Introduction
Medical approach to management of patients with chronic diseases has changed over time due to changes in technology, the fact that people acknowledged new rights of all human race, scientific advancement in the health sector and the use of patient advocacy. These have also influenced decision making and care management has been imposed as ethical and legal consideration in patient management. All these changes have necessitated the act of addressing ethical concerns that can match well with the changes where humanistic aspects are the foundation of palliative medicine care practices. Palliative care is centered on the patient and the family (Brock, 2003).
Definition of palliative care
These are services that alleviate or reduce the pain of the symptoms which hinders the quality of life. These are only used as the last resort when curative treatments are no longer appropriate to treat the life threatening illness. Ethics is a generic term that has also been used in palliative medicine care as a way of examining moral life. Clinical ethics is very crucial practical discipline that aids in decision making among the health professionals as it helps to identify, carry out analysis hence postulates ethical issues in clinical medicine. Ethics in palliative care is subject of concern and it involves practical reasoning about personalities who demands substantial medicinal care practices (Bradshaw, 2000).
There are varieties of the principles that have been put forward by ethicists as way forward of analyzing and resolving incredible situations. The major principles used are beneficence, non-maleficence, justice and respect of autonomy. The principles are balanced to match with particular ethical scenario. These principles sometime can be hectic as it may conflict leading an ethical dilemma (Brock, 2003)
Physicians, nurses, psychologist, social workers and chaplains must practice the ethical principles to ensure that their patients get the best quality services. The patients can get quality life through comprehensive management of the psychological, social and spiritual needs of a patient while taking care of their personal, cultural and religious beliefs (Brock, 2003)
Case study
Mrs. Smith was admitted at the hospital due to chronic pulmonary diseases. She had signed such as cough, headache and shortness of breath. Her case worsened when she was at the hospital and she was transferred to ICU and the person who was supposed to take care of her was not familiar with the case. The problem continued and she was left alone at night with a ventilator that supplied air into her lungs to keep her alive.
As her case continued to worsen, the doctors and nurses did not attend her at all and there was no health care directive. The family could not understand what was going on as her health was not improving. This case draws a lot of ethical concerns. She failed to receive adequate pain and symptom management. In addition, there was inadequate communication between the family, the patient and the health care team. This is a clear indication that the clinical team did not follow the ethical principle
Developed countries are well ingrained in cultural matters, traditional and family values and religious and other spiritual aspects of life. The practices of ethical palliative care in these countries have been promoted extensively where ethical issues are stressed. The principles of palliative care practices are adhered to in these developed countries. In the traditional and undeveloped countries, these practices are subjected to a lot of critical dilemma. The way the principles of ethics are incorporated to the patient life is quite different and diverse hence dilemma in these ethics arises (Brock, 2003)
One of the major principles used in palliative care practices is respect for autonomy. This principled recognize the right and the capability of individuals to fully make decisions for himself considering personal values, beliefs and life span. This indicates that an individual is at liberty to choose a treatment according to his decisions and attitudes towards certain treatment practices hence leading to disparity with the postulated care management practices that have been put in place by the Health Organizations.
According to this principle, patient is at liberty to either accept or refuse certain therapy which is contrary to their religious practices. He is also at liberty to refuse these therapies based on their cultural values. It is recommendable that the patient’s decision should be incorporated as it reflects personal values and beliefs. The fact that doctors also have much to say when offering treatments to the patients has interfered with the decisions of the patients. This has conflicted with the expression and patient’s preferences. There are also certain factors that interfere with the patient’s preferences and these includes compromised competence of the patient, problems experienced in understanding the situation and stress of illness.
It is imperative to note that the principle of respect of autonomy implies full disclosure of the relevant information concerning goals of care, options and expectations of the patient and status of the patient. Patient’s autonomy should be subjected to discussion by all relevant persons such as family friends and relatives of the subject. The adoption of these principles has been subject to a lot of criticism in the developing countries due to incompatibility of the ideologies with the principles. Cultural incompatibility has been a great problem to the implementation of the principle hence giving rise to ethical dilemma. Some factors hinder the practice of some of the palliative care practices in the developing countries. These factors include poverty, extended families, and insufficient health structures (Hook, 2000)
From the excerpt given, we can notice some ethical dilemma. The hospital team has not followed the principle of respect of autonomy. The doctors are not fair enough in the sense that they are giving the true information about the status of the patient. The care of Fulkerson was married with a lot of mishaps. The fact that the parents were not allowed to see their son is another conflict hence ethical dilemma. The parents wanted their son to be intubated but the advice of the doctors in the course of treatment differs substantially.
The parents were bored about the care that was given to their son hence falls asleep. The treatment team did not deliver the information concerning the condition of their child at expected time. The parents were complaining that the doctors were not given information at the right time. When the doctor told the parents of the victim that their son could not be saved, they pleaded that their son is put in a breathing machine. The physician insisted that they had done to their best hence all were impossible. The death of their son was shocking to them as they were informed early enough. All these practices were against the principle of respect for autonomy which stipulates that all aspects of expectation and preferences of the relatives and friends of the patient must be incorporated in the care and management of the victim.
The doctors did not deliver rightful information on time hence failure to follow the principle and this amount to ethical dilemma. It is quite important to note that palliative care practices differ from country to country and it is been determined by both economical and cultural factors. According to some experienced physicians such as Maddocks, the application of the principle of respect of autonomy differed between developed and developing countries (Hook, 2000)
In the rapidly changing world, there may be ethical dilemmas that apply to most countries irrespective of their development and others that are unique to developing or low-resource countries. There may also be certain issues that are unique to the Indian setting and some in common with other South-East Asian countries
Another principle which is very relevant in palliative care is the principle of beneficence. This principle requires that it is the role of the physician to prevent harm while promoting good. This principle has been employed severally in the application of care. The health care team must promote good in their daily operations in the care of the patients. They should try as much as possible to maximize benefits while reducing harm that might face the patient and the relatives and friends of the patient. The principle postulates that the health management team should deliver the most effective treatments that are of paramount importance to the patient.
These treatments should relief pain and reduce some severe symptoms. It is the role of the physicians and other health care management team to offer very sensitive support. The principle further holds that the health care team has to assist the families and patient in any way possible and in a very effective way. Palliative care practices are applied differently in different countries. For example, palliative care has been practised in India based on the spiritual and cultural customs and rituals. With the advancement of the medicinal treatments, palliative care is reforming. The patients are no longer being served well hence they receive futile treatments that are sometime very expensive.
These are very contrary to their expectations which are to receive maximum medical management in the form of palliative care and psychological support. From the excerpt given, there are clear indications that there were ethical dilemmas in the care of Fulkerson. The doctors did not maximize their efforts for the benefit of the patient. When the mother of the child requested the patient to be put in a breathing machine, the doctors claimed that there had done everything possible but all in vain.
This indicates that we’re not willing to deliver the most effective and beneficial care practices to safe the life of the patient. After the death of Fulkerson, the parents were advised transfer the dead body to another facility claiming that the facility did not provide insurance for the patient. This is very weird behavior among all doctors who are required to provide psychological support to the families of the bereaved. According to the principle of beneficence, it is very crucial that the doctors and other health care team to offer very sensitive support to both the family members and the patient himself. The excerpt also indicates that the doctors failed to fully communicate with the family of the patient.
There was no proper communication between the health care team and the family. The health care team also failed to provide the family with the adequate time with the patient during his final hours was against the principle of beneficence. The health care team failed to offer social services or resources that the family could use to gather for burial expenses. All these were shortcomings of the health care team and are against the principle of the beneficence. This is an ethical dilemma. It is the role of the health team to have systems that are very efficient especially the orchestrated systems. In this hospital, we are told that there was poor orchestrated system which made the death of the patient very painful (Hook, 2000)
The third principle which is very important is the non-maleficence. These principles state that the health care team should not offer information in a very insensitive way, they should not provide inappropriate treatment to patients, treat the patient aggressively when he or she does not require such kind of treatment, withdraw treatment when the patient still requires it and provision of the unwanted sedation to the patient when they are unnecessary. It is mandatory that the health care team put more efforts to ensure that the patient gets improved quality end-of-life care. From the information given, it depicts that the team did nothing to improve the end-life of the patient. They did not offer quality services to promote improved quality life of the victim (Bradshaw, 2000).
Last but not least is the principle of justice. This relates to practices that are apparent in most health institutions and postulates that the health care team should be fair in application of care. It states that patients should receive health care that is legal and are right medically. Justice in this case refers to giving equal care to all the as they deserve. The principle of justice entails a concern for common good and communal considerations (Arnold & Jorge, 2001)
How to resolve the ethical dilemma on palliative care
Well-orchestrated system of care is very crucial in resolving ethical dilemma on palliative care. This encompasses duties and obligations of policymakers, health care workers, hospitals, individuals and community organizations. Some states have had strategies to resolve the matter. They have established end-of-life organizations that are concerned with designing of the assess care. Health care personnel and policymakers are recommended to:
- They should tailor policies to people who are affected by a terminal illness
- There should be proper drug prescription that is used for symptom relief
Conclusion
Countries with traditional background are adamant in implementing the four principles of ethics. It is quite difficult to understand the complexity of the developing countries. Ethical issues that are related to palliative care should be handled with care within the framework of traditions and culture. Financial constraints are also very dangerous to ethical issues
References List
Bradshaw, G (2000). Ethical Dilemma on Palliative Care. The Hospital-Hospice Interface. Oxford: Oxford UP, 1998, pp. 200-240.
Brock, G (2003). Palliative options of Last Resort: A Practical Approach to Ethical Decisions in Clinical Medicine, 6th Ed. New York: McGraw Hill, 150-178.
Campbell, Arnold & Jorge, A (2001). Responsibility of Physician. Health Professionals and Volunteers. San Francisco: Jossey-Bass Inc. 860-890.
Hook, M (2000). Palliative Care and Hospice: Basic Issues in Medical Ethics, 6th ed. Belmont, CA: Thompson, 260-280.