Palliative Care and End-of-Life Decisions

G. Smith

• Editorial: Palgrave Pivot
• Año: 2013
• ISBN:
  9781137377395
• Categoría: Law
• Categoría: Medical Law

Total pain management mandates that an ethic of adjusted care be implemented at the end-stage of life which acknowledges ethically, legally, and clinically the use of terminal sedation as efficacious treatment.

1

Broadening the Boundaries of Palliative Medicine

Abstract: Acknowledging the great promise of palliative care management for assuring that the end-of-life becomes a more compassionate experience, this book’s bold thesis advocates the liberal use of sedative medications to relieve refractory distress by the reduction in patient consciousness. Accordingly, palliative sedation therapy must be seen as proper medical treatment and consistent with sound principles of adjusted care which, in turn, should be the standard for all hospice medicine. When a diagnosis and prognosis present the patient as suffering a futile medical condition, and where patient consent or surrogate approval is obtained, compassion directs palliative (or terminal) sedation be offered as efficacious treatment to alleviate intractable physical and existential suffering.

George P. Smith. Palliative Care and End-of-Life Decisions. New York: Palgrave Macmillan, 2013. DOI: 10.1057/ 9781137377395.

Over the next 30 years, the projected population of seniors in the United States will more than double—rising from 34 million in 1997 to, by 2030, over 69 million.¹ By that time, one out of five Americans will have attained the age of 65 or older.² For baby boomers, one in nine may expect to reach the age of 90; and by the year 2040, those Americans over the age of 85 will have reached nearly four times that of those in 2003.³ The potential use of both hospice and palliative care for these Americans staggers the imagination.⁴

In 2007, it was estimated that every 72 seconds an American developed Alzheimer’s disease;⁵ and by mid-century, this diagnosis will be made every 33 seconds.⁶ Unless medical science finds a way to prevent or to treat effectively this disease, the predictions are that by 2050, the number of individuals aged 65 and over with Alzheimer’s could range from 11 million to 16 million.⁷ The Medicine Payment Advisory Committee—an independent commission that advises Congress—reported that from 1998 to 2008, Alzheimer’s and chronic dementia hospice cases grew from 28,000 to 174,000.⁸

In the United States, today, for Medicare Hospice Benefits to be activated, one must have a “terminal illness”⁹ which means that a patient’s medical prognosis is that he has only six months or less of life remaining.¹⁰ Within some 39 pages in the Code of Federal Regulations,¹¹ procedures are laid out carefully for the administration of hospice care and the scope of financial responsibility for the government—for which Medicare covers nearly all costs associated with this care.¹² Throughout these policies and regulations, the stated goal for hospice care is to provide assistance which “optimizes quality of life by anticipating, preventing and treating suffering,” and thereby “facilitate patient autonomy, access to information and choice” is unwavering.¹³

According to Medicare records, Medicare spending on hospice care from 2005 through 2009 rose 70% to $4.31 billion.¹⁴ The Inspector General for the U.S. Department of Health and Human Services found for-profit hospices were paid 29% more per beneficiary than non-profit hospices. Medicare pays for 84% of all hospice patients.¹⁵ All too frequently, for-profit hospices have been thought to “cherry pick” those patients who will live the longest and require the least amount of care—as for example, patients with dementia or Alzheimer’s rather than those with cancer.¹⁶

Very often, palliative care practice seeks to manage incurable illness in “the least unpleasant course” and thereby allow a patient to die from their incurable illness in a manner which is the least traumatic.¹⁷ In order for a competent patient to exercise his autonomy and be informed sufficiently to determine the course of his medical treatment or non-treatment, an admittedly “gruesome discussion about ways of dying” must follow;¹⁸ for, this then allows the patient to decide—essentially—which, of several terminal events, will end his life.¹⁹ Understandably, some patients will not be willing, or psychologically capable, of entering into such a discussion.²⁰ In situations of this nature, the health care decision-makers must attempt to discern the patient wishes by evaluating the patient’s “total good or best interests.”²¹ The challenge here is that if the patient is not informed, he cannot have a basis for formulating and evaluating ideas which promote his own best interests as he approaches his death.²²

Political obstructions

When the United States Congress tackled this issue of advance planning consultations in debating the Patient Protection and Affordable Act,²³ high drama and near-hysterical rantings occurred over an irrational fear that discussions with one’s general practitioners of this nature were little more than a precursor to end-stage decisions by so-called “death panels” regarding who would receive treatment and who would not.²⁴

The Act was signed into law in March 2011, and did not include any provisions concerning end-of-life planning.²⁵ Rather, it was added initially to a complex Medicare-proposed regulation by the U.S. Department of Health and Human Services, setting payment rates for physicians’ services during “annual wellness visits” for Medicare beneficiaries to include “advance care planning” for end-of-life management.²⁶ The final rule promulgated, however, excluded this very provision for consultation.²⁷

End-of-life conversations: a national effort

The American Academy of Nursing has taken a leadership role in promoting a national dialogue aimed at educating the public as well as health professionals of the need for end-of-life conversations, which allow patient values and preferences for end-care and treatment to be discussed and considered before they become issues.²⁸ Ideally, this type of advance planning should occur rightfully among the supervisory care professionals, the involved patients, and their families.²⁹

When forced to determine whether to offer life-prolonging and life-sustaining treatments to terminally ill autonomous patients, health care decision-makers should be guided by an evaluation of whether treatment measures are physiologically futile and the intrinsic burdens and risks they raise are overwhelmingly greater than their benefits;³⁰ or, in other words, is the ...