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Introduction. The traditional model of end-of-life (EOL) care is not adjusted to the needs of patients with life-limited conditions other than cancer. By presenting a case of chronic obstructive pulmonary disease (COPD) patient, Taylor (2011) develops representation of common patterns of dying in terminal stage lungs disease, and focuses on such patients’ needs to elaborate the optimal care model. This paper discusses the case presented in the video by Taylor & Trotman (2011) summarizing its key points and concepts.
Legal Considerations. ACP made by hospice team together with Martin, under New Zealand’s common law, should be logically followed by the patient’s advance directive (AD) in accordance with the Code of Health and Disability Services Consumers' Rights (CHDSCR, 1996). Such AD should explicitly indicate the patient’s wishes and preferences on treatment, and any actions to be taken about the patient’s health in case he becomes incapacitated due to the illness. Any relevant changes in preferences typical for the older patients (Fried et al., 2006) and carefully double-checked by CN visiting Martin, should be reflected in AD. In UK, Mental Capacity Act (MCA) (2005) allows the patients appointing proxies for decisions on life-supporting treatment continuation or withdrawal. To enable a proxy to sign a DNR (“do-not-resuscitate”) order on the patient’s behalf, MCA (2005) requires only the patient’s writing consent and witnessing. In New Zealand the rights of such proxies allowed by Protection and Property Rights Act (PPRA) (1988) are limited: they cannot take decisions on treatment withdrawal (HDC, 2009). To reconcile the both legal issues: realizing a right for treatment refusal in the case of being incapacitated (CHDCR, 1996) and signing a DNR which cannot be effected by a proxy, the patient needs a very carefully planned AD, where the statement of informed consent to life-saving treatment refusal is essential (HDC, 2009).
Ethical Considerations. Due to unpredictable trajectory of COPD and unawareness what exacerbation will be the last one (Ambrosino & Goldstein, 2007) the GP’s judgement on COPD treatment “futility” is very subjective. Unability to anticipate the final stage of disease course often creates ethical conflicts between beneficence, non-maleficence and justice making it extremely difficult to define when the treatment becomes“ prolonging death not life” (Taylor & Trotman,2011), when invasive treatment should be preferred to non-invasive ventilation, and what setting is a better option for the patient’s death (Simonds,2003).The lack of any more or less precise prognosis of disease trajectory can result in the delay in AD signing: more COPD patients become involved in ACP as Martin was, but very few of them complete ADs (Ambrosino & Goldstein, 2007). Another COPD-specific ethical controversy highlighted by GP, is the doctrine of double effect where Martin’s breathlessness was successfully managed by morphine, also known for ability to cause respiratory depression leading to death. Small doses morphine is proven to reduce ventilatory response to hypoxia and hypercapnia, as well as pain which often goes unnoticed in COPD (Taylor, 2011). Bioethicists agreed that every measure prescribed for the patient’s beneficence, dignified and peaceful death and not deliberately hastening this death, is ethical and legal (Cavanaugh, 2006). Still, morphine use should always be discussed with COPD patient and family who may be afraid of its harmful effect.
Reflection on the case. The EOL care for Martin was initially organized in line with the new paradigm of care proposed for COPD patients by Taylor (2011). The continuity of care stipulated by Liverpool Care Pathway (LCP) (2009) was ensured through the application of the same care model within all care settings, rapid discharge from hospice to home, home to hospital and constant education of the patient and family. In spite of unpredictability of COPD, the most typical barriers for EOL care (Escarrabill, 2009): the questions of dying (difficulty to predict the disease terminal phase, coma or bronchopneumonia), psychosocial (consequences of being deprived of driving) and spiritual (kids informing) issues were successfully overcome by discussion with Martin. The patient’s preferences on the optimal care setting (hospice or home) were taken into considerations, and advance care plan was adjusted by CN throughout the disease trajectory (LCP, 2009; NHS, 2008). The healthcare team at all levels (hospital, hospice, community) tried to provide a holistic approach demonstrating a patient-friendly supporting and reassuring behaviour which was emotionally touching. However the same concept had not probably been applied up to the terminal stage. There was an evident lack of multidisciplinary approach to the patient: e.g. consultant’s remark about any movement provoking breathlessness in Martin could have been mitigated, postponed or even prevented by the timely application of 5”P”s rule (prioritizing, planning, pacing, positioning, permission) aimed at energy conservation and dyspnea relief in COPD patients which proved effective at various COPD stages (Cooper, 2013). The frequent hospitalizations of Martin had probably been happening earlier, though current best practice is aimed at reducing hospitalizations rate in COPD and good community palliative care is associated with significant reduction of hospitalization episodes (Escarrabill, 2009). That can be indicative of unsufficiencies in New Zealand model of palliative care for COPD built as cancer care (Taylor,2011), in spite of huge variations in disease patterns between cancer (“cancer trajectory’) and COPD ( “organ system failure trajectory”) clinical courses (Lunney, Lynn, & Hogan, 2002). The stepwise decline with sudden exacerbations acknowledged by Martin was challenging for the patient and the family, and more information should have been given to the caregivers about the “false starts” (Taylor, 2011) and the signs of terminal phase. Finally, there was no trail of any bereavement support\planning for the caregivers which should have started before Martin’s death (Hooman & Kramer, 2006). Still, Martin’s case represents a “good death” as multiple measures to meet all patient’s needs, to avoid distress and to preserve his dignity, such as ACP, pain and dyspnea relief, familiar death setting with relatives’ presence were taken by healthcare team (Escarrabill, 2009; Thomas & Day, 2000).
Conclusion. Martin Cavanagh’s case presented in the video by Taylor & Trotman (2011) was holistically managed by EOL healthcare professionals, with consideration of most difficult ethical and legal decisions. ACP was sucessfully implemented and though the patient probably lacked continuity of care at earlier disease stages, the collaboration of healthcare professionals at all levels ensured the patient’s “good death”. The patient’s case shows the traditional model of EOL care in New Zealand is adjusted to cancer trajectory, but should rather be shaped to COPD course to cover the patient’s needs in the end of life and to provide a seamless holistic care.
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