Top Ten Tips Palliative Care Clinicians Should Know About Their Work's Intersection with Clinical Ethics

9121 Background: There is limited empirical research exploring the nature of clinical ethical consultations within the oncology population. Our objective is to review, describe and compare clinical ethics consultations at two NCI-designated comprehensive cancer centers, in order to identify opportunities for systems improvement in clinical care. Methods: This case series is derived from prospectively-maintained clinical ethics consultation databases at each institution. All adult oncology patients receiving ethics consultation from 2007 through 2011 were included as eligible cases. Both qualitative and quantitative analyses were undertaken. Demographic and clinical information were obtained from the databases for all patients, and verified via chart abstraction. Additional variables studied included the reason for and context of the ethical consultation, the patient’s code status before and after consultation, and involvement of palliative care or other adjuvant services. Opportunities for systems-level improvements and/or educational initiatives were identified. Results: A total of 207 eligible cases were identified. The most common primary issues leading to ethics consultation were code status and advance directives (25%), surrogate decision-making (17%), and medical futility (13%). Communication lapses were identified in 41%, and interpersonal conflict arose in 51%. Prior to ethics consultation, 26% of patients were DNR; 60% were DNR after ethics consultation. Palliative care consultation occurred in 41% of cases. Opportunities for systems improvement and professional education related to goals of care at the end of life, the role of palliative care involvement, and improved communication. Conclusions: Ethics consultations among cancer patients reflect the realities inherent to their clinical management. Appropriately addressing advance directives within the context of overall goals of care is crucial. Thoughtful consideration of communication barriers, sources of interpersonal conflict, symptom control, and end-of-life care are paramount to optimal management strategies in this patient population.

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A whole greater than the sum of the parts: Close collaboration between palliative care and clinical ethics.

Journal of Clinical Oncology ◽

10.1200/jco.2016.34.26_suppl.53 ◽

2016 ◽

Vol 34 (26_suppl) ◽

pp. 53-53

Author(s):

Nneka Obiajulu Sederstrom

Keyword(s):

Palliative Care ◽

Clinical Ethics ◽

Sudden Onset ◽

Surgical Intensive Care Unit ◽

Do Not Resuscitate ◽

Power Of Attorney ◽

Close Collaboration ◽

Surgical Intensive Care ◽

Clinical Role ◽

Comfort Care

53 Background: The disciplines of palliative care (PC) and clinical ethics (CE) share common content but also important distinctions in method, skill set, and clinical role in a given patient encounter. Particularly in cases of advance care planning, complex decision-making, and clarifying goals oncology teams may be challenged to know which consultation service to involve. Methods: Case report and commentary. Results: A 60 year-old man with a 3-year history of glioblastoma multiforme presented with sudden onset right-sided weakness and altered mental status. In the emergency department, a computed tomography (CT) scan demonstrated a left-sided intracranial bleed with concomitant cerebral edema and left-to-right midline shift. The patient was admitted to a surgical intensive care unit (SICU) where neurosurgery declined to operate. Within hours of admission, while the patient’s son (also his durable healthcare power-of-attorney) was considering a do-not-resuscitate order, local police arrived at the hospital, having received a 911 call from the patient’s daughter who claimed her brother and medical providers were attempting to murder her father by shifting to comfort care. The SICU team urgently consulted PC and CE. Within an hour, PC and CE clinicians met with the patient’s family to review the patient’s advance directive, counsel regarding clinical management strategies and prognosis, broach comfort care, introduce hospice, and liaise with a hospice case manager. Additionally, PC collaborated with the SICU to provide best symptom management; CE worked with hospital risk management and security to ethically mitigate escalation of more reactive family members. Within 4 hours of the consults, the patient was being transferred to a local inpatient hospice facility, where he died several days later. Conclusions: As this case demonstrates, models of close collaboration between PC and CE consultative services may swiftly facilitate appropriate transitions in care for patients with advanced cancer and simultaneous de-escalation of hospital risk. Evolving models for quality supportive care should further examine such strategies.

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