A Palliative Ethic Of Care: Clinical Wisdom At Life's End / Edition 1

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Overview

This volume explains how to develop a set of patient and physician goals for improving quality of life, resolving end of life issues, and treating dying patients. The author, Dr. Joseph Fins, pragmatically blends ethical theory and clinical practice, presenting readers with theoretical and historical considerations about end of life care and offering practical wisdom about the care of dying patients and their families. A Palliative Ethic of Care employs the ground-breaking Goals of Care Assessment Tool (GCAT) as a framework of knowledge that links practical considerations about patient care with more theoretical concerns to provide deeper insights into why end-of-life care is so challenging and to help foster necessary reform in how people die.
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Editorial Reviews

Doody's Review Service
Reviewer: David B Cotton, MA; MDiv.(Jersey Shore University Medical Center)
Description: Dr. Fins, in a highly readable, conversational style, presents residents and experienced physicians with a two-part guide to the ethics of caring for patients at the end of life. Part one traces the ethical and legal underpinnings of palliative care, along with some historical context for its appearance on the medical-ethical landscape. Part two is a comprehensive guide for practical application, featuring a specific clinical pathway with goal setting as its guiding principle.
Purpose: The purpose is to educate physicians-in-training regarding the best way to care for the dying. It shares principles and offers relevant information on the skills and strategies necessary for developing a plan of care that meets the patient's needs and respects the patient's goals. In the literature and in the life of the hospital, it is evident that physicians are well prepared for high-tech, aggressive, curative interventions. They are, on the other hand, quite ill prepared to address the complex bundle of issues surrounding death and dying. This book takes direct aim at correcting this imbalance.
Audience: The book is directed specifically to physicians-in-training, especially residents and perhaps fellows. Dr.Fins' wealth of experience and impressive educational credentials combine to make this book worthwhile for practitioners at any level. Reading it is like being on rounds with a master!
Features: The book is divided into two distinct sections. The first chapter addresses the audience directly, stating the case for learning what the book teaches. The following three chapters present the historical, ethical, and legal contexts pertinent to the rise of bioethics consults and the growing emphasis on end-of-life care. The second section builds upon this ethical, historical, and legal framework by presenting a practical guide for bedside care of the dying. This section begins by stressing the importance of the often overlooked step of goal-setting. The need to communicate and formulate a plan of care centered on the patient's and/or family's goals is the most important contribution of the book. The entire application section is centered upon the critical issue of the goal of care as the driver of medical decisions. Fins presents the reader with a Goals of Care Assessment Tool (GCAT) in the book's appendix. It is a terrific answer to the medical-ethical dilemma that presents itself when the physician reaches the point of asking the all-too-familiar question, "Which direction should I go from here with this patient?" Exhausted residents may be tempted to skip the first section and cut right to the practical stuff, but those who hang in there will gain a great deal of wisdom in return for a small sacrifice of time.
Assessment: This is a comprehensive, yet concise, compelling review of the concept, the context, and the content of quality end-of-life care. The emphasis on the need for individual medical decisions to be driven and directed by the goal of care is the book's finest hour and most important contribution. Hopefully it will make the pronouncement, "There's nothing more we can do," obsolete. Dr. Fins encourages and empowers the professional with the idea that competent, compassionate, goal-centered care is every bit as rewarding as cure.
From The Critics
Reviewer: David B Cotton, MA; MDiv.(Jersey Shore University Medical Center)
Description: Dr. Fins, in a highly readable, conversational style, presents residents and experienced physicians with a two-part guide to the ethics of caring for patients at the end of life. Part one traces the ethical and legal underpinnings of palliative care, along with some historical context for its appearance on the medical-ethical landscape. Part two is a comprehensive guide for practical application, featuring a specific clinical pathway with goal setting as its guiding principle.
Purpose: The purpose is to educate physicians-in-training regarding the best way to care for the dying. It shares principles and offers relevant information on the skills and strategies necessary for developing a plan of care that meets the patient's needs and respects the patient's goals. In the literature and in the life of the hospital, it is evident that physicians are well prepared for high-tech, aggressive, curative interventions. They are, on the other hand, quite ill prepared to address the complex bundle of issues surrounding death and dying. This book takes direct aim at correcting this imbalance.
Audience: The book is directed specifically to physicians-in-training, especially residents and perhaps fellows. Dr.Fins' wealth of experience and impressive educational credentials combine to make this book worthwhile for practitioners at any level. Reading it is like being on rounds with a master!
Features: The book is divided into two distinct sections. The first chapter addresses the audience directly, stating the case for learning what the book teaches. The following three chapters present the historical, ethical, and legal contexts pertinent to the rise of bioethics consults and the growing emphasis on end-of-life care. The second section builds upon this ethical, historical, and legal framework by presenting a practical guide for bedside care of the dying. This section begins by stressing the importance of the often overlooked step of goal-setting. The need to communicate and formulate a plan of care centered on the patient's and/or family's goals is the most important contribution of the book. The entire application section is centered upon the critical issue of the goal of care as the driver of medical decisions. Fins presents the reader with a Goals of Care Assessment Tool (GCAT) in the book's appendix. It is a terrific answer to the medical-ethical dilemma that presents itself when the physician reaches the point of asking the all-too-familiar question, "Which direction should I go from here with this patient?" Exhausted residents may be tempted to skip the first section and cut right to the practical stuff, but those who hang in there will gain a great deal of wisdom in return for a small sacrifice of time.
Assessment: This is a comprehensive, yet concise, compelling review of the concept, the context, and the content of quality end-of-life care. The emphasis on the need for individual medical decisions to be driven and directed by the goal of care is the book's finest hour and most important contribution. Hopefully it will make the pronouncement, "There's nothing more we can do," obsolete. Dr. Fins encourages and empowers the professional with the idea that competent, compassionate, goal-centered care is every bit as rewarding as cure.

5 Stars! from Doody
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Product Details

  • ISBN-13: 9780763732929
  • Publisher: Jones & Bartlett Learning
  • Publication date: 10/5/2005
  • Edition description: 1E
  • Edition number: 1
  • Pages: 281
  • Product dimensions: 6.94 (w) x 8.44 (h) x 0.93 (d)

Table of Contents

Foreword xi
Preface xv
Acknowledgments xxv
Permissions xxxi
Part I Death and Dying in Context 1
Chapter 1 Medical Students, Residents, and the Dying Patient 3
The Challenge of Caring for the Dying 3
Goal-Setting Near the End of Life 9
How This Book Is Organized 10
Closing Words 11
Chapter 2 The Rise of Bioethics and Palliative Care Movements 13
European Origins of Hospice and Palliative Care 14
The American Context 17
The Rise of Self-Determination 19
Toward an Ethic of Patients' Rights 22
Chapter 3 Death, Dying, and the Law 29
The Law and the Rise of Patient Self-Determination 29
Quinlan and the Right to Die 30
Quinlan and the Institutionalization of Hospital Ethics Committees 32
Cruzan and the Patient Self-Determination Act 34
Advance Care Planning in Theory and Practice 36
From Self-Determination to Physician-Assisted Suicide 37
Physician-Assisted Suicide: Laying out the Arguments 39
Physician-Assisted Suicide in the Courts 41
A Consensus on Palliative Care 45
Back to the Future: The Schiavo Case 48
Epilogue 52
Chapter 4 End-of-Life Care in the Hospital 63
Death in the Modern Hospital 63
Medical Rescue and Intensive Care 64
Fostering Communication 70
Communication, Palliation, and the Road Not Taken 72
Milestones at the End of Life 73
Ambivalence and Medical Futility 77
Futility: A Definitional Primer 79
The Evolution of Futility Disputes 82
Goal Convergence, Palliative Care, and the Avoidance of Futility Disputes 85
Part II Goal-Setting: A Strategy for Effective Palliative Care 91
Chapter 5 Goals of Care: Triggering the Process 93
Goal-Setting as Differential Diagnosis 93
Triggering the Process 95
Concluding Comments 99
Chapter 6 Goals of Care: When Death Is Near 101
Introduction 101
Clinical Perceptions 101
Patient Perceptions 104
When a Patient Wants to Die 106
Surrogate Perceptions 109
Decision-Making Capacity 110
Helping Surrogates Decide 113
Chapter 7 Goals of Care: End-of-Life Decisions 119
Introduction 119
Do Not Resuscitate Orders 121
Advance Care Planning 125
Working with the Proxy 129
Withdrawals of Care 132
Hospice or Palliative Care Referral 134
Hospice Care 137
Chapter 8 Goals of Care: Medical Developments 145
Introduction 145
A Life-Threatening Illness 146
Prognosis 149
Acute Decompensation and the Use of Life-Sustaining Therapies 153
Consideration of ICU Transfer 153
Symptoms at the End of Life 155
The Ethics of Opioid Use 156
Chapter 9 Goal-Setting: Gathering Information 163
Introduction 163
Sources of Information 163
Demographics and Local Culture 165
The Power of Diagnosis 167
Forced Prognostication and Patient Expectations 169
Assessment of Capacity and the Refusal of Life-Sustaining Therapies 172
Knowledge of Diagnosis and Prognosis 174
Constructing a Shared World of Meaning with the Patient and Family 176
Breaking Bad News 180
The Therapeutic Exception 186
DNR in the OR 189
The Elusive Advance Directive 192
Family Dynamics 195
The Symbionic Family 198
Cultural Issues: Religious Objections to Brain Death 201
Public Perspectives on Pain and Meaning 211
Biological Symptom Assessment 212
Chapter 10 Formulating the Goals of Care 225
Introduction 225
Defining Goals 226
Hospital Resources 232
Psychiatry Consultation 233
Pastoral Care/Chaplaincy 236
Pain Service/Palliative Care Consult/Referral to Palliative Care Unit 239
Hospice Referral 241
Social Work 242
Ethics Committees 244
The Centrality of Communication and Consensus 250
Working with Nurses 252
Involving the Patient and Family 255
One Good Death 256
Appendix The Goals of Care Assessment Tool (GCAT) 263
Index 267
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