Ethics & Palliative Care Emily Bowles, RN, BSN Palliative Care Coordinator

Objectives Identify how Palliative Care Services can add to the patient experience, Identify when and how to order a Palliative Care Consult, Define what is a medical Surrogate Decision Maker and gain skills for discussing this with the patient, Assess patients for Advance Healthcare Directives, Identify actions to take when a patient does not wish to be a “full code”, Identify actions to take when perceiving an Ethical dilemma.

What is Palliative Care? Patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information and choice. (Center to Advance Palliative Care, 2012)

Palliative Care Philosophy and Delivery Care is provided and services are coordinated by an interdisciplinary team; Patients, families, palliative and non-palliative health care providers collaborate and communicate about care needs; Services are available concurrently with or independent of curative or life-prolonging care; Patient and family hopes for peace and dignity are supported throughout the course of illness, during the dying process, and after death.

What Can a Palliative Care Consult Provide? The Palliative care team will: Listen to hopes, wishes, values, and goals of care of the patient and family Talk to the patient and family about the probable course of the patient’s illness, which may include: Current symptoms and treatment Decisions about life-sustaining and life- extending measures Plans for changing or worsening conditions Choice of a surrogate decision maker Information for post-hospital care Advance healthcare planning

Who Can Request a Palliative Care Consult? Anyone can make a request for Palliative care. An MD order is not required. Physicians Nursing Social Work Speech Therapy Physical Therapy Radiology Respiratory Therapy Spiritual Care Dietary Patients and Families

How Do I Know if Palliative Care is Appropriate? Listen to the patient and family If they don’t seem to understand all of the information about the patient’s medical condition or diagnosis; There appears to be a conflict between the patient and their family in regards to medical decisions; The patient or family has questions about advance directives, code status, plan of care, treatment options, etc.; The patient or family are having a hard time dealing with serious or chronic illnesses; The patient has symptoms related to serious or chronic illnesses that are hard to manage.

How to Request a Consult Place an order for a Palliative Care Consult in CPOE under “any order”. MD order is not needed Enter the order as a nursing intervention if you do not have an MD order. Call the Palliative Care Coordinator at x1535. After hours and weekends contact the House Supervisor for extenuating circumstances. The House Supervisor will triage the request and contact PCC as needed. ICCU nurses: complete the Palliative Care Screening Tool Required to be completed for every patient within the first 48 hours of arrival to the unit. An order will generate depending on the patient’s score.

How you can help We are all a part of the Palliative Care team when we provide comfort through our care. Listen to and acknowledge the patient’s and family’s needs and concerns. Assess pain, nausea, dyspnea, bowel habits, and other symptoms, and obtain and carry our orders as appropriate. Complete the admission assessment. Ask the adult patient about, and document: Code status Advance Healthcare Directive status Surrogate decision maker.

Code Status

Code Status What do I if my patient does not want to be a “full code”? Assess the patient’s wishes for resuscitative treatment. Notify your charge nurse and the physician immediately of the patient’s expressed wishes Obtain orders as appropriate. Ensure the “Do Not Resuscitate“ purple order is placed in the patient’s chart and relay this information during patient handoffs.

Advance Healthcare Directives

Advance Healthcare Directives If the patient has an Advance Healthcare Directive with them upon arrival, it should be reviewed for content by the nurse, discussed with physicians as appropriate, copied, and placed in the chart. If the patient has an Advance Healthcare Directive, but not with them, encourage the patient to have a family member bring the document to the hospital as soon as possible. If the patient does not have an Advance Healthcare Directive they can be provided with more information upon request.

Advance Healthcare Directives Advance decisions for medical care can come in many forms such as: Advance Healthcare Directive Durable Power of Attorney for Healthcare (health care power of attorney, health care proxy) Physician’s order for Life Sustaining Treatment (POLST) Living Will (Coalition for Compassionate Care, 2015)

Surrogate Decision Makers

Identifying the Surrogate Decision Maker What is a surrogate decision maker? A individual who will make medical decisions for the patient, should the patient become unable to make his or her own medical decisions. Who can be the surrogate decision maker? The surrogate decision maker can be any adult the patient names. If the patient has not named a SDM, this role is defaulted to an individual pursuant to California’s Health and Safety Code 24178(c) (State of California Legislative Counsel, 2015). Why Identify a surrogate decision maker? Patient’s conditions can change rapidly. Even if the patient is awake, alert, oriented, and making their own medical decisions, the patient should be encouraged to name a surrogate decision maker. If a person is unable to make decisions about their medical care, some other person or people must provide direction in decision making. Some patients who are capable of making their own decisions prefer to defer medical decisions to a loved one.

Identifying the Medical Surrogate Decision Maker What should the patient be asked? Who would you want/trust to make medical decisions for you, if you become to tired/sleepy/ill to make your own medical decisions? Have you talked to this person about your wishes? Encourage patients to speak with their loved ones about their wishes for medical treatment. If a patient says they make their own decisions, educate the patient on when a surrogate decision maker would speak for the patient and assess for social support. Where should this be charted? In the patient’s admission assessment. Chart the name, relationship, and phone number, of the person the patient identifies as being their surrogate decision maker.

Ethical Dilemmas

Ethical Dilemmas Ethical dilemmas may arise for patients, families, and staff. If there is an ethical dilemma about a patient’s care, refer to the Ethic’s Desk Manual that can be located on each unit. Discuss the dilemma with the physician, charge person, supervisor, manager or the House Supervisor. Offer a family meeting to attempt to resolve the dilemma. Refer to your profession’s Code of Ethics. At anytime, anyone can call the Ethics Hotline at 909-806-1729 (x1SAY).

References Center to Advance Palliative Care (2012). What is palliative care. Retrieved from http://getpalliativecare.org/whatis/ Coalition for Compassionate Care (2015). Talking about advance healthcare planning. Retrieved from http://coalitionccc.org/tools-resources/advance-care-planning-resources/ State of California Legislative Counsel (2015). Official California legislative information. Retrieved from http://www.leginfo.ca.gov/cgi-bin/displaycode?section=hsc&group=24001- 25000&file=24170-24179.5