Public’s awareness of palliative care creates fear, anxiety among providers
Physicians and nurses feel caught in middle of storm
Two recent court cases heightened the public’s awareness of the problems surrounding palliative care and, at the same time, increased the anxiety of health care providers. Physicians and nurses feel caught between providing comfort care to patients and facing criticism from colleagues that their actions may be wrong.
In June, the Nevada Supreme Court overturned a trial court’s decision allowing the state nursing board to suspend a nurse’s license arbitrarily. The supreme court found that the nursing board’s conclusions on key issues lacked evidentiary support. [Nevada State Board of Nursing v. Merkley, Nevada Sup. Ct., No. 27620 (June 4, 1997).] (See Medical Ethics Advisor, October 1997, p. 128.)
The case demonstrates how palliative care can become a thorny issue for health care providers, particularly when the hospital and patient’s family disagree over the level of care provided. In the Nevada case, the nurse refused to accept a written order for a second morphine drip from the patient’s son, who was an anesthesiologist at the hospital but not on the patient’s care team. Another physician on the patient’s care team called in a second order around midnight, but the patient died about an hour later. The nurse back-timed the order, however, by several hours.
In the same month, a Tampa, FL, physician was acquitted of first-degree murder for injecting a terminally ill cancer patient with morphine and potassium chloride. [Florida v. Pinzon-Reyes, Florida Cir. Ct., No. CF-96-00666A-XX (June 26, 1997).] (See MEA, October 1997, p. 128.)
The muddled issues surrounding palliative care may get a much-needed boost when the Joint Commission on Accreditation of Healthcare Organizations issues pain control standards by the year 2000. The Joint Commission, with the Wisconsin Cancer Pain Initiative in Madison, is developing the standards to incorporate in all accreditation chapters. (See MEA, October 1997, pp. 113-119.)
Peers feel actions are wrong
Although aspects of the Florida and Nevada cases were slightly different, both involved a colleague who thought the provider aided in the patient’s death. Both cases involved colleagues who thought the provider acted in an inappropriate manner. The Nevada nurse, for example, was reported by a unit nurse manager for gross negligence and unprofessional conduct. In the Florida case, a nurse refused to administer the medication ordered by the physician.
"There is no formal definition for palliative care or a policy to protect against situations like [the one involving the Nevada nurse]," says Beth Schrimpf, RN, an intensive care unit nurse and chair of the ethics committee at Saint Mary’s Regional Medical Center in Reno, NV. The nurse involved in the case is employed at Saint Mary’s.
"We’ve been pretty successful on an individual patient basis by providing comfort care tailored to that patient’s needs," adds Schrimpf. "If a patient tells us they don’t want any type of measures taken to prolong their life, we take the middle ground and provide comfort care, which might include intensive pain management."
The idea of providing palliative care suited to each patient’s needs is echoed by Kelle Brogan, MD, medical director at Saint Mary’s Hospice of Northern Nevada, which is part of the Saint Mary’s Health System, also in Reno.
"We have no written policy or procedure, but if a patient identifies a suicidal wish, whichever team member identifies that wish will speak to me," Brogan says. "At that point, we will have a group meeting to identify the reason the patient feels the way they do."
Typically, a case manager or the admitting nurse at the hospice will identify a patient’s desire to die. At that point, the care team, consisting of the medical director, the case manager, social worker, and chaplain, will meet to discuss the patient’s case. The hospice’s philosophy regarding palliative care, says Brogan, is to identify each patient’s fear. "We have to approach each patient’s fear of death by identifying the reason for the fear," she explains. "If the patients say they are afraid of the pain, then we discuss how their pain will be controlled. If it’s a spiritual issue, then the staff provides assistance in conjunction with the chaplain’s services.
"I’m not afraid to use high doses of narcotics like Ativan when the patient is having severe pain. My intent is to relieve the pain, but I’m not there to participate in a suicide. I won’t abandon patients either or judge whether their fear of death is right or wrong."
All care providers should have a voice’
Getting patient care issues out in the open is the best way to counteract potential disagreements about delivery of care, Schrimpf says. "If there’s an instance where a nurse or physician does not agree with a colleague, the issue is brought to the ethics committee and discussed."
Providers are asked if they have an alternative method in mind and whether they’ve discussed it with the patient, she says. "All care providers should have a voice, but we haven’t had any issues that can’t be resolved. Physicians are coming to the attitude that it’s a matter of opinion, and making the patient well-informed is most important. They are viewing their role as being available to guide and counsel but not make the decision for the patient."
In addition to the Joint Commission’s efforts to develop standards for pain control, several managed care plans and patient advocacy groups are offering to help clarify the palliative care area. In Massachusetts, for example, Brookline-based health plan Harvard Pilgrim, Fallon in Worcester, and Tufts in Medford are looking internally at end-of-life issues, including pain management.
In Minnesota, the Minneapolis-based Allina Foundation, the charitable arm of the Allina Health System, has identified strategic priorities, including the "limits of life," says executive director Mike Christenson. "Nobody else in the managed care area has done what we have regarding end-of-life decision making," he adds.
The priorities are presented as part of Allina’s Project Discussion of Evolving Choices in Dying and Ethics (DECIDE). A goal of the project is to improve how pain is relieved during end-of-life care. (For more on DECIDE, see story, at right.)
"One of the findings was that intensive care unit [ICU] nurses and physicians were surveyed, and both had completely opposing views of how aggressive care should be for patients within that setting, or worse yet, there was a lack of communication," Christenson says. Open communication between nurses and physicians is particularly important in the ICU setting, where terminally ill patients often receive aggressive palliative care to reduce or eliminate pain.
Despite the technological advances in health care delivery, the majority of the decisions regarding palliative care rest with the patient and the family, Schrimpf says.
"Although a care plan can change from one of technology to care, we are still focusing on the comfort aspect," she says.
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