Palliative_Care

Palliative Care Withdrawing Treatment in an Acute Care Setting         An issue that arises in palliative care is when it is the right time to withdraw treatment, this situation happens frequently in haematology, which shall be focused on in this essay. The World Health Organisation (WHO, 1990) defines palliative care as an ‘approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of pain and suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.’ This quotation reflects that palliative care is about offering patients holistic treatment which often not only affects patients but their families too.  Patients with haematological diseases such as leukemia or lymphoma, after having chemotherapy, are prone to sepsis and therefore have to be admitted to hospital. Sepsis is a condition in which the body is fighting a severe infection that has spread to the bloodstream. People at risk are people with cancers and who are being treated with chemotherapy (eMedicine Health, 2009). Once they are in hospital they are treated with a course of antibiotics, usually Tazocin, gentamicin or vancomycin and in some cases antifungal treatments are necessary (Griffiths, 2008). As well as being treated with antibiotics for their low white cells and neutrophils, their haemaglobin and platelet counts drop too so they are treated with blood transfusion's and platelet transfusions. Many patients loose their appetite and become dehydrated and are then started on intravenous fluids (Chemocare.com, 2005). Certain leukaemia's and lymphoma's have a poor prognosis (Miller, 2009). However many doctors continue to actively treat such patient's and some people from the medical profession feel that treatment should be withdrawn earlier so they then can be made comfortable and be treated for symptom control. Springer Berlin and Heidelberg (2009) state, ‘that physicians are generally trained on saving and prolonging the patient’s life rather than paying attention to the inevitable process of dying.’ Furthermore, the British Medical Association (BMA) (2001, as cited in Randall & Downie 2006) state ‘that if the treatment does not have a real benefit to the patient’s health then treatment may be withdrawn on ethical and legal grounds.’ This suggests that if the treatment is failing and the patient's health is deteriorating it should then be withdrawn. Nurses can then take on the role of involving the palliative care team for symptom control and support and the patient can be made as comfortable as possible. However Kinghorn and Gaines (2001) state ‘that even in the palliative care stage there is no moral difference between withdrawing treatment and knowing the patient will die and deliberately ending the life of the patient.’ This means that if doctors and nurses knowingly withhold treatment from patients then this would be ethically wrong and considered to be killing the patient even if it is to save them from more pain and suffering. Many medical professionals are not happy to treat patients who are in the palliative care stage as they feel this would prolong there life. Also as well as prolonging the patient's life they feel, using blood products, antibiotics and fluids on a patient who is at the end stage of their life can be seen as a waste of resources. As Randall and Downie (2006) point out ‘if these resources were stopped earlier on then they can be used to benefit other patients.’ Furthermore Emanuel (2009) argues that ‘interventions for patients whose death is imminent are inherently wasteful since they neither cure nor ameliorate disease or disability.’ This means that patients in the palliative care stage who are receiving treatment are not benefiting from it as they will never be cured and therefore the treatment could be saved and given to a patient who would benefit from it and get well. The overall choice of withdrawing treatment should be the patients. Payne, Seymour and Ingleton state that ' The motivation for withholding or withdrawing life-prolonging treatment should be done to respect the wishes of the patient or else it is done because further treatment would be futile, for medical and ethical reasons.' Furthermore the General Medical Council (GMC,2007) also state that adult competent patient's have the right to refuse treatment even where refusal may result in harm to themselves or in their own death and doctors are legally bound to respect their decision.' In addition Kinghorn & Gamlin (2001) state that ‘When treatment becomes futile, in the sense that it is neither doing the patient harm but equally it is not benefiting the patient, treatment should be withdrawn’. That way the patient can be made comfortable and be treated for symptom control. Kuebler, Davis and Moore (2005) go on to say ‘that once everything has been done to treat the patient then “care” rather than “cure” should be offered.’ In some cases withdrawing treatment must be easier for nurses to accept rather than doctors as nurses spend the majority of their time with the patients and therefore can see them suffering from the effects the treatment is having on them. Part of a doctor’s role is to treat patients, even when treatment is failing and the patient's are deteriorating rapidly the doctor's still continue to treat. Dalinis and Henhelman (1996) say ‘that many doctors feel stopping treatment seems to constitute giving up or abandoning the patient.’ The patients families may also feel this way when their relative is at the stage were they cannot express the wish to withdraw treatment so the doctor has to then ask the question to the next of kin. The BMC (2009) state that ‘when the patient is incompetent and the decision for the patient’s best interest lies on the family, they may feel a lot of stress since decision making is a great responsibility. Also if the families feel a lot of guilt or denies the hopelessness of the situation, they may press for cure rather then care, or to prolong treatment.’ They may feel that they are letting their partner or parent down by agreeing to withdraw treatment when really it is the right decision to make as they would die anyway if treatment was to be continued.  However it must be very hard and upsetting for the families watching their loved one go through the pain and suffering when they are receiving treatment. LaPorte Matzo and Witt Sherman (2006) state ‘that families are devastated and deeply affected when their loved ones have a long drawn-out death.’ Therefore it may be kinder for the patient and their family to withdraw the treatment and make sure the patient is kept comfortable and free from any discomfort. Many health care providers seem to have greater difficulty withdrawing treatment already in place than withholding treatment not yet begun. One issue is what treatment should be withdrawn first. Dalinis and Henhelman (1996), state that ‘particular attention has been given to the withdrawal of fluids’. Studies have shown that the only discomfort from stopping fluids is the dryness of the patient's mouths and increased risk of pressure sore formation, but this can be remedied by implementing basic nursing care. However Shah and Lloyd-Williams (2003), state that ‘certain medical treatment such as blood transfusions, platelet transfusions and antibiotics are used in palliative care to relieve any distressing symptoms’. This is the case with haematology patients due to their blood counts dropping rapidly. When the haemaglobin level drops they become anemic and when the platelet count drops they are prone to bleeding. Symptoms of anemia are fatigue, short of breath and even chest pain (emedicine 2009). Therefore it is only the cytotoxic therapy which is withdrawn and blood transfusions, platelet transfusions and in some cases antibiotics are continued. So the patient is kept comfortable and their symptoms are controlled, the treatment is only withdrawn when the patient is at the very end stage of their life. Glee and Spencer (1995) state that blood transfusions are a valued supportive treatment in patients with haematology diseases in the palliative care stage, which relieve symptoms and improve patients well being.’ One of the issues that patients may have when it is time for treatment to be withdrawn is the feeling that it is the end and this would be a terrifying thought. The BMA (2007), state that 'doctors should strive to assist patients to understand that life cannot be prolonged indefinitely and to accept the inevitability of death.’ Maybe then the patients and their families can accept their future and will feel able to plan in advance and state clearly their wishes for end of life care. Also the GMC (2007) state that ' It is important to ensure that the patient's palliative care needs are met such as their choice of place for receiving care and their religious and spiritual needs.’ In withdrawing treatment at an earlier stage it then gives the patient and the family time to plan what their end of life wishes are. This may also help the patient and their family to come to the realisation of the patient's death and may make it easier for the families to cope with it in the long term. To conclude the essay it is a hard decision for health care professionals to decide when it is the right time to withdraw treatment. However when a patient has a poor prognosis and treatment is futile it is best for the patient to withdraw the necessary treatment and have their care shift to the palliation of symptoms. It has been shown that there is a difference with withdrawing treatment for haematology patient's as palliative care may mean continuing with blood transfusions, platelet transfusions and intravenous antibiotics. However even though they are still receiving this treatment it is for the best and is relieving any symptoms they may have. There is a big support system for patients in the palliative stages, nurses have a major role to making sure the patient is free from pain and not in any discomfort. Also the palliative care team are excellent and always there to give advice and support and to make sure the patient is being treated with the correct drugs.