ABSTRACT
Managing risk is a necessary component of living a full moral life. Evaluating which risks are acceptable, for what reasons, in what conditions, and then taking actions based on those evaluations, are exercises of moral agency-of intentionally actualizing values that shape an embodied personhood. Health-care institutions in the United States are risk averse, designed to manage risk in ways that can impede the full exercise of patients' moral agency. Home hospice care, conceived as an alternative to institutionally based end-of-life care and driven explicitly by patient goals and values, would seem to be an environment in which patients are empowered to express the full spectrum of their personhood-including making decisions about risk consistent with their values. While home hospice patients have more discretion over risk than patients receiving care in institutions like hospitals and nursing homes, efforts to limit that discretion abound. Such limits can be experienced by patients as failures to recognize their dignity as persons, even while those limits are perceived by others as necessary to preserve that very dignity by keeping them safe. This article uses a running case study to reconceptualize "risk" in home hospice care by (1) challenging the clinical assumption that physical harm is the most important lens through which to view risk, and (2) presenting and applying the concept of positive risk-taking as one way to develop the concept and assessment of risk more fully.
Subject(s)
Hospice Care , Hospices , Humans , Nursing Homes , Personhood , Respect , United StatesABSTRACT
Advance directives are often used to help patients articulate their end-of-life treatment preferences and guide proxy decision makers in making health care decisions when patients cannot. This case study and commentary puts forth a situation in which a palliative care consultation team encountered a patient with an advance directive that instructed her proxy decision maker to consider estate tax implications when making end-of-life decisions. Following presentation of the case, the authors focus on two ethical issues: 1) the appropriateness of considering patients' financial goals and values in medical decision making and 2) whether certain kinds of patient values should be considered more or less relevant than others as reasons for expressed treatment preferences. Clinicians are encouraged to accept a wide range of patient values as relevant to the clinical decision-making process and to balance the influence of those values with more traditional notions of clinical harm and benefit.
Subject(s)
Advance Directives , Palliative Care/economics , Palliative Care/ethics , Taxes/economics , Terminal Care/economics , Terminal Care/ethics , Aged, 80 and over , Decision Making , Female , Humans , Palliative Care/legislation & jurisprudence , Shock, Septic/therapy , Taxes/legislation & jurisprudence , Terminal Care/legislation & jurisprudenceABSTRACT
For patients at the end of life, active automatic implantable cardioverter-defibrillators (AICDs) may no longer achieve the treatment goals present at the time of implantation. It is possible to deactivate AICDs in patients with terminal and life-limiting diagnoses, thereby preventing the pain and distress of nontherapeutic discharge. This article presents a moral argument for the right of such patients to have their AICDs deactivated. It then explains that hospice and home care agencies have an obligation to address AICD deactivation at a policy level and offers recommendations for doing so.
Subject(s)
Defibrillators, Implantable , Home Care Services/ethics , Hospice Care/ethics , Morals , Patient Rights/ethics , Terminal Care/ethics , Withholding Treatment/ethics , Aged , Equipment Failure , Hospice Care/psychology , Humans , Male , Terminal Care/psychologyABSTRACT
Understanding, shared meaning, and mutual trust lie at the heart of the therapeutic nurse-patient relationship. This article introduces the concept of clinical intimacy by applying the interpersonal process model of intimacy to the nurse-patient relationship. The distinction between complementary and reciprocal behaviours, and between intimate interactions and intimate relationships, addresses background concerns about the appropriateness of intimacy in nursing relationships. The mutual construction of meaning in the interactive process between nurses and patients is seen to lie at the heart of clinical intimacy as a hermeneutic enterprise. Intimacy is distinguished from empathy based on intentionality and the status and location of meaning. Reasons for continued investigation into clinical intimacy as an explanatory model for nursing as a hermeneutic practice are presented.
Subject(s)
Empathy , Nurse-Patient Relations , Practice Patterns, Physicians' , HumansSubject(s)
Defibrillators, Implantable/psychology , Hospice Care/psychology , Patient Acceptance of Health Care/psychology , Patient Participation/methods , Patient Participation/psychology , Terminal Care/methods , Terminal Care/psychology , Aged , Defibrillators, Implantable/ethics , Hospice Care/ethics , Humans , Male , Physician-Patient Relations/ethics , Quality of Life , Terminal Care/ethics , United StatesABSTRACT
Noncompliance of family caregivers can present home hospice nurses with difficult ethical choices and powerful feelings about those choices. This is particularly so when family members do not adequately palliate their loved ones, resulting in treatable symptom distress during the dying process. This article presents a case study, moral analysis, and an evidence-based, practical plan of action for engaging family members of palliative care patients on a home hospice service.
