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Annals of Gerontology and Geriatric Research
Cite this article: Senderovich H (2015) Overcoming Dilemmas in Palliative Care. Ann Gerontol Geriatric Res 2(1): 1025.
*Corresponding author
Helen Senderovich, Department of Family and
Community Medicine, University of Toronto, Geriatrics
& Pain Medicine & Palliative Care Physician, Baycrest
Health Sciences, 3560 Bathurst Street, Room 1R16
Toronto, ON, Canada, Tel: 416-785-2500; Fax: 905-794-
3508; Email:
Submitted: 07 February 2015
Accepted: 22 March 2015
Published: 23 March 2015
Copyright
© 2015 Senderovich
OPEN ACCESS
Keywords
•Palliative
•Physician-patient relations
•Advanced care lanning
•Patient-centered
•Healthcare professionals’ distress
Case Report
Overcoming Dilemmas in
Palliative Care
Helen Senderovich*
Department of Family and Community Medicine, University of Toronto, Canada
Abstract
There comes a point when physicians have to recommend patients to seek Palliative
Care due to the deteriorating progression of their illness (es). Healthcare providers
often wrongly assume that the families of the patients have a clear idea of the type
of care that will be provided, but the providers are usually wrong by assuming this.
The families of these patients often have false expectations of the care that their loved
one (s) will be receiving, especially in situations where an Advanced Care Plan was not
established when the patient still had decision-making capacity. This poses challenges
on the healthcare staff. Acting in the patient’s best interests, healthcare staffs are
trying to balance meeting the healthcare needs of the patient, and expectations of
the family, while maintaining both a professional and ethical character. The paper
describes a case that addresses some of the conicts which may arise in settings where
Palliative Care is provided. It addresses the challenges that healthcare providers may
come across due to the differing expectations and demands from the family members.
CASE PRESENTATION
Who Should the Physician Listen To?
I received a message from the nephew of my patient to
contact him urgently two weeks after her admission. I debated
However, at a later time, when I returned the page, I discovered
Methotrimeprazine, and when I had told him that I needed to get
his grandmother, he had requested to listen to his concerns and
I agreed. The nephew became the communicator through the
put in both verbal and written forms, allowing the health care
rights, but the staffs were still required to listen to his orders, due
having to follow their suggestions.
based on what they presume their family member would want,
and the healthcare staff who believe that they know what the
patient wants [1]. This will make it harder to develop a care plan
medications. The grandmother was an elderly Jewish individual
to the Jewish Long Term Care facility Palliative Care Unit in
with responsive behaviour and
frequently restless and agitated, in addition to having abdominal
pain, dyspnea, pruritis, frequent myoclonus and constipation.
the patient was fully alert and able to participate in the decision
making process [2].
transfer to acute care in case of acute emergency, but accepted
oral antibiotics to treat infection if it was required. One of the two
daughters who were present at the time of the discussion agreed
with the wishes of the mother. Both daughters were shared POA
[3]. The patient was given opioids and psychotropic medications
including Methotrimeprazine, which were titrated carefully with
Methotrimeprazine given to her mother was titrated to meet
as the main goals of management during the initial consultation
on admission with the patient. During my conversation with the
associated with the Methotrimeprazine given to her, such as
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Ann Gerontol Geriatric Res 2(1): 1025 (2015) 2/6
the patient declining and her approaching end of life. A family
meeting with the interdisciplinary team was suggested to clarify
interventions from all members of the team, but, this was declined
by the daughters [3]. A psychiatry follow up was also arranged.
with dyspnea, restlessness and agitation, potentially due to a
visual and auditory hallucination, and ongoing confusion,
in addition to abdominal pain, pruritis, repeated myoclonus
and constipation. Antipsychotic medications (particularly
Palliative Care facilities to achieve comfort of those who are at
the end of life. Despite the fact that the medications were titrated
carefully with consent from both the patient and daughter, the
deemed capable of making her own decisions at that time. As a
on admission and if she was competent, there may have not
request and try to address caregiver distress. Thus, these
daughters, indicating that the nurses and doctors no longer had
their consent to treat their mother with Methotrimeprazine
and other typical antipsychotics that were used prior to
Methotrimeprazine to control the symptoms. The letter was also
Throughout my career, I had learned that these types of
I had an interview with both daughters. As they described
mother with medications to ease their job, noting that these
our approach and philosophy in regards to Palliative Care,
was not a comfort and instead a chemical restraint which was not
symptoms which will be opposed to the wishes of the mother, and
suggested a private caregiver to help to avoid a possible injury
as a result of uncontrolled agitation which may be secondary
to discontinuation of Methotrimeprazine. But, the daughters
said they could not afford one. A clinical ethics consult was also
only be taken when the requests seem inappropriate or even
harmful for the patient [5].
I stayed in contact with the healthcare staff and though the two
request, communication primarily occurred with the nephew after
his letters were received. The daughters were comfortable with
having their nephew be the primary communicator, due to the fact
that he was a physician and therefore could comment based on his
understanding of various medications. The Methotrimeprazine
was discontinued, a private caregiver was hired, the medications
were reassessed and changes were made according to the
requests of the nephew, with the consent of the daughters.
were discontinued, and gabapentin and risperidone were titrated
shortness of breath with conversation. The symptoms that were
once controlled with Methotrimeprazine became evident again.
The patient was facing ongoing threatening visual and auditory
hallucinations. Abdominal pain also reappeared, which required
frequent adjustment of opioids intake. But, repeated myoclonus
and constipation were under control.
more clearly, but as time progressed, her verbal response was
congested and had a few episodes of aspiration events.
Methotrimeprazine, she appeared to be reasonably comfortable.
The family became happier and made it a goal to prolong the life
could, despite the fact that the patient felt terrible after each meal.
the rounds she was talking about her discomfort associated with
meal intake, and was more vocal when left alone by the family.
for their mother, during the last days of her life. Although the
eating, and the family received multiple educational sessions
about absence of hunger at the end of life, and persistent risk of
situation of not feeding the Mother [6].
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During such situations it is important for healthcare staff
patient?” Through the discussion, the patient, family members and
healthcare staff should be open to agree upon goals of nutritional
support for the patient during their Palliative Care. Despite of a
clear understanding of the lack of evidence to support oral intake
The family was very protective about disclosing the diagnosis
to the patient. They felt that revealing her fatal diagnosis would
me to discuss everything with her daughter, as time progressed,
she became very interested, in learning more about her condition
disclosed to her through either a nurse or social worker during
the care conversation [9]. Once the information was disclosed
the diagnosis, prognosis, and approaching the end of her life.
We then discussed the prognosis and after I had answered her
hoping to live for another couple of months to see her to be born
Patients trust their physicians, but at times the physician may
have to think twice before disclosing information to the patient,
simply because it may have a negative impact on the patient. It is
in the fatal news being brought to them. As a result, sometimes it
patient.
In this case, a patient centered approach, by telling the truth
episode of urosepsis, but settled for a short period of time with
the daughter who stated that the baby was delivered and now
they wanted their mother to be comfortable and were ready to let
her go. They also said they give their consent to administer all the
medications that are needed to keep their mother comfortable,
including the once refused typical antipsychotics. Ten days prior
to her death, her pain escalated, and she developed another
congested. Her symptoms were managed with opioids, Haldol
and Methotrimeprazine. During her last days, her symptoms
were stabilized and she entered a state of varying degrees of
somnolence. The daughters were preparing themselves for their
mother was comfortable without food and being unresponsive
[6]. The mother had died in comfort, two weeks after the arrival
and communication” in which individuals with autonomous
capacity make decisions regarding health management in the
treatment or other care” [2]. This allows the healthcare team
patients and family members [9].
Care Planning, which become barriers as to why some choose
to not take part in it. Data suggests that patients who have an
advanced directive have a secondary or higher education, chronic
medication use, higher than average number of specialist visits,
history of having advanced directives and lower levels of social
interaction [12]. Along with these factors, education, gender,
planning [13]. These results show that there are several factors,
functional status can play role whether or not the patient decides
to formulate an advanced directive.
may interfere in decision making process, use of pain medications,
beliefs will have such populations away from an Advanced
Care plan. Therefore, communication between the patient and
physician is important to help the patient to understand the
importance of an Advanced Care Plan.
Many Palliative Care patients identify the major issue as the
and the healthcare culture and setting [15]. Thus, it becomes
environment for patients to communicate their wishes. A
study conducted by Wagner et al. indicated that only 53% of
the participants reported that they had discussed their care
preferences with their providers [16].
Plan, it is important that healthcare professionals are aware of
and work around these potential barriers to ensure that their
patients understand the importance of having an Advanced Care
Plan.
In the presented case, the mother had not planned in advance
about the care that she would have wanted to receive during her
last days. If Advanced Care Planning had been discussed earlier
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prior to admission to the Palliative Care unit, both the mother
which could have improved the outcome for the patient and her
family members/caregivers, achieved greater adherence to the
who then also became a communicator through the permission
physicians continue to vary in their attitudes toward engaging
patients and their family in the care process [18]. In order to
develop a trusting and satisfactory relationship between the
patient and physician, ongoing communication and engagement
advice and treatment [19].
has also been shown to enhance patient satisfaction [10]. By
trust in the physicians, and are more willing to accept their
subjective functioning, appearance and health” [21].
The majority of physicians believe that the surrogate should
prioritize what the patient would have wanted over what they
physician.
when a patient transitions to Palliative Care. Often, families
care that will be provided, and their emotions may overpower,
take place in advance [6].
It is important to emphasize that healthcare professionals
a correlation between
professionals come across a situation where patients do not have
process due to their physical, mental or cognitive status. As
a result, the decision must be made by either the family or the
surrogate decision maker. Disagreements frequently arise while
such decisions are being made, which may affect the quality of
healthcare professionals and caregivers. This may be reduced
through continuous professionals and psychosocial support
provided to the patient and their family by the multidisciplinary
prognosis.
During this crucial period of time, it is important for the
provide the best care for the patient, keeping in mind that in
Unfortunately, healthcare providers are not always right
by assuming that the families of patients have a clear idea of
the type of care that will be provided. Most participants have a
is only needed for patients during the last days of their life [26].
as healthcare staff would like to discuss a variety of questions,
primarily about medications use, symptoms management,
of the services included, such as holistic support, symptoms
control, good communication and practical support to enable
choices [26].
barriers and although question prompt sheets can be helpful in
overcoming barriers in this area, not many have been developed
for family caregivers [27]. Moreover, study conducted by
Andrews et al., revealed that aging healthcare providers have
little understanding of the information and evidence available
to them to better support family members, regardless of the
health care staff to provide better support family members in
making decisions [28]. The family members must be educated on
funeral or burial plans, and willingness to consider hospice [29].
These interventions to communicate with the health care staff
providing care for the patient are essential as it is only through
communication the patient, family members and healthcare
providers can work together to achieve the most from the care
being provided.
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they approach the end of life and optimize outcomes for patients,
especially during a time where they may lose the ability to voice
their opinions
In our case the family had lacked Advanced Care Planning.
Had the mother prepared in advance about the care she wanted
to receive, many of the issues that arose may have been solved
by following the requests of the mother. As described above
.
CONCLUSION
The described case demonstrates the multitude of factors that
need to be taken into consideration when caring for a Palliative
Care patient by bringing forth the intricacies and important
members/caregivers about the type of care that will be provided
important for physicians in an interprofessional team to work
responsibilities, the patient is entitled to have the best quality of
MD Candidate 2018, for their editing efforts in preparation of this
material.
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Senderovich H (2015) Overcoming Dilemmas in Palliative Care. Ann Gerontol Geriatric Res 2(1): 1025.
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