Hospice eNews 
|
|
What the Media
Said about End-of-Life Care This Week
Week of October 24, 2005
…a service of
___________________________________________________________
BIOETHICS
MEDIATION MAY RESOLVE EOL CONFLICTS
“Conflict and Consensus at the End of
Life,” an article in the recent Hastings Center Report titled “Improving End of Life Care: Why Has It Been So Difficult?,” examines the
history of end-of-life consensus and conflict and suggests ways in which it may
be managed. Author Nancy Neveloff Dubler says that from a
“tentative consensus” after the Quinlan case, where death was not always seen
as the worst thing that could happen, we
have come to this: “A process that should shield patients as they disengage
from life instead leads with increasing frequency to conflict and media
attention and provides an opportunity for third parties with political or
self-serving agendas to feather their particular ideological and personal
nests.” Dubler
is director of the Division of Bioethics, Department of Epidemiology and
Population Health at
Dubler says that the previous tentative consensus is collapsing and that, increasingly, families are demanding treatment for persons with “lost relational ability and conscious appreciation of surroundings.” Additionally, end-of-life decisions are “part of a new political and moral agenda” that applies the “right to life” to life’s end as well as its beginning. Conflict dominates the discussion, with serious consequences for patients and family, healthcare providers and society. According to Dubler, “Our once emerging but now declining consensus about the end of life -- forged in courts and state legislatures, supported by model legislation, and regulated by departments of health – is in danger of being entirely undercut by politics and the needs of the infotainment industry.”
The early cases of end-of-life conflict “occurred in a very different time in American social history,” Dubler writes. “Courts and state legislatures struggled honorably” with questions of withdrawing medical treatment, decision-making by and for the patient and review of those decisions. That process “produced thoughtful opinions and legislation that grappled with developing legal and ethical concepts.” But that process occurred before 24-hour radio and television news and “before tabloid sensationalism. … For many listeners and viewers, hearing it on the radio or seeing it on television provides apparent legitimacy for dubious assertions.”
Also in the last few years, the potential for conflict in medicine has increased exponentially. Cost-containment issues have intruded into all areas of patient relationships and “the doctor-patient relationship has become rather crowded with discharge planners, fiscal officers, reimbursement specialists, and length-of-stay managers.” Possible areas of dispute often become actual ones when race, color and class issues intrude.
While acknowledging that the Schiavo and Francis cases (discussed in the article) “illustrate out-of-control, irresolvable conflict,” Dubler asserts, “While conflict is endemic in medicine and is exacerbated by the emotional rawness that surrounds the process of dying, it can often be recognized and managed for the benefit of families, providers and patients.” She quotes Leonard Marcus, who wrote about conflict in biomedical ethics a decade ago, as saying, “By the very nature the arena of medical ethics is replete with conflict. … In a health care setting, doctrines of justice and patients’ rights translate into concrete decisions based on immediate reality. Although an action may directly affect one particular patient, many people affect and are affected by it, and thus may claim a secondary stake in what happens. Herein lie the ingredients for conflict.”
Dubler says, “Most calls for bioethics consultations are calls to resolve conflicts. There is generally a bioethical hook on which to hang this first request for consultation, but that hook typically constitutes 5 percent of the problem; the remainder of the issues are facets of conflict.” Not only is mediation “one of the most efficient routes to resolving conflict,” Dubler writes, but it is the route that “best respects differences in the cultures of patients, families and health care providers.”
Dubler writes that bioethical analysis, one way of resolving conflicts, very often “privilege[s] ideas that are the basis for academic exploration and analysis,” and favors the “dominant medical culture.” Mediation, on the other hand, “parses those closed systems of analysis and intelligence and requires respect for the unarticulated values and preferences of the particular patient and family.” Dubler believes that, setting aside the exceptional cases such as Schiavo, effective interventions in most bioethical dilemmas, “informed by techniques of dispute resolution and mediation, can be found.”
Additionally, mediation is particularly effective at the end-of-life because time is a factor – not to decide is a luxury not possible in the situation. Mediators are usually optimistic and realistic guides. They teach staff about the process and literature and function as mentors. More importantly, they “translate doctor-speak into language that is accessible to patients and family members, and they help to amplify nonmedical voices.”
The bioethics mediator “comes fresh to the facts of the case” to facilitate discussion among the concerned parties. The mediator “combines the clinical substance and perspectives of bioethics consultation with the tools and techniques of the mediation process,” with several goals in mind:
* To identify parties with a stake in the conflict;
* To understand the interests of the persons involved, both stated and unstated;
* To “level the playing field” between medical personnel and the family;
* To “search for common ground”;
* To “ensure that the consensus reached is a ‘principled resolution,’ in the light of legal rights and ethical scholarship;” and
* To make sure that arrived-at agreements have sufficient support to be translated into patient care.
Dubler closes by saying. “Conflict in life is inevitable. Conflict in health care, given the stakes and the context, is endemic. Conflict in end of life decisions is sad and potentially destructive for surviving family members. Skilled providers who are committed to managing, not banishing, disputes can help to tame some conflicts. Medical providers must acquire the skills of dispute resolution to counteract the effects of politics and media on the stories of life’s endings.” (Improving End of Life Care: Why Has It Been So Difficult?)
Editor’s note: This is the third in a series of articles from the recent Hastings Report, “Improving End of Life Care: Why Has It Been So Difficult?” We will continue the series as space permits.
PUBLIC POLICY NOTES
*
* CMS has initiated its first survey of healthcare providers with an eye to mending relations between the providers and the federal contractors who dispense Medicare money. Survey questions focus on provider communications and inquiries, claims processing and appeals, provider enrollment, medical review and audit and reimbursement of providers. The article says that though many “applaud the move,” the attempt to improve relationships between payers and providers is “too little, too late.” (Modern Healthcare, 1/9)
* At his confirmation
hearings before the Senate Judiciary
* The
OTHER NOTES
* The
* Jane Potter,
president-elect of the American Geriatrics Society, says that the
* Gentiva
Health Services, Inc. has announced an agreement to acquire The Healthfield Group, Inc. The press release says the purchase will make
Gentiva, already the largest provider of
comprehensive home health services in the
* Nurses are not
confident of their communication skills in talking to families about
end-of-life care, says Margaret Q. Rosensweig,
PhD, associate professor at the University of Pittsburgh School of
Nursing. This uncertainty results in “superficial discussions that are often
overly optimistic and focused on medical/technical issues and treatment timing,
rather than quality of life or emotional issues.” The issue was recently addressed at a workshop
held for the
* Healthcare costs the
most in a persons’ final years, according to a Burlington Free Press article which interviewed, with her
permission, the healthcare personnel, providers, and insurers involved in Dorothy
LaForce’s care. The article is online at www.burlingtonfreepress.com/apps/pbcs.dll/article?AID=/20060109/NEWS01/601090307/1009/NEWS05. (
* The table of contents and abstracts from the current Journal of the American Geriatrics Society are online at www.blackwell-synergy.com/toc/jgs/54/1. Articles include “Racial/Ethnic Preferences, Sex Preferences, and Perceived Discrimination Related to End of Life Care,” “Older Adults’ Views of ‘Successful Aging’: Comparison of Older Japanese and Americans,” and “Outcome of Critically Ill Oldest-Old Patients (Aged 90 and Older) Admitted to the Intensive Care Unit.” (Journal of the American Geriatrics Society, 2005;54(1):110)
* In “What You Need to Know,” Dr. Isadore Rosenfeld discusses possible causes of Alzheimer’s and conditions that may mimic it but respond to treatment. Rosenfeld cites recent research which possibly implicates insulin in the disease, suggesting that Alzheimer’s may be a type of diabetes. The original research was published last year in the Journal of Alzheimer’s Disease. (Parade, 1/15)
* Dr. R. Knight
Steel, professor of geriatrics at the
Glatfelter Insurance Group is the national sponsor of Hospice News
Network for 2006. Glatfelter Insurance
Group provides property and liability
insurance for hospices and home healthcare agencies through their Hospice
and Community Care Insurance Services division.
Ask your insurance agent to visit their website at www.hccis.com.