By Kristian Dye
Dhillon et al. present a case discussing the care of a patient with Ebola, which demonstrates in a micro
cosm some of the biggest issues facing healthcare providers in patients with palliative or terminal care needs – albeit in a particular extreme care environment.
In the case, the patient is declared palliative and restarted on active management, before being considered palliative once again and passing away.
These are issues which perplex physicians in all care settings.
- When do we consider a patient for palliative
care only? - How can we reconcile differing beliefs and values within the team to deliver the best care for patients?
Deciding a patient is palliative
This is an issue that continues to vex physicians the world over. Cardona-Morrell and Hillman identify no less than 18 different scales and assessment tools available to attempt to guide these decisions, none of which are perfect.
Rightly, much of this effort is focused on identifying those within the population who are entering the end of life, and for whom discussions and decisions surrounding palliative care can help them to avoid invasive and unpleasant interventions – in the UK the Gold Standard Framework is the current tool used in community settings.
The difficulty with many of these tools is that they are not well-suited to the kind of case presented here. The ‘normally fit but acutely unwell’ patient presents a real problem for prognostication – where patients in similar situations receive the same care, some will still die, others stage recoveries that would make Lazarus jealous. In these situations, how can we make clinical judgement without losing the patient in the interest of treating clinical indicators?
Team-based approaches in palliative care
Palliative care is one of the areas of medical practice where personal values can have the biggest impact on the judgements physicians make. We all bring with us a multiple of baggage – emotional, cultural and religious – that colour our views.
A helpful summary of religious views on palliative care, by Steinberg, demonstrates the breadth of both agreement and disagreement between major religions on this topic.
Alongside this, our practice has to be informed by the ethical principles underpinning medical care. Respect for autonomy, the duty to act in the patient’s best interest and the duty not to harm our patients are all critical to decisions around palliation of the dying patient – and all are open to interpretation by the practitioner.
What approaches can we take to ensure that judgement are taken by consensus, objectively, and within the context of the individual patient?