Ethical dilemmas in palliative care in traditional developing societies, with special reference to the Indian setting

BACKGROUND

There are intriguing and challenging ethical dilemmas in the practice of palliative care in a traditional developing society.

OBJECTIVE

To review the different ethical issues involved in cancer and palliative care in developing countries, with special reference to India.

METHODS

Published literature on pain relief and palliative care in the developing countries was reviewed to identify ethical issues and dilemmas related to these, and ways in which ethical principles could be observed in delivery of palliative care in such countries are discussed.

RESULTS

The literature review revealed a number of ethical dilemmas and challenges that professionals, cancer patients and their families encountered during palliative care. It was noted that patients' preferences and decisions are influenced by family members. Dilemmas leave the professionals and families confused about how ethical their actions have been. Specific ethical issues were noted in relation to the availability and use of oral morphine for pain relief, spiritual care, lack of adequate palliative care services, and palliative care education.

CONCLUSIONS

The four principles of ethics posed difficulties in understanding the complex ethical issues in a developing country with a traditional background. Ethical issues need to be handled delicately and sensitively in palliative care settings, within the framework of the traditions and culture of the society and financial constraints. The possible role of ethics committees in palliative care settings to help decision-making needs to be studied and discussed.

French district nurses' opinions towards euthanasia, involvement in end-of-life care and nurse patient relationship: a national phone survey

OBJECTIVES

To assess French district nurses' opinions towards euthanasia and to study factors associated with these opinions, with emphasis on attitudes towards terminal patients.

DESIGN AND SETTING

An anonymous telephone survey carried out in 2005 among a national random sample of French district nurses.

PARTICIPANTS

District nurses currently delivering home care who have at least 1 year of professional experience. Of 803 district nurses contacted, 602 agreed to participate (response rate 75%).

MAIN OUTCOME MEASURES

Opinion towards the legalisation of euthanasia (on a five-point Likert scale from "strongly agree" to "strongly disagree"), attitudes towards terminal patients (discussing end-of-life issues with them, considering they should be told their prognosis, valuing the role of advance directives and surrogates).

RESULTS

Overall, 65% of the 602 nurses favoured legalising euthanasia. Regarding associated factors, this proportion was higher among those who discuss end-of-life issues with terminal patients (70%), who consider competent patients should always be told their prognosis (81%) and who value the role of advance directives and surrogates in end-of-life decision-making for incompetent patients (68% and 77% respectively). Women and older nurses were less likely to favour legalising euthanasia, as were those who believed in a god who masters their destiny.

CONCLUSIONS

French nurses are more in favour of legalising euthanasia than French physicians; these two populations contrast greatly in the factors associated with this support. Further research is needed to investigate how and to what extent such attitudes may affect nursing practice and emotional well-being in the specific context of end-of-life home care.

Euthanasia and physician-assisted suicide in the Dutch homecare sector: the role of the district nurse

AIM

This paper is a report of the findings of a study into the role of district nurses in euthanasia and physician-assisted suicide in homecare organizations, conducted as part of a study into the role of nurses in medical end-of-life decisions.

BACKGROUND

Issues concerning legislation and regulation with respect to the role of nurses in euthanasia and physician-assisted suicide gave the Minister for Health reason to commission a study into the role of nurses in medical end-of-life decisions in hospitals, nursing homes and homecare organizations. This is the first quantitative study from the perspective of nurses. Previous quantitative studies were conducted under physicians and information on the role of nurses was obtained indirectly.

METHOD

A questionnaire was sent in 2003 to 500 district nurses employed in 55 homecare organizations. The absolute response rate was 86.0% and 81.6% (408) could be used for analysis.

RESULTS

In 22.3% of 278 cases, the district nurse was the first with whom patients discussed their request for euthanasia or physician-assisted suicide. In about half (49.8%) of 267 cases nurses were not involved in the general practitioner's decision-making process, and in only 13.3% of 264 cases, did they attend the administration of the lethal drugs. District nurses had provided some degree of aftercare to the surviving relatives in 80.3% of 264 cases.

CONCLUSION

Collaboration between general practitioners and district nurses needs improvement, particularly in relation to decision-making. Our Dutch data could help nurses in other countries to define their (future) role in euthanasia and physician-assisted suicide.

Morphine prescription in end-of-life care and euthanasia: French home nurses' opinions

OBJECTIVE

This study aimed to investigate factors that might lead French homecare nurses to consider the prescription of high-dose morphine to terminally ill patients to be euthanasia.

METHODS

The researchers conducted an anonymous telephone survey among a random sample of 602 French homecare nurses (response rate = 75 percent) in 2005.

RESULTS

Overall, 27 percent of responding home nurses considered prescribing high-dose morphine to terminally ill patients to be euthanasia. Such an opinion was more frequently held by older nurses, those who had not followed terminally ill patients during the previous three years, and those with less knowledge about pain management involving opioid analgesics.

CONCLUSION

There is an urgent need to strengthen pain management education among French homecare nurses--especially regarding the use of morphine--in order to both improve their technical skills and correct some misconceptions about opioid analgesics.

Managing Pain, Managing Ethics

Noncompliance of family caregivers can present home hospice nurses with difficult ethical choices and powerful feelings about those choices. This is particularly so when family members do not adequately palliate their loved ones, resulting in treatable symptom distress during the dying process. This article presents a case study, moral analysis, and an evidence-based, practical plan of action for engaging family members of palliative care patients on a home hospice service.

Neither seen nor heard: children and homecare policy in Canada

Changes in public policy have led to increasing numbers of children with disabilities and complex medical needs being cared for in the homes of Canadians. Little work, however, has explored the ethical implications of these policies. This paper focuses on some of the shortcomings of current policy and describes a developing method for policy analysis with an explicit focus on ethics that could be adopted in other nations. Three forms of analyses - descriptive, conceptual and normative - conducted on Canadian homecare policy documents describe various dimensions of Canadian homecare policy. The descriptive analysis demonstrated that the jurisdiction of homecare services is dispersed across numerous programs and ministries with no single structure for policy implementation and accountability. The needs of children and youth are rarely mentioned in home healthcare policies, but instead are addressed under broader social policies that are focused upon children and family. The conceptual analysis revealed four over-arching themes that represent the predominant elements of a value-structure that underlie homecare policy. They include: (1) home and community care as ideal; (2) the importance of independence and self-care of citizens; (3) family as primary care provider; and (4) citizenship as entitlement to rights and justice. Overall, these themes tend to reflect a neoliberal ideology that shifts the responsibility of care from the state to the individual and his/her family. A normative framework based on critical healthcare ethics is used in the paper to make recommendations to redress the current imbalance between state and family support. For example, including homecare services within the Canada Health Act (CHA) or the development of separate legislation consistent with the principles of the CHA would make it possible to ensure that the principles of universality, accessibility, portability and public administration, as opposed to principles that reinforce competitive individualism, direct the provision of homecare services in Canada.

Ethical dilemma and resolution:a case scenario

This article illustrates an ethical dilemma that I faced while treating an 86-year-old woman at her home. The ethical dilemma was caused due to several factors such as the expectations of the client (client/consumer rights), organisational expectations (employer, governmental and payer-source regulations) and my own personal values (one's moral philosophies, perceived social responsibilities, sense of professional duty) and how they all interact with each other. The case is a classic example of a seemingly simple yet frequent dilemma encountered by occupational and physical therapists in the United States serving clients who are covered by Medicare (the government's health insurance) for home health. The article is aimed at highlighting the various ethical principles involved in clinical decision-making, and it suggests methods for resolution of ethical dilemmas. Although the article is based against the backdrop of the US health care system, students and health care practitioners globally can relate to it.

Ethical considerations for the utilization of tele-health technologies in home and hospice care by the nursing profession

Home care, including hospice care, is a growing component of the current healthcare system and pertains to care services that are provided to individuals, their family members, and caregivers in their own residence. Both domains face funding limitations as life expectancy and the segment of the population older than 65 years increase. Tele-health, defined as the use of advanced telecommunication technologies to enable communication between patients and healthcare providers separated by geographic distance, is perceived as a concept that can enhance both home and hospice care and address some of the current challenges. This article discusses ethical challenges associated with the utilization of tele-health technologies by the nursing profession in the home setting. These factors form a framework for the ethical considerations that result from the introduction of these technologies in nursing practice. Specifically, the article discusses the issue of privacy and confidentiality of patient data, informed consent, equity of access, promoting dependency versus independence, the lack of human touch and the impact of technology on the nurse-patient relationship, and the medicalization of the home environment. These issues constitute a road map both for nursing practitioners who are aiming to provide an efficient delivery of services in the home and for nursing administrators who are asked to make judgments about the use of tele-health technology as a supplement to traditional care and as a cost-saving tool.

Concerned about client decision-making capacity? Considerations for practice

Many more people are reaching old age than ever before, and older people are increasingly living longer. As the nation experiences this unprecedented growth of older Americans, geriatric case managers are likely to encounter many clients at very advanced ages. Concomitantly, practitioners will confront elders with questionable decision-making capacity, as dementia and other cognitive impairments are more common among the older age groups. These clients pose potential safety and well-being concerns and may be vulnerable to exploitation, neglect, and abuse in their homes. Case managers' responses to such client scenarios may range from little involvement, by acquiescing to the client's right to make autonomous decisions, to resorting to legal action, which may lead to a substantial loss of rights for the elder. This article provides considerations for practice with elders presenting with questionable decision-making capacity and precarious living situations. The distinction between capacity and competency is presented and factors affecting decision making are discussed. Ethical aspects are addressed and the process of assessing capacity is reviewed to enhance case managers' practices in this area.

Ethical Issues in Mobile Psychiatric Treatment with Homebound Elderly Patients: The Psychogeriatric Assessment and Treatment in City Housing Experience

Unique and challenging ethical difficulties arise during mobile psychiatric treatment of elderly patients. This article outlines and analyzes five of these challenges that have been encountered during nearly 20 years of experience with the Psychogeriatric Assessment and Treatment in City Housing Program in Baltimore, Maryland. The ethical challenges reviewed are: establishing the treatment contract versus the right to refuse treatment, protecting confidentiality versus patient protection, protecting autonomy versus asserting beneficence, treatment termination versus open-ended treatment, and cost versus benefit of care. Ethical challenges with homebound elderly patients are unique because of patient characteristics as well as features of the treatment environment.

Advanced care planning: A study on home health nurses

The purpose of this research was to assess home health nurses' (HHNs) knowledge, comfort levels, barriers, and personal participation in advanced care planning (ACP), a practice that recognizes patient preferences for health care treatment. Licensed nurses who identified home care as their primary area of practice (N = 519) were surveyed about their knowledge of laws governing ACP and their perceptions of patients' preferences for ACP. Most respondents were women (97%), and the average age of the respondents was 54 years. Most nurses felt knowledgeable and capable of educating patients on advance directives (ADs), although the nurses' knowledge of laws governing ACP was limited and often inaccurate. Generally, nurses felt comfortable during ACP discussions with patients and families. HHNs perceived patient or family reluctance as the greatest barrier hindering discussions of ACP. No association was found between level of education and whether a nurse had a personal AD. Twenty percent of the nurses had their valid personal AD. A greater knowledge base concerning ACP would facilitate HHN discussions with patients and families. Recognition of patient preferences can be enhanced by understanding and overcoming barriers that hinder discussions of ACP. Educational opportunities focusing on ACP are encouraged for all health care providers.

Management guidelines for motor neurone disease patients on non-invasive ventilation at home

Most motor neurone disease (MND) patients die of respiratory system complications. When patients have advanced disease with symptoms of respiratory failure, management issues can become complicated by the introduction of assisted ventilatory devices. Therefore, care provision by a multidisciplinary team must be structured and co-ordinated in order to ensure that patients and their carers receive the optimal level of care. The objective of this article is to review the literature and explore the complex issues surrounding the use of non-invasive positive pressure ventilation (NIPPV) in home care MND patients as a justification for the development of a management guideline for medical practitioners. A guideline for multidisciplinary care of home ventilated MND patients will be proposed.