Saturday, December 31, 2011
Friday, December 23, 2011
Thursday, December 22, 2011
Tuesday, December 20, 2011
Sunday, December 18, 2011
Saturday, December 17, 2011
- “What is your understanding of your condition?”
- “What worries you about your situation?”
- “How do you make decisions in your family?”
- “What is important to you right now when making decisions?”
- If the patient is not capable, document this before proceeding to step 2.
- See hierarchy of decision-makers (from Ontario’s Health Care Consent Act).
- Document decision-maker(s)
- “Is there a living will?”
- “Do you know your role?” (e.g., to act on prior expressed wishes or best interests)
- “ Do you know what the patient would have wanted in this situation and what was important to this person?” (share beliefs or stories)
- Document what you learn.
- “ If there are no prior expressed wishes, we then have to consider what is in the best interests of the patient – this means we can propose treatments that will change or improve the condition of the patient for the better, while taking into account this individual’s goals, values and beliefs.”
- “We are going to do what will benefit your loved one, and we will continue the treatments that are indicated and in [his/ her] best interests.”
- “ [Patient’s name] is really sick. We will provide treatment that improves or changes [his/her] condition for the better, so that leaves us with the following options: palliative care, comfort care …”
- “When a treatment is no longer indicated, we will let you know that we are no longer providing it.”
- “It is a challenge when we cannot reach agreement; however, we have a resource that can help us, called the Consent and Capacity Board. It is a neutral third party that will come into the hospital and listen to both sides of the story. The board will then decide what is in the best interests of the patient.”
- “The patient would be appointed a lawyer, and the physician may have a lawyer as well. You personally are entitled to have one also (refer to www.ccboard.on.ca).”
- Document that you have explained the role of CCB. Give the family time to ask questions.
Wednesday, December 14, 2011
Monday, December 12, 2011
"It was remarkable how a low-tech piece of equipment moved our team from the dry efficiency of updates and to-do lists to the fundamental process of caring for the patient."
Friday, December 9, 2011
Hiram Lawrence’s parents have agreed, and Children’s Hospital in Oakland, California, will remove the 1-year-old from life support this afternoon. Writes medical futility scholar Thaddeus Pope: “Apart from the media exposure here, this is how most end-of-life conflicts are resolved. With a little more time and more communication, consensus is usually reached.”
Thursday, December 8, 2011
A toddler, shot in the head, is in an induced coma. Agonized parents want life support at least until the child’s second birthday. “My baby is still fighting,” the mother says. The hospital is testing for brain activity. A pediatrician faces a second opinion with wrenching consequences. And a ethicist says there is no legal or ethical reason the hospital cannot disconnect life support if the child is declared dead. This is playing out now in Oakland, California.
Wednesday, December 7, 2011
Doctors die, but not like everybody else.
They know what’s possible and what’s not.
Or what’s probable.
They know well what “do everything” means, so don’t tend to ask for it.
So says Ken Murray, MD, Clinical Assistant Professor of Family Medicine at University of Southern California.
Don’t miss his compelling and insightful blog:
An effort is underway in Ireland to make palliative care a common component of primary care. Why? It is an acknowledgement of the specialty’s skill with patients in the process of dying, coupled with an awareness that more than 90 percent of the final year of life is spent at home -- so care is heavily reliant on primary care.
Now that the Irish Hospice Foundation has issued its report, “Primary Palliative Care in Ireland: Identifying improvements in primary care to support the care of those in their last year of life,” the next step is making it happen.
A 2010 survey on end-of-life care informs the report and found “a desire for enhanced communication skills for interacting with patients and families at end-of-life.” The survey also underscored the importance of developing “patient information transfer systems, improvement of out of hours services, and training in end-of-life care.”
Another welcome sign that palliative care is emerging from its ghetto of last resort.
Tuesday, December 6, 2011
I’m just now beginning to comprehend the language and usefulness of Twitter and the social network’s means of organizing feeds within the use of hash tags. So maybe this is nothing new. But in the past few weeks, #palliative and #hospice have opened my eyes to the widespread engagement, locally and internationally, of important questions about how we die -- and how patients in the process of dying are treated.
For example, a woman in western Canada is pursuing in court her “right” to an assisted suicide, a practice that could be headed for the 2012 ballot in Massachusetts and to which the Massachusetts Medical Society has reaffirmed its opposition. Meanwhile, the recognized benefits of palliative care are increasing its stature within medical practice at the very time the ranks of trained palliative nurses is shrinking.
All of which fed my interest in a tweet linking to the National Institute for Health and Clinical Excellence, or NICE, website. NICE provides guidance and standards on prevention and treatment in the United Kingdom.
NICE, which is developing clinical guidelines related to the use of strong opioids in palliative care, has posted draft recommendations and invited public comment into the new year.
Importantly, the draft report addresses public concern when the focus of treatment moves from disease to pain, as well as strategies for better communication between the care team and patient, and the side effect of addiction.
"The new draft guideline puts a strong emphasis on good communication between patient and healthcare professionals,” said Dr Fergus Macbeth, director of the Centre for Clinical Practice at NICE. “This is key to ensuring that any doubts or uncertainties are addressed, thereby enabling the patient to feel content in following what has been prescribed and therefore potentially improving their pain control and reducing any associated side effects.”
Notably, the draft guidelines include: “When offering a patient pain treatment with strong opioids, ask them about concerns such as: addiction, tolerance, side effects, fears that treatment implies the final stages of life. Offer patients access to frequent review of pain control and side effects and information on who to contact out of hours, particularly during initiation of treatment.”
For more on the draft guidelines, see: http://guidance.nice.org.uk/CG/Wave24/4.
Monday, December 5, 2011
Studies have shown that palliative care can improve a patient’s quality of life, and sometimes even extend that life. But palliative care tends not to come up in the doctor-patient conversation until rather late in the process. So, if it can do some good, how can palliative care be brought into the conversation earlier?
How about changing the name?
The Oncologist has published a study from the Department of Palliative Care and Rehabilitation Medicine at the University of Texas M.D. Anderson Cancer Center showing that referrals came earlier and more frequently when palliative care was known instead as supportive care.
But is “supportive care” a clear enough term? Might “comfort care” be even better? Or is the meaning of “palliative care,” which covers a broad spectrum of pain management, so well known within medical practice that changing the name would cause confusion and do more harm than good?
Maybe palliative care, like hospice care, just needs to be better understood.
For more on the Anderson study, see: http://theoncologist.alphamedpress.org/content/16/1/105.short