A Palliative Ethic of Care: Clinical Wisdom at Life's End
http://www.100md.com
《新英格兰医药杂志》
"If there were a silver lining about the physician-assisted suicide debate, it was that this tension helped catalyze the palliative care movement." So writes Joseph Fins in A Palliative Ethic of Care. People on both sides of the issue of physician-assisted suicide for terminally ill patients, as well as the justices of the Supreme Court, concur that palliative care should be the reasonable alternative. Given the recent déjà vu challenges to Oregon's legislation permitting physician-assisted suicide, and the ordeal of Terri Schiavo, I am hopeful that these events will push the development of palliative medicine forward.
Fins's book is divided into two sections and consists of 10 chapters and an appendix. The first section, entitled "Death and Dying in Context," and in particular chapters 2, 3, and 4, should be required reading not only for medical students but also for residents, fellows, and attending staff. The second section, entitled "Goal-Setting: A Strategy for Effective Palliative Care," sets about addressing, in a clinically astute fashion, the ethical dilemmas that arise at the end of life. The appendix provides a clinically workable tool, called the Goals of Care Assessment Tool, which is best understood in light of the material presented in chapters 5 through 10.
The barriers to effective palliative care are both patient-centered and physician-centered. Most patients do not understand palliation, because "they have not been acculturated to think about palliative care as a goal of care." Cure and the restoration of functioning to a premorbid state are the "unspoken goals of care for most encounters with physicians and the health care system." As a result, although the "focus of care changes" with the disease trajectory, the goals of care remain unaddressed. This situation may culminate in a "conflict over futility," which is the "antithesis of palliative care."
The transition in the goals of care toward palliation is "emblematic of good communication between the clinician, patient, and family." Goal setting with patients and families "overcomes the routinization of care decisions that often lead to an escalation of care when this was neither desired nor likely to influence the outcome." Instead of "letting available technology drive the goals of care, let the goals of care drive the therapy. . . . Setting goals is both the implicit organizing principle and explicit objective of end-of-life discussions." A mistake frequently made by residents and fellows is to assume that do-not-resuscitate (DNR) orders constitute a plan of care. However, DNR orders are not "a comprehensive strategy for palliative care."
In the second section of the book, Fins provides eight clinical triggers that should prompt a reassessment of the goals of care. The delineation of these triggers is followed by well-developed discourses on advance directives, proxy and surrogate decision making, prognostication, breaking bad news, use of opioids and the ethics of double effect, family dynamics that influence decisions, and effective communication that facilitates goal setting. The role of the multidisciplinary team is covered in the final chapter. The Goals of Care Assessment Tool, if used properly, would minimize miscommunication and help in the articulation of preferences and goals related to end-of-life care.
This book has two very minor flaws, from my perspective. The mosaic health care delivery model of palliative care, as integrated with "curative" care late in the book, is incongruent with the highway (cure) and byway (palliation) model presented earlier. The misconception that palliative care is not active care is implicit in the statement, "While palliation is generally provided to patients who are dying and have eluded cure, palliative care can also be an element of therapy for patients who are receiving active care." I would like to think that palliative care is active care, which may involve the use of opioids, radiation, surgery, chemotherapy, diuretics, or beta-blockers. Perhaps the term "palliative medicine" would better describe the field as a subspecialty than the term "palliative care" does.
A Palliative Ethic of Care is well worth reading, even by veteran clinicians. The only mistake that Fins makes is to limit his audience to medical students. This book is for physicians, nurses, and all others who care for those with life-limiting illnesses.
Mellar P. Davis, M.D.
Harry R. Horvitz Center for Palliative Medicine at Cleveland Clinic
Cleveland, OH 44198
davism6@ccf.org(By Joseph J. Fins. 281 pp)
Fins's book is divided into two sections and consists of 10 chapters and an appendix. The first section, entitled "Death and Dying in Context," and in particular chapters 2, 3, and 4, should be required reading not only for medical students but also for residents, fellows, and attending staff. The second section, entitled "Goal-Setting: A Strategy for Effective Palliative Care," sets about addressing, in a clinically astute fashion, the ethical dilemmas that arise at the end of life. The appendix provides a clinically workable tool, called the Goals of Care Assessment Tool, which is best understood in light of the material presented in chapters 5 through 10.
The barriers to effective palliative care are both patient-centered and physician-centered. Most patients do not understand palliation, because "they have not been acculturated to think about palliative care as a goal of care." Cure and the restoration of functioning to a premorbid state are the "unspoken goals of care for most encounters with physicians and the health care system." As a result, although the "focus of care changes" with the disease trajectory, the goals of care remain unaddressed. This situation may culminate in a "conflict over futility," which is the "antithesis of palliative care."
The transition in the goals of care toward palliation is "emblematic of good communication between the clinician, patient, and family." Goal setting with patients and families "overcomes the routinization of care decisions that often lead to an escalation of care when this was neither desired nor likely to influence the outcome." Instead of "letting available technology drive the goals of care, let the goals of care drive the therapy. . . . Setting goals is both the implicit organizing principle and explicit objective of end-of-life discussions." A mistake frequently made by residents and fellows is to assume that do-not-resuscitate (DNR) orders constitute a plan of care. However, DNR orders are not "a comprehensive strategy for palliative care."
In the second section of the book, Fins provides eight clinical triggers that should prompt a reassessment of the goals of care. The delineation of these triggers is followed by well-developed discourses on advance directives, proxy and surrogate decision making, prognostication, breaking bad news, use of opioids and the ethics of double effect, family dynamics that influence decisions, and effective communication that facilitates goal setting. The role of the multidisciplinary team is covered in the final chapter. The Goals of Care Assessment Tool, if used properly, would minimize miscommunication and help in the articulation of preferences and goals related to end-of-life care.
This book has two very minor flaws, from my perspective. The mosaic health care delivery model of palliative care, as integrated with "curative" care late in the book, is incongruent with the highway (cure) and byway (palliation) model presented earlier. The misconception that palliative care is not active care is implicit in the statement, "While palliation is generally provided to patients who are dying and have eluded cure, palliative care can also be an element of therapy for patients who are receiving active care." I would like to think that palliative care is active care, which may involve the use of opioids, radiation, surgery, chemotherapy, diuretics, or beta-blockers. Perhaps the term "palliative medicine" would better describe the field as a subspecialty than the term "palliative care" does.
A Palliative Ethic of Care is well worth reading, even by veteran clinicians. The only mistake that Fins makes is to limit his audience to medical students. This book is for physicians, nurses, and all others who care for those with life-limiting illnesses.
Mellar P. Davis, M.D.
Harry R. Horvitz Center for Palliative Medicine at Cleveland Clinic
Cleveland, OH 44198
davism6@ccf.org(By Joseph J. Fins. 281 pp)