience weighing key health-related decisions, including those at the end of life.” In what she refers to as “lifecare dialogues,” the patient and family members debate the anticipated trajectory of the condition, as well as the merits and downsides of possible therapies, with the help of the interdisciplinary team. They collaborate to identify the patient’s objectives and choose the best way to achieve them. Writing an advanced directive, which should be reevaluated on a regular basis, is frequently a component of this procedure.
What about do-not-resist (DNR) orders?
CPR is required for respiratory or cardiac arrest, even if the patient has an advanced directive or has said clearly that he or she does not want CPR in a life-threatening situation—unless the file has a PCP’s DNR order. It’s critical for nurses to explain this to patients and their families, to offer information about the chances of resuscitation efforts succeeding, and to determine whether the patient or the chosen surrogate wants a DNR order and, if so, to get one from a PCP.
Risks and ethical conundrums
End-of-life care frequently necessitates challenging ethical decisions and raises concerns about potential liability. Withdrawal of life-sustaining treatments like dialysis or a feeding tube, as well as the necessity for high or growing doses of opioids (which can have major side effects or possibly be fatal) or sedatives, are all concerning problems.
According to the American Nurses Association, nurses have a moral obligation to advocate for patients when prescribed medicine is poorly managing pain and other unpleasant symptoms. It is morally acceptable to increase medicine titration to treat symptoms. The Hospice and Palliative Nursing Association has a similar view on the use of potentially lethal sedatives, called terminal sedation.
Euthanasia and assisted suicide
which are not sanctioned by nursing rules of conduct and are illegal in practically every state, are not the same as actions based on these principles.
In some situations, withholding or terminating life-sustaining therapy is legal and ethical. Artificial feeding and hydration is avoided. Obey your institution’s rules and the law. You must advocate for the patient’s wishes, advance directive or not. A palliative care professional may be consulted to help the family make end-of-life decisions. Care plans are developed based on patient and family desires, says Hospice and Palliative Nurse Association CEO Judy Lentz.
Request that a patient’s care be transferred to a colleague if the patient’s desire to stop life-sustaining treatments clashes with your own beliefs. To protect yourself from potential responsibility, properly document any talks you have with the patient, family, or other professionals concerning end-of-life decisions.