Subject(s)
Intestinal Fistula/therapy , Intestinal Obstruction/therapy , Intestine, Small , Parenteral Nutrition, Total/methods , Patient Care Planning , Peritonitis/therapy , Female , Humans , Intestinal Fistula/complications , Intestinal Obstruction/complications , Middle Aged , Nutrition Assessment , Peritonitis/complicationsABSTRACT
The use of home parenteral nutrition (HPN) in advanced cancer evokes ethical problems related to risk/benefit, patient autonomy, justice, medical futility, and cost. Case series have been beneficial for some patients, particularly when survival is expected to be longer than 2 months. A team approach to involving the patient and family in evaluating risk and benefits is preferred. Social workers serve a key role in enabling the patient and family to make end-of-life decisions by helping them clarify the psychosocial and ethical aspects of these decisions. Clinical standards and case law will further define whether HPN in advanced cancer is futile treatment. Broader social issues of rationing, access to HPN, and costs must be addressed. Further research on outcomes and patient/family decision making on HPN are needed.
Subject(s)
Bioethics , Home Care Services , Neoplasms/therapy , Parenteral Nutrition, Home , Risk Assessment , Beneficence , Cost-Benefit Analysis , Counseling , Humans , Parenteral Nutrition, Home/economics , Parenteral Nutrition, Home/psychology , Patient Selection , Personal Autonomy , Quality of Life , Resource Allocation , Social Work , Stress, Psychological , Withholding TreatmentABSTRACT
In many cases, initiation of specialized nutritional support is a final attempt at medically managing illness for which other treatments have failed. Patients may have suffered for months or even years with their underlying diseases and are usually aware that poor response to nutritional support and concurrent therapies may lead to surgical intervention or more complex treatment. In some cases, there may be few alternatives left to pursue. For such patients, this paints a very stressful picture. If we as caregivers are empathetic to each patient's situation, we are better able to offer the support that these patients need. Health care professionals must keep patients informed of treatment plans and encourage participation in the planning process--during hospitalization, through the discharge phase, and after hospitalization. We need to pay close attention to those needs, whether nutritional support is short-term during hospitalization, prolonged, or permanent. The health care environment is demanding greater proficiency in cost containment and quality assurance in the delivery of care. Complex patient cases are becoming more difficult to manage as time constraints and resources become more restrictive. The ingenuity and imagination of health care providers trying to find ways to continue providing high-quality and safe care to patients are being tested daily. These worthwhile goals can be met only through cooperation, communication, and support among all levels and disciplines involved with the delivery of care. Feelings of helplessness, dependence, and loss of control can be diminished if health care providers maintain optimistic, confident attitudes, offer positive reinforcement for patients successes, and try to restore hope during this stressful period in patients' lives.
