Palliative care specialists encounter a wide range of ethical challenges in their day-to-day practice, such as navigating institutional policies, interprofessional conflicts, and resource allocation, according to a review of 13 studies from nine countries.1

“My hope is that our research will help provide a robust evidence base from which others can design ethical resources for palliative care practitioners,” says Guy Schofield, MD, the study’s lead author and a clinical research fellow at the Centre for Ethics in Medicine at Bristol Medical School in the United Kingdom.

The study’s findings show the range of ethical challenges palliative care practitioners face is “far broader than people might first think,” Schofield adds.

Palliative care specialists often become involved in difficult goals-of-care decisions with families of hospitalized patients who are incapacitated with a poor prognosis, says David Y. Hwang, MD, FAAN(Neurology), FCCM, FNCS, an associate professor in the division of neurocritical care and emergency neurology at the Yale School of Medicine.

At Yale New Haven Hospital, if a clinical team experiences conflict with a family over a request for potentially inappropriate care at the end of life, and is calling the ethics team for consultation, the palliative care consult team also becomes involved. In a typical case, the clinical team believes it would be in an intubated, brain-injured patient’s best interest to switch to comfort measures, but the family is insistent on continuing aggressive care. “It is helpful for all teams involved in caring for a patient to huddle before family meetings and ensure that all are on the same page,” Hwang offers.

It can be difficult to coordinate schedules for all busy team members. Someone from the primary team has to contact all the involved parties, including the family. That person has to sort out when everyone can meet. “But it is invaluable in making sure that communication is consistent among all parties,” Hwang adds.

In the neurological ICU, “goals of care” conflicts arise occasionally. “We have had situations where miscommunication among all teams — not just palliative care and ethics, but the primary team as well — has inadvertently happened,” Hwang laments. This makes maintaining trust with the family difficult. In one recent case, an attending who was caring for a patient with a poor prognosis was under the impression the ethics team had recommended hospital protocol be initiated to withdraw care against a family’s request. A second attending (who took over for the first attending) communicated that recommendation to the family.

The second attending later learned that, in fact, the ethics team had not yet rendered a final, formal opinion. This miscommunication complicated subsequent discussions with the family. “The effort that is paid in trying to ensure all clinical teams are on the same page is well worth it,” Hwang stresses.

“There is a good deal of cross-pollination that occurs between the disciplines of palliative care and clinical ethics,” says Richard Sams, MD, an associate professor in the department of family medicine and the Center for Bioethics & Health Policy at Augusta (GA) University.

Palliative care providers are members of ethics committees and oversee clinical ethics programs. “Common ethical dilemmas occur at the fringes of life, both at the beginning and near the end,” Sams notes.

Non-beneficial treatments, advance directives, surrogate decision-makers, and requests for physician-assisted suicide are examples of ethical issues that also involve palliative care. “Where palliative care services are not available, there are many more ethics consults due to the moral distress of the treating team caused by non-beneficial treatments,” Sams observes. A robust palliative care program identifies goals of care and adequately addresses suffering. This results in fewer ethics consults.

“Clinical ethicists can support palliative care services by providing an additional voice to especially complicated clinical-ethical cases,” Sams adds.

REFERENCE

  1. Schofield G, Dittborn M, Huxtable R, et al. Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice. Palliat Med 2020; Dec 10;269216320974277. doi: 10.1177/0269216320974277. [Online ahead of print].