Essay Sample on Planning for End-of-Life Care: Decisions and Difficulties

Introduction

In recent times a lot of studies are being conducted with the aim of understanding terminal care and plan for it appropriately. The planning for the end of life can be challenging and difficult, but when done early, even when one is still healthy, everything becomes a little easier. This paper tries to focus on the aspects of decision making and the issues that surround the end of life care that makes the decision-making process complicated for not only the caregivers but also the patients. End-of-life decision making can be defined as the process which patients, patients' families, and the healthcare providers go through when trying to figure out which treatments will or will not be used to treat a life-threatening illness. (Myburgh, 2018) A lot of consideration is involved during this process, and communication is a vital component. Physicians want to preserve life, but decisions on end-of-life go against this, yet it is the physicians that are heavily depended on. It is for this reason that proper understanding is important in end-of-life issues.

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Forms of Decision Making

Different forms of decision making are possible. To begin with, the advance directives which involve living wills and allow the patient to express their preferences clearly in writing before the occurrence of a critical illness. It has, however, been observed that such directives on some occasions have had very little impact on the actual care received by patients during their end-of-life care. A study by Silveira shows that patients with advance directives are more likely to receive end-of-life care, which is in line with what they wanted. 82% of the patients who requested for limited care received it while 97.1% of those who opted for comfort care received it. The study involved adults 60 years of age or older and 3746 subjects. Advance directives allow for easy decision making and can contribute to resource utilization, especially with patients who choose limited care.

Secondly, the resuscitative efforts encompass another common form of end-of-life decisions in that some patients opt for the aggressive forms of treatment such as admission to the ICU with hope for a cure while others choose to try and enjoy their last days alongside their loved ones and not surrounded by machines. Futility disputes often occur with physicians and the patients' family having opposing views on the appropriate care to be administered. It mostly involves moral judgment on ethical care, the obligation to preserve the patient's and physician's autonomy, and the impact on the actual improvement of the patient. (Sinuff, 2015) A recent study shows that nearly two-thirds of third surrogate decision makers would not believe a physician who tells them that treatment is futile while 75% of the public believe that they have the right to demand care which is not recommended by the doctor but which they believe is I the best interest of the patient.

The third form of end-of-life decision making involves whether to withhold or withdraw life-sustaining therapies such as mechanical ventilation, dialysis, and antibiotic therapy, among others. A lot of cultural and religious differences exist in this case, and it is the work of the healthcare provider to help the patient and their families understand what is at stake and the possible options they have before a decision can be made whether to withhold or withdraw therapies. (Tamura, 2017) Often when these therapies are withdrawn, a decision is made to pursue comfort for the patient in that diagnostic and therapeutic procedures are discontinued as they do not contribute to the patient's comfort. At the same time, sedatives and even analgesics are given to the patient to ease the pain and control other uncomfortable symptoms.

In the western healthcare system, the caregiver is the major decision maker in the end-of-life process as it is assumed that they have the relevant knowledge to aid in objective decision making. It is influenced by the healthcare provider's past education and experience related to end-of-life care. Studies have shown that in the US, nurses have reported providing care for patients at the end-of-life by trial and error. It is not encouraging since it is people's lives at stake hence the need for more understanding on this topic.

Both physicians and nurses have established that end-of-life decision making provides a frequent ethical problem in the healthcare sector. It is because the physicians have to live with the fact that their decisions have a huge impact on the lives of others. (Oosterink, 2016) At times when nurses show dissonance towards the decisions made everything becomes even more challenging. Little information is available on the patients' perspective on end-of-life decision making. It is a fact that every patient wants to be involved since such decisions directly impact their health as well as their lives. Studies have shown that a large number of seriously ill and hospitalized patients are willing to talk about their preferences about end-of-life care. The family member also wants to be involved in this process, but then they tend to harbor strong emotional reactions.

Several strategies exist which aim to facilitate end-of-life decision making; the first strategy is changing perspective which involves engaging patients to talk about and be involved in decision making about what will happen at the end of their life. It was in contrast to the past when end-of-life decisions were considered a last resort often after the patient was no longer able to participate in making decisions actively. It is beneficial to everyone if the issues related to end-of-life decisions be discussed with the patients and their families in the course of a life-threatening illness.

Another perspective that needs to change is how caregivers value palliative care. (Bollig, 2016) Palliative care is not offered only when nothing else can be done; it should be careful that aims to relieve suffering and ultimately improve the quality of life not only for patients with life-threatening illnesses but also their families. Another strategy involves the creation of awareness for patients' family members before they participate in the decision-making process. Moreover, an interdisciplinary approach is another strategy, and it involves teamwork from the healthcare team in assisting patients and their families. Trust and collaboration are crucial for active, end-of-life decision making.

To deeply understand healthcare decisions at the end of life is difficult as a lot of factors are involved. In a cross-sectional study of end-of-life decision making and communication of bereaved family members of African Americans with serious illnesses, it was found that decisional conflict was low on family members who reported a higher quality of communication with healthcare providers. (Brogan, 2018) Also, those family members who received comfort-focused care had less regret on the decision than those who received life-prolonging treatment. A lot of factors act to influence the end-of-life care decisions, but what should stand out is the approach known as best interest, which focuses on what is best for the dying patient. Substituted judgment is also critical when making decisions for a patient who is no longer able to participate in decision making. When the two approaches are combined, then arrangements can easily be made without risk of future regret. Understanding the principles of biomedical ethics such as autonomy, justice, and fidelity are essential in addressing the issues that physicians and patients are confronted with at the end of life care.

A review of the research literature on ethnic diversity and end-of-life decision making, thirty-three empirical studies were identified in which race or ethnicity was investigated as a variable which predicted treatment choices and preferences, also comparing ethnic groups in their end-of-life decision making. The results showed that non-white racial groups lacked knowledge on advance directives and were less likely than whites to support such instructions. On the other hand, African Americans preferred the use of life-prolonging methods, while the Asians and Hispanics preferred family-centered decision making when compared to the other racial or ethnic groups. These findings were as a result of the variations existing among the racial and ethnic groups. One can conclude that race, ethnicity, and culture have huge impacts on end-of-life decision making hence, the healthcare providers ought to know more about cultural differences and influences for effective decision making.

Conclusion

End-of-life decision making continues to be a growing need while at the same time challenging as medical technologies enhance the ability to prolong life. However, the quality of life is what is essential since life-sustaining devices have their limitations. Physicians, patients, and caregivers are faced with numerous ethical dilemmas regarding end-of-life decision making. These dilemmas can be avoided with proper communication between all the parties involved as well as with good advance care planning. Improving communication acts to reduce the distress experienced by both healthcare providers and the patients' family members.

In some cases medical processes are futile, and so the patient should be shown love by those close to them instead of spending their last days surrounded by machines which in a real sense only provide false hope. More studies should be conducted on this topic since it is delicate and deals with the end of life. Most healthcare providers go into their profession to preserve life; hence, such decisions at times go against everything the medical world stands for and can be confusing to caregivers who are dependent upon.

Reference

Bollig, G., Gjengedal, E., & Rosland, J. H. (2016). They know!-Do they? A qualitative study of residents and relatives views on advance care planning, end-of-life care, and decision-making in nursing homes. Palliative Medicine, 30(5), 456-470.

Brogan, P., Hasson, F., & McIlfatrick, S. (2018). Shared decision-making at the end of life: A focus group study exploring the perceptions and experiences of multi-disciplinary healthcare professionals working in the home setting. Palliative medicine, 32(1), 123-132.

Myburgh, J., Abillama, F., Chiumello, D., Dobb, G., Jacobe, S., Kleinpell, R., ... & Torra, L. B. (2016). End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine. Journal of critical care, 34, 125-130.

Oosterink, J. J., Oosterveld-Vlug, M. G., Glaudemans, J. J., Pasman, H. R. W., Willems, D. L., & Onwuteaka-Philipsen, B. D. (2016). Interprofessional communication between oncologic specialists and general practitioners on end-of-life issues needs improvement. Family practice, 33(6), 727-732.

Sinuff, T., Dodek, P., You, J. J., Barwich, D., Tayler, C., Downar, J., ... & Heyland, D. K. (2015). Improving end-of-life communication and decision making: the development of a conceptual framework and quality indicators. Journal of pain and symptom management, 49(6), 1070-1080.

Tamura, M. K., Montez-Rath, M. E., Hall, Y. N., Katz, R., & O'Hare, A. M. (2017). Advance directives and end-of-life care among nursing home residents receiving maintenance dialysis. Clinical Journal of the American Society of Nephrology, 12(3), 435-442.