Apr 06, 2012, 06:42 am
I believe the main issue is how does one determine if a patient is on a palliative pathway and apply the appropriate interventions in a timely manner. Why this happens is because all doctors and medical professionals are human and can be WRONG. It is not uncommon to find that patients that are sent to palliative care based on medical judgement who instead gets better and return to the community for very long periods of time.
To avoid second guessing nature and fate, the palliative protocol adopted in my hospital is as follows -
1) Step one - Withdraw active treatment. i.e. no obs and no medical treatment to address the underlying morbidity. However comfort measure medications AND procedures are put in place to manage pain and agitation. This is where an ethical issue arises. Pain management must not be excessive such that the patient is unable to exercise capacity - i.e. decision making process must not be impaired. Will explain this later. What does it means to put in place procedures? In some cases like cancer for example, surgery may still be performed on a patient to relief the patient's pain or discomfort, and accord the patient a better quality and dignity in palliation. This procedure is NOT active treatment because it does not halt progression of the disease, merely to minimize the effects on the patients comfort.
2) Step 2 - Where the patient deteriorates rapidly due to withdrawal of active treatment and is unable to eat and has increased pain levels, GCS scores below 6, pain medications are increased and patient is then put on Nil By Mouth. This is an important transition point as we have seen many who come back from step 1 and if we did not correctly titrate opioids, we could impair the patient's ability to eat due to undue reduction of capacity. This is where ethical issues are generally debated as the plan is to not deny the patient's natural and mental capacity to make decisions for self preservation. If one is so doped up and cannot eat, it naturally becomes a death sentence. I have fought with doctors on this issue many times when we see "overactive" pain management that leads to the patient losing capacity. And is some cases where we advocated for patients, we have seen some who come back and continue to live for a good deal longer become their number is up, and without pain. But then again sometimes, we are wrong and in hind sight, the pain management was the appropriate thing to do despite its ability to diminish capacity. Because of this, our hospital has recently put into place a very detail plan where we sign of literally every 2 hours and report variances for the medical team to determine the need to titrate higher dosages or to add to the cocktail
Step 3) Active comfort care measures - With step 2 clearly defined, we then implement active comfort measures. A patient in step one may still be able to brush their teeth but by the time their GCS drops below 6, we then need to initiate mouth and eye toileting, suctioning and any other necessary measures
Hope you might be able to extract ethical issues from this. cheers
