In the current world there is an increase in the medical knowledge as well as technology and as a result, the options of healthcare have increased as well. When we are faced with decisions regarding how to treat a patient who is at the end of their life, there arise many ethical dilemmas. It becomes very difficult for any human being to have to make a decision about the best treatment that will ease the final suffering of the patient (Kleespies, 2004). Sometimes a decision needs to be made on whether treatment should be terminated to allow the patient’s life to end peacefully or whether to hold on until the last minute. Such decisions regarding the care of the dying loved ones confront people all over the world and from all walks of life. End of life or death often arises as a result of serious illness or advanced age. “More than half of the deaths recorded in the United States of America are attributed to heart diseases and cancer” (Kleespies, 2004). The term known as death has a likelihood of being sudden and violent in the younger generation. The mission of many individuals and organizations dedicated to the end of life care has been to advocate for a good death. A good death has been identified as one in which there involves palliative care, one that avoids extending the process of dying, has a clear communication base with the physician, patient and family, and that there is sufficient preparing for the patients death by not only the patient but also loved ones.
The various approaches to end of life care include; hospice care and palliative care. “Hospice care provides a holistic and philosophical approach to the end of life care whereby it pulls together the doctors, the nurses, the social workers and other professionals as a dedicated team” (Singer, Martin & Kelner, 1999). The main goal of the hospice working as a team is to make the patient at ease and comfortable during their end of life. The hospices care not only focuses on pain control but also making sue the patient is not feeling any negative symptoms/side effects, and assuring physical body comfort. A good death respects the autonomy principle and encourages an individual to choose the best decisions concerning the appropriate medical options at the end of life. The philosophy of hospice care also attempts to support the patient and their family to ensure quality care over the deaths. The hospice team takes care of the passing patient whether from home, a nursing home, hospital or a separate hospice facility (Aroskar, 1985). Apart from medical care, the hospice team also provides emotional and spiritual support, nutrition counseling, social services and even grief counseling for the patient close individuals from the patient, weather family or friends. The palliative care, on the other hand, makes an attempt at achieving the primary healthcare goal of relieving painful symptoms. The palliative care is an appropriate route of care for those patients who are suffering tremendously and terminally ill (Phair, 2008). It aims at providing the upmost quality of life by stressing the importance and doing of total comprehensive care for all the patients needs such as management of pain and symptoms, the spiritual, and both psychological/emotional well-being. Palliative care has similarities to hospice care though it is not only for the patients who are at the end of life and palliative care can be applied in both short term and long-term care settings. I would say the most significant similarity between both cares involves the great team of doctors, nurses, psychologists, social workers and any others who aid in providing this comprehensive care (Calanzani, Koffman & Higginson, 2013).
The traditional American medical practices majorly focus on healing injuries and curing illness but the second most important focus deals with symptom relief. The curative treatments for the terminal illness do not relief against physical pain and don’t entitle attention to the emotional, psychological and spiritual aspect that these patients may endure. The supporters of palliative care advocate that failure to focus on the suffering of the patients with a terminal illness is a violation of two main ethical principles of health care; providing relief or benefit to the individual or the beneficence principle and not harming the patient or the non-maleficence principle (Bernat, 2001). The healthcare professionals should use various treatments in hope to relief pain, discomfort, hunger, depression, and other problems faced by the dying patients (Kleespies, 2004). More often than not, medical drugs are the appropriate treatment for these symptoms and they may be combined with other more simple treatments. Drugs such as morphine and sedatives can lead to negative adverse effects for patients that always need to be looked out for. There may also be chemical reactions when using several drugs which unfortunately precede with adverse and very dangerous side effect when dealing with these patients. Very common and dangerous side effects is shortness or breath which can lead to many other side effects like drowsiness, unconsciousness, delirium and much more.
Addiction and drug abuse are known to be dangerous due to their effects on the patients, and there are fears that the patients are likely to become addicted and abuse the narcotics. Although the addiction of drugs is a serious matter, it becomes less serious when dealing with end of life care patients because this should not be a factor of importance when the biggest issue is having the patient go in peace without pain and common sense, without overdosing the patient. The dying patients are given narcotics for pain relief of pain as well as other symptoms and not to induce highness in the patients (Field & Cassel, 1997). A big debate in the United States involves the drug marijuana. For patients who are at the end of life, marijuana may relieve nausea and actually improve appetite for the terminally ill patients. Some states have made it legal for use by the ill patients who are at the point of end of life care. The non-drug related options for symptom and pain relief include hypnosis, aromatherapy, and massage therapy. There are also non-western forms of treatment options called complementary and alternative medicine (CAM) which are often used by the palliative care providers and hospices to relieve the pain that the unfortunate terminally ill patients are going through.
There are various ethical challenges at the end of life care. One of the significant challenges is the access to hospice care. According to experts, many Americans are not able to access hospice care when they are approaching the end of their lives. There is no easy and equitable access to hospice services in the US thus violating the desire for a just medical system. Where one lives affects the access to hospice care and also public awareness and having the right tool near you such as the right training of health care professionals near patients plays an role when it comes to availability of hospice care. The unfair access to hospice care is also partly faulted by the limitations of the government on its reimbursement to the hospice organizations for the Medicare patients (Calanzani et. al, 2013). Additionally, there are difficulties in the accurate prognosis, which limits the effectiveness of hospice care. There is also an ethical challenge of Medicare because Medicare usually pays a majority of the hospice patient care. The requirement of Medicare is that a patient should have a six months or less prognosis before being allowed to begin hospice care. This condition prevents patients from getting into hospice as well as put many financial restraints in certain hospice programs. The patient is also required to sign a consent form while selecting the Medicare Hospice Benefit that they were able to choose or what ever was provided for them. The Medicare program usually pays a certain amount per day for the patient without consideration of weather the care of that patient may be very expensive or not (Carlet et. al, 2004).
Another serious ethical problem for the patients faced with the end of life is pain management. As stated previously, as many patients get near the end of life, the symptoms such as pain become intensified. Many ethical dilemmas on hospice and palliative care arise from the use of pain relievers in the terminally ill patients. Various questions such as how important treating the symptoms is, the fear of the addiction to narcotics and the value of individual autonomy play a crucial role on how pain management is viewed by people (Prendergast, Claessens & Luce, 1998). Narcotics act on the spinal cord and brain to relieve pain, alleviate diarrhea and reduce a cough. The most common narcotic for pain treatment and other symptoms is morphine. In particular, morphine is one of the strongest medical opioids. This medication is used to relieve severe pain and consequentially, also causes shallow respirations. A major side effect of morphine is called respiratory depression, which can lead to death. Such a case may make a physician under-describe a drug even to those terminally ill patients who are going through some form of intensified pain (Truog et. al, 2001).
The nutrition and hydration decisions are one of the most emotional and ethical challenges at the end of life care. The major problem is concerned with nature and social means of providing the patients with food and water. Nutrition and hydration is a very important aspect of palliative care. Palliative care can be summarized, as a non-evasive procedure, which improves the quality of life of a patient. Nutrition and hydration, is a form of palliative care for an individual. An individual cannot survive more than a few days without food nor water. If these simple elements are withdrawn or withheld, the patient is likely to die within a few days. In practice, the health professionals as well as the patient’s loved ones usually consider whether the provision of nutrition and hydration will be a benefit or more of a bother to the patient (Oberle & Hughes, 2001). The nutrition and hydration treatments may become a strain to some of these patients. As one’s body “goes on a declining trajectory” food and water is not utilized as efficiently as that of a healthy individual. According to the principle of proportionality, treatment benefits should always outweigh the risk and consequences. For example, if a patient receiving total parental nutrition has a burden that far outweighs the benefits, then artificial nutrition and hydration should be withdrawn or withheld. Principle of proportionality should be applied in every medical case.
Kidney dialysis is another ethical dilemma at the end of life. Without kidney dialysis, the waste products in the body of the patient would reach a toxic level and thus result in a coma followed by death. With many individual’s dependent on multiple dialysis treatments a day, dialysis can not only become time consuming, but it also takes an emotional and physical burden on that patient and those loved ones. In some situations, stopping dialysis is one of the most appropriate treatment options that promotes the respect of the patients’ autonomy as well as the ability for self-direction. The ethical challenge occurs, when the patient requests withholding renal treatment. Ethically, withdrawal should be exercised when the patient has the capability of making decisions and thus decides to withhold the dialysis, when there is a written health directive that expresses a patients wish of discontinuing the dialysis, when a health care agent sees discontinuation as the best alternative or when the doctor makes a decision that dialysis is no longer of benefit to the patient (Singer et.al, 1999).
The use of antibiotics also presents an ethical stress by the public health professionals whereby they warn that an unnecessary use of antibiotics is resulting in bacterial infections, known as “superbugs” which have mutated and have become resistant to various common