End-of-Life Issues: Ethical Topic in Medicine #hotel #breaks

#end of life issues

#

End-of-Life Issues

A s care of the dying involves so much of one’s self, in this topic page I will describe my approach as an one example of how clinicians think about end-of-life care. I remember, the first time one of my patients died, feeling a chill of horror and fascination. I wasn’t prepared for it. The resident yawned–a long night, then a long code. “We better go talk to the family.” What in the world would we say? The dead patient, now dusky blue, looked unreal and unfamiliar. I was so wrapped up in my own feelings that I can’t recall much else.

Now I find care of the dying to be one of the richest parts of my clinical life. But it is demanding in a different, more personal way, than, say, treating pneumococcal pneumonia with penicillin. Here I will describe some ways of thinking about care of the dying that have helped me figure out where I am going as I guide someone who is really sick.

Many medical students first encounter care of the dying as an unsuccessful code or a strategic withholding of CPR. Of course, an ethically sound understanding of withdrawing and withholding treatment is crucial to good care of the dying. Yet “withholding and withdrawing” only describe what we, as clinicians, decide not to do. To provide excellent care of the dying requires that we also decide what we should do. What should be the goals of medical care for people who are dying? What makes a good death?

What is a “good death”? A medical perspective

The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a “death-defying” culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician aid-in-dying is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like “ER” as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person.

Interestingly, contemporary medical literature contains little that might characterize what makes a death “good.” Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is “bad” (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as “bad,” we could certainly agree that they were not “good deaths.”

In caring for a person who is dying, knowing what would make the experience of dying “good” is an important goal for physicians and other members of the care team. I find it doesn’t take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, “Knowing that all of us have to think about dying at some point, what would be a good death for you?” What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can’t always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

What goals should I have in mind when working towards a decent death for my patient?


I have several working clinical goals when I am caring for someone near the end of life. I work towards:

  1. Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.
  2. Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.
  3. A degree of acceptance by the patient. Acceptance doesn’t mean that the patient likes what is going on, and it doesn’t mean that a patient has no hopes–it just means that he can be realistic about the situation.
  4. A medical understanding of the patient’s disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.
  5. A process of care that guides patient understanding and decision making. One great physician does not equal great care–it takes a coordinated system of providers.

How do you know when someone is dying?

This question is not as simple as it might sound. The SUPPORT study demonstrated that even for patients with a high probability of dying, it is still difficult for a clinician to predict that a particular patient is about to die. Thus it may be more useful for clinicians to give up relying on their predictive skills, and look at the common clinical paths (or trajectories) taken by dying patients, and design medical care that includes “contingency plans” for clinical problems that a person with incurable lung cancer (for example) is likely to experience. Such contingency plans might include advance directives and perhaps DNAR orders. as well as lines such as: “You will probably die from this, although we can’t predict exactly when. What is really important for you in the time you have left?”

What should I know about the hospice approach?


In order to help someone towards a decent, or even good, death, the hospice framework is very helpful. Hospice started as a grassroots effort, as a view of dying that lets go of the possibility of cure. Instead, hospices emphasize symptom control and attention to psychological and spiritual issues. Pathophysiology becomes less important and personal meaning becomes more important. Thus this framework analyzes a person’s medical care into four major topics, and this can be used to outline day-to-day care plans for a patient:

  1. Pain – one of the things most feared by patients with life-threatening illness.
  2. Symptom control – including dyspnea, nausea, confusion, delirium, skin problems, and oral care.
  3. Psychological issues – especially depression, sadness, anxiety, fear, loneliness.
  4. Spiritual or existential issues – including religious or non-religious beliefs about the nature of existence, the possibility of some type of afterlife.

Hospice care in Washington State is most often provided by multidisciplinary teams who go to patients’ homes. This care is covered by Medicaid for patients judged to have less than six months to live. Hospice care is generally underutilized, and even though most hospice teams feel that at least six weeks of hospice care is optimal, most patients receive much less because they are either referred very late or have not wanted hospice. A major problem in connecting hospice care to acute medical care is that referral implies a “switch” from curative to palliative medicine-a model that does not fit comfortably in many illnesses.

What you need to understand to care for the dying


Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying.

  1. The patient’s story – including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.
  2. The body – which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.
  3. The medical care system available for this particular patient – knowing how you can make the system work for the patient, as well as the relevant law and ethics.
  4. Finally, you must understand yourself – because you, as a physician, can be an instrument of healing, or an instrument that does damage.

Obviously, learning how to do all this is beyond the scope of this web page–these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.

How do physicians who care for the dying deal with their own feelings?

It is not hard to find physicians who are burned out – ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you – in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, “you must be present to win.”





Security Assessment, VAPT, ECSA Training in Bangalore, Chennai, Mumbai, Pune, Delhi, Gurgaon,


#

A penetration test is done to evaluate the security of a computer system or network by simulating an attack by a malicious user / hacker. The process involves active exploitation of security vulnerabilities that may be present due to poor or improper system configuration, known and / or unknown hardware or software flaws, or operational weaknesses in process or design.

This analysis is carried out from the position of a potential attacker, to determine feasibility of an attack and the resulting business impact of a successful exploit. Usually this is presented with recommendations for mitigation or a technical solution.

About this workshop

This workshop gives an in-depth perspective of penetration testing approach and methodology that covers all modern infrastructure, operating systems and application environments.

This workshop is designed to teach security professionals the tools and techniques required to perform comprehensive information security assessment.

Participants will learn how to design, secure and test networks to protect their organization from the threats hackers and crackers pose. This workshop will help participants to effectively identify and mitigate risks to the security of their organization s infrastructure.

This 40 hour highly interactive workshop will help participants have hands on understanding and experience in Security Assessment.

A proper understanding of Security Assessment is an important requirement to analyze the integrity of the IT infrastructure.

Expertise in security assessment is an absolute requirement for a career in information security management and could be followed by management level certifications like CISA, CISSP, CISM, CRISC and ISO 27001.

There are many reasons to understand Security Assessment:

  • Prepare yourself to handle penetration testing assignments with more clarity
  • Understand how to conduct Vulnerability Assessment
  • Expand your present knowledge of identifying threats and vulnerabilities
  • Bring security expertise to your current occupation
  • Become more marketable in a highly competitive environment

Therefore this workshop will prepare you to handle VA / PT assignments and give you a better understanding of various security concepts and practices that will be of valuable use to you and your organization.

This workshop will significantly benefit professionals responsible for security assessment of the network / IT infrastructure.

  • IS / IT Specialist / Analyst / Manager
  • IS / IT Auditor / Consultant
  • IT Operations Manager
  • Security Specialist / Analyst
  • Security Manager / Architect
  • Security Consultant / Professional
  • Security Officer / Engineer
  • Security Administrator
  • Security Auditor
  • Network Specialist / Analyst
  • Network Manager / Architect
  • Network Consultant / Professional
  • Network Administrator
  • Senior Systems Engineer
  • Systems Analyst
  • Systems Administrator

Anyone aspiring for a career in Security Assessment would benefit from this workshop. The workshop is restricted to participants who have knowledge of ethical hacking countermeasures.

The entire workshop is a combination of theory and hands-on sessions conducted in a dedicated ethical hacking lab environment.

  • The Need for Security Analysis
  • Advanced Googling
  • TCP/IP Packet Analysis
  • Advanced Sniffing Techniques
  • Vulnerability Analysis with Nessus
  • Advanced Wireless Testing
  • Designing a DMZ
  • Snort Analysis
  • Log Analysis
  • Advanced Exploits and Tools
  • Penetration Testing Methodologies
  • Customers and Legal Agreements
  • Rules of Engagement
  • Penetration Testing Planning and Scheduling
  • Pre Penetration Testing Checklist
  • Information Gathering
  • Vulnerability Analysis
  • External Penetration Testing
  • Internal Network Penetration Testing
  • Routers and Switches Penetration Testing
  • Firewall Penetration Testing
  • IDS Penetration Testing
  • Wireless Network Penetration Testing
  • Denial of Service Penetration Testing
  • Password Cracking Penetration Testing
  • Social Engineering Penetration Testing
  • Stolen Laptop, PDAs and Cell phones Penetration Testing
  • Application Penetration Testing
  • Physical Security Penetration Testing
  • Database Penetration testing
  • VoIP Penetration Testing
  • VPN Penetration Testing
  • War Dialing
  • Virus and Trojan Detection
  • Log Management Penetration Testing
  • File Integrity Checking
  • Blue Tooth and Hand held Device Penetration Testing
  • Telecommunication and Broadband Communication Penetration Testing
  • Email Security Penetration Testing
  • Security Patches Penetration Testing
  • Data Leakage Penetration Testing
  • Penetration Testing Deliverables and Conclusion
  • Penetration Testing Report and Documentation Writing
  • Penetration Testing Report Analysis
  • Post Testing Actions
  • Ethics of a Penetration Tester
  • Standards and Compliance

Online Course: Effective Communication 101 – CEUs and Certificate #communications #class #online,


#

Effective Communication 101

Lesson 1: Recognizing and Understanding Communication Styles

This lesson will help recognize four of the major communication styles. Each style serves a different purpose, and you will be able to identify those and understand which is the most effective.

  • Lesson 2: Verbal Communication

    This lesson will break down verbal communication into various subcategories. It will help to find key areas for improvement when misunderstandings arise.

  • Lesson 3: Nonverbal Communication

    This lesson will help you learn to use nonverbal cues to better understand others. Likewise, you can hone these skills to be sure you are effectively communicating your ideas.

  • Lesson 4: Communicating in Writing

    This lesson will address the different components of written communication. It will enable individuals to use writing to maximize their ability to communicate for personal and business reasons.

  • Lesson 5: Cultivating Conversational Skills

    This lesson teaches the most important skills required to use conversation as an effective form of communication. Mastering conversational skills makes you more interesting, and more likely to truly experience two-sided communication.

  • Lesson 6: Group Communication

    In this lesson, you will learn more about group dynamics and how to use them to your advantage. Groups have very specific ways of interacting, and anticipating this can be invaluable in making sure the group actually is effective.

  • Lesson 7: Communications Technology

    In this lesson, you will learn more about the technology currently available to make communication faster and easier. You will also learn what kinds of repercussions this access to instant communication has on business and personal relationships.

  • Lesson 8: Barriers to Communication

    The goal of this lesson is to learn to recognize where there might be breakdowns in communication. By knowing what problems you are facing, you are more prepared to avoid them altogether.

  • Lesson 9: Cultural Aspects of Communication

    In this lesson, you will learn about the field of cross-cultural communication. You will discover what types of barriers to expect, and what you can do to overcome them.

  • Lesson 10: Disagreements and Conflicts

    In this lesson, you will learn how to handle disagreements before and after they occur.

  • Lesson 11: Negotiation

    In this lesson, you will learn the basics of negotiation. It will also pull together some of the skills you have learned throughout this course and show you how to utilize them to reach a specific goal.

  • Lesson 12: Constructive Criticism

    In this lesson, you will learn how to offer and receive constructive criticism. You will also learn the dynamics of the critical relationship.

  • Additional Course Information

    • Document Your Lifelong Learning Achievements
    • Earn an Official Certificate Documenting Course Hours and CEUs
    • Verify Your Certificate with a Unique Serial Number Online
    • View and Share Your Certificate Online or Download/Print as PDF
    • Display Your Certificate on Your Resume and Promote Your Achievements Using Social Media

    Course Title: Effective Communication 101

    Course Number: 7550121

    Learning Outcomes

    By successfully completing this course, students will be able to:

    • Recognize and describe various communication styles.
    • Define verbal communication.
    • Define nonverbal communication.
    • Demonstrate proper techniques when communicating in writing.
    • Demonstrate techniques for improving conversational skills.
    • Demonstrate techniques for improving group communication.
    • Describe techniques for improving communications with technology.
    • Define barriers to communication.
    • Compare and contrast cultural aspects of communication.
    • Describe communication strategies to resolve disagreements and conflicts.
    • Describe negotiation strategies.
    • Describe how to receive and deliver constructive criticism, and
    • Demonstrate mastery of lesson content at levels of 70% or higher.

    Related Courses

    Follow Us Online

    Copyright 1999-2017 Universal Class All rights reserved.


    End-of-Life Issues: Ethical Topic in Medicine #midwest #palliative #& #hospice #carecenter

    #end of life issues

    #

    End-of-Life Issues

    A s care of the dying involves so much of one’s self, in this topic page I will describe my approach as an one example of how clinicians think about end-of-life care. I remember, the first time one of my patients died, feeling a chill of horror and fascination. I wasn’t prepared for it. The resident yawned–a long night, then a long code. “We better go talk to the family.” What in the world would we say? The dead patient, now dusky blue, looked unreal and unfamiliar. I was so wrapped up in my own feelings that I can’t recall much else.

    Now I find care of the dying to be one of the richest parts of my clinical life. But it is demanding in a different, more personal way, than, say, treating pneumococcal pneumonia with penicillin. Here I will describe some ways of thinking about care of the dying that have helped me figure out where I am going as I guide someone who is really sick.

    Many medical students first encounter care of the dying as an unsuccessful code or a strategic withholding of CPR. Of course, an ethically sound understanding of withdrawing and withholding treatment is crucial to good care of the dying. Yet “withholding and withdrawing” only describe what we, as clinicians, decide not to do. To provide excellent care of the dying requires that we also decide what we should do. What should be the goals of medical care for people who are dying? What makes a good death?

    What is a “good death”? A medical perspective

    The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a “death-defying” culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician aid-in-dying is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like “ER” as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person.

    Interestingly, contemporary medical literature contains little that might characterize what makes a death “good.” Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is “bad” (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as “bad,” we could certainly agree that they were not “good deaths.”

    In caring for a person who is dying, knowing what would make the experience of dying “good” is an important goal for physicians and other members of the care team. I find it doesn’t take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, “Knowing that all of us have to think about dying at some point, what would be a good death for you?” What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can’t always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

    What goals should I have in mind when working towards a decent death for my patient?


    I have several working clinical goals when I am caring for someone near the end of life. I work towards:

    1. Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.
    2. Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.
    3. A degree of acceptance by the patient. Acceptance doesn’t mean that the patient likes what is going on, and it doesn’t mean that a patient has no hopes–it just means that he can be realistic about the situation.
    4. A medical understanding of the patient’s disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.
    5. A process of care that guides patient understanding and decision making. One great physician does not equal great care–it takes a coordinated system of providers.

    How do you know when someone is dying?

    This question is not as simple as it might sound. The SUPPORT study demonstrated that even for patients with a high probability of dying, it is still difficult for a clinician to predict that a particular patient is about to die. Thus it may be more useful for clinicians to give up relying on their predictive skills, and look at the common clinical paths (or trajectories) taken by dying patients, and design medical care that includes “contingency plans” for clinical problems that a person with incurable lung cancer (for example) is likely to experience. Such contingency plans might include advance directives and perhaps DNAR orders. as well as lines such as: “You will probably die from this, although we can’t predict exactly when. What is really important for you in the time you have left?”

    What should I know about the hospice approach?


    In order to help someone towards a decent, or even good, death, the hospice framework is very helpful. Hospice started as a grassroots effort, as a view of dying that lets go of the possibility of cure. Instead, hospices emphasize symptom control and attention to psychological and spiritual issues. Pathophysiology becomes less important and personal meaning becomes more important. Thus this framework analyzes a person’s medical care into four major topics, and this can be used to outline day-to-day care plans for a patient:

    1. Pain – one of the things most feared by patients with life-threatening illness.
    2. Symptom control – including dyspnea, nausea, confusion, delirium, skin problems, and oral care.
    3. Psychological issues – especially depression, sadness, anxiety, fear, loneliness.
    4. Spiritual or existential issues – including religious or non-religious beliefs about the nature of existence, the possibility of some type of afterlife.

    Hospice care in Washington State is most often provided by multidisciplinary teams who go to patients’ homes. This care is covered by Medicaid for patients judged to have less than six months to live. Hospice care is generally underutilized, and even though most hospice teams feel that at least six weeks of hospice care is optimal, most patients receive much less because they are either referred very late or have not wanted hospice. A major problem in connecting hospice care to acute medical care is that referral implies a “switch” from curative to palliative medicine-a model that does not fit comfortably in many illnesses.

    What you need to understand to care for the dying


    Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying.

    1. The patient’s story – including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.
    2. The body – which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.
    3. The medical care system available for this particular patient – knowing how you can make the system work for the patient, as well as the relevant law and ethics.
    4. Finally, you must understand yourself – because you, as a physician, can be an instrument of healing, or an instrument that does damage.

    Obviously, learning how to do all this is beyond the scope of this web page–these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.

    How do physicians who care for the dying deal with their own feelings?

    It is not hard to find physicians who are burned out – ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you – in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, “you must be present to win.”





    UKCEN: Ethical Issues -End of Life Decisions #low #price #hotels

    #end of life issues

    #

    Ethical Issues – End of life decisions

    Ethical Considerations

    A number of ethical theories and principles are relevant when considering treatment decisions at the end of life.

    Sanctity of Life Doctrine

    The argument underpinning this doctrine is that all human life has worth and therefore it is wrong to take steps to end a person s life, directly or indirectly, no matter what the quality of that life. This is in keeping with both traditional codes of medical ethics and a general perception of what doctors and other health professionals should do, that is save and preserve life. One challenge to this principle in the context of health care is to ask should life be preserved at all costs. Is there no place for consideration of quality of life? One of the problems with considering quality of life is the question of how this is defined and by whom. An objective view of someone s life may be very different to the view of the person who is living that life. However, this problem does not remove the challenge to the sanctity of life doctrine. There may be some circumstances where a person s quality of life, however defined, is so poor that it should not be maintained even if it is possible to do so. Some ethical arguments have been developed to address this challenge.

    Acts /omissions distinction

    This distinction argues that there is a difference between actively killing someone and refraining from an action that may save or preserve that person s life. Thus it is morally wrong to push someone into a river to their death but we may not have a moral duty to leap into the river to save someone who is drowning. In a medical context this distinction would mean that a doctor could not give a patient a lethal injection to end his/her life, whatever the circumstances, but could, withhold treatment that may sustain it. Withholding treatment would only be permissible if the patient s quality of life was so poor, and the burden of treatment so great, that it would not to be in the patient s best interests to continue treatment. For example, it might be permissible not to ventilate a patient if he/she was in chronic respiratory failure, or not to use tube feeding if he/she was in a permanent vegetative state.

    Doctrine of Double Effect

    The doctrine of double effect argues that there is a moral distinction between acting with the intention to bring about a person s death and performing an act where death is a foreseen but unintended consequence.

    The doctrine of double effect allows that performing an act that brings about a good consequence may be morally right even though the good consequence can only be achieved at the risk of a harmful side effect. Prescribing pain relieving drugs which in large doses shorten the life of a terminally ill patient is often used as an example of double effect. The intention is to relieve pain and the foreseen but unintended consequence is that the patient’s life will be shortened. Current practice in palliative medicine and the range of drugs available may reduce the appropriateness of this doctrine.

    Respect for autonomy

    The principle for respect for autonomy acknowledges the right of a patient to have control over his or her own life, including decisions about how his/her life should end. Thus a competent person should be able to refuse life saving treatment in both current situations and future foreseeable situations. Should respect for autonomy mean that a person can request assistance in ending his/her life? Some would argue that this is the case but as assisted suicide is currently illegal in the UK this is not an issue that a clinical ethics committee should need to consider. Does respect for autonomy mean that a patient can request treatment that the clinician does not think is in his/her best interests, or treatment that is futile? In these situations the principle of respect for autonomy comes into conflict with other ethical considerations, such as preventing or avoiding harm, or distributive justice.

    A duty to act in the patient s best interest (Beneficence)

    The duty of beneficence, that is to act in a way that benefits the patient, is an important ethical principle in health care. In treatment decisions at the end of life the dilemma often revolves around what course of action will be in the patient’s best interests. It is difficult to see how death can be a benefit or in the patient’s interests, but in some circumstances, if existing quality of life is so poor, or treatment is very burdensome, then the balance of harms and benefits may suggest that continuing treatment is not a benefit to the patient.

    A duty not to harm (Nonmaleficence)

    The concept of nonmaleficence – an obligation not to inflict harm intentionally, is distinct from that of beneficence – an obligation to help others. In codes of medical practice the principle of nonmaleficence (primum non nocere) has been a fundamental tenet. However, in the context of health care it can sometimes be difficult to comply with this principle depending on the definition of harm. Many medical treatments may have harmful side effects but save or improve lives. In end of life decisions the question of how much harm is caused by the treatment needs to be considered, as does the question of whether death itself is always a harm.

    Page created: May 26, 2011





    End-of-Life Issues: Ethical Topic in Medicine #motel #stari #hrast

    #end of life issues

    #

    End-of-Life Issues

    A s care of the dying involves so much of one’s self, in this topic page I will describe my approach as an one example of how clinicians think about end-of-life care. I remember, the first time one of my patients died, feeling a chill of horror and fascination. I wasn’t prepared for it. The resident yawned–a long night, then a long code. “We better go talk to the family.” What in the world would we say? The dead patient, now dusky blue, looked unreal and unfamiliar. I was so wrapped up in my own feelings that I can’t recall much else.

    Now I find care of the dying to be one of the richest parts of my clinical life. But it is demanding in a different, more personal way, than, say, treating pneumococcal pneumonia with penicillin. Here I will describe some ways of thinking about care of the dying that have helped me figure out where I am going as I guide someone who is really sick.

    Many medical students first encounter care of the dying as an unsuccessful code or a strategic withholding of CPR. Of course, an ethically sound understanding of withdrawing and withholding treatment is crucial to good care of the dying. Yet “withholding and withdrawing” only describe what we, as clinicians, decide not to do. To provide excellent care of the dying requires that we also decide what we should do. What should be the goals of medical care for people who are dying? What makes a good death?

    What is a “good death”? A medical perspective

    The good death is not a familiar idea in American culture. Some experts in palliative care describe the United States as a “death-defying” culture, with a mass media that spotlights only youth and beauty. Yet public interest in care of the dying is currently high. The striking public interest in physician aid-in-dying is one obvious reason. But there are other reasons: over the past 100 years, there has been a epidemiologic shift in the reasons people die. In the pre-antibiotic era, people most often died young, of infectious diseases; now, thanks to medical technology, most Americans (and others with access to this technology) live much longer, to die of degenerative, neoplastic, and even man-made diseases. Finally, there is a marked public fear that a medical death, depicted in TV shows like “ER” as an unresponsive, uncommunicative body hooked up to an array of flashing monitors, represents an irresponsible use of technology and a dishonorable way to treat a person.

    Interestingly, contemporary medical literature contains little that might characterize what makes a death “good.” Recently, a large, expensive empirical study of intensive care unit deaths suggested that medical care for a common type of in-hospital death is “bad” (the SUPPORT study, referenced below). In this study of dying patients, severe pain was common, decisions to withhold invasive treatments were made at the last minute, and physicians often had no knowledge of patient preferences not to have CPR. Even worse, an intervention designed to provide physicians with better prognostic information had no effect on medical decision making prior to death. While the SUPPORT authors did not actually describe these deaths as “bad,” we could certainly agree that they were not “good deaths.”

    In caring for a person who is dying, knowing what would make the experience of dying “good” is an important goal for physicians and other members of the care team. I find it doesn’t take fancy techniques-you just need to be sincere and patient and interested. Listen more and talk less. Try asking something like, “Knowing that all of us have to think about dying at some point, what would be a good death for you?” What people choose when they think about a good death for themselves is often beyond what medicine can provide-for instance, an affirmation of love, a completion of important work, or a last visit with an important person. As a physician, I can’t always make those things happen. But I can help the dying person get ready-and in this way, contribute to a death that is decent.

    What goals should I have in mind when working towards a decent death for my patient?


    I have several working clinical goals when I am caring for someone near the end of life. I work towards:

    1. Control of pain and other physical symptoms. The physical aspects of care are a prerequisite for everything that follows.
    2. Involvement of people important to the patient. Death is not usually an individual experience; it occurs within a social context of family, significant others, friends, and caregivers.
    3. A degree of acceptance by the patient. Acceptance doesn’t mean that the patient likes what is going on, and it doesn’t mean that a patient has no hopes–it just means that he can be realistic about the situation.
    4. A medical understanding of the patient’s disease. Most patients, families, and caregivers come to physicians in order to learn something about what is happening medically, and it is important to recognize their need for information.
    5. A process of care that guides patient understanding and decision making. One great physician does not equal great care–it takes a coordinated system of providers.

    How do you know when someone is dying?

    This question is not as simple as it might sound. The SUPPORT study demonstrated that even for patients with a high probability of dying, it is still difficult for a clinician to predict that a particular patient is about to die. Thus it may be more useful for clinicians to give up relying on their predictive skills, and look at the common clinical paths (or trajectories) taken by dying patients, and design medical care that includes “contingency plans” for clinical problems that a person with incurable lung cancer (for example) is likely to experience. Such contingency plans might include advance directives and perhaps DNAR orders. as well as lines such as: “You will probably die from this, although we can’t predict exactly when. What is really important for you in the time you have left?”

    What should I know about the hospice approach?


    In order to help someone towards a decent, or even good, death, the hospice framework is very helpful. Hospice started as a grassroots effort, as a view of dying that lets go of the possibility of cure. Instead, hospices emphasize symptom control and attention to psychological and spiritual issues. Pathophysiology becomes less important and personal meaning becomes more important. Thus this framework analyzes a person’s medical care into four major topics, and this can be used to outline day-to-day care plans for a patient:

    1. Pain – one of the things most feared by patients with life-threatening illness.
    2. Symptom control – including dyspnea, nausea, confusion, delirium, skin problems, and oral care.
    3. Psychological issues – especially depression, sadness, anxiety, fear, loneliness.
    4. Spiritual or existential issues – including religious or non-religious beliefs about the nature of existence, the possibility of some type of afterlife.

    Hospice care in Washington State is most often provided by multidisciplinary teams who go to patients’ homes. This care is covered by Medicaid for patients judged to have less than six months to live. Hospice care is generally underutilized, and even though most hospice teams feel that at least six weeks of hospice care is optimal, most patients receive much less because they are either referred very late or have not wanted hospice. A major problem in connecting hospice care to acute medical care is that referral implies a “switch” from curative to palliative medicine-a model that does not fit comfortably in many illnesses.

    What you need to understand to care for the dying


    Another useful framework was outlined by Joanne Lynn, who was one of the principal investigators of SUPPORT. She suggests that there are four things clinicians must know to care for the dying.

    1. The patient’s story – including how that person has viewed her life, the other persons important to her, and how she could bring her life to a close in a way that would be true to herself.
    2. The body – which covers the biomedical understanding of disease, and what limits and possibilities exist for that person.
    3. The medical care system available for this particular patient – knowing how you can make the system work for the patient, as well as the relevant law and ethics.
    4. Finally, you must understand yourself – because you, as a physician, can be an instrument of healing, or an instrument that does damage.

    Obviously, learning how to do all this is beyond the scope of this web page–these are goals that guide a career of learning and reflection. But this framework provides guidelines for you as you develop your own approach to caring for dying patients.

    How do physicians who care for the dying deal with their own feelings?

    It is not hard to find physicians who are burned out – ask any nurse. What is difficult is to find for yourself a type of self-care that will enable you to develop your gifts as a physician, and continue to use them in practice. It helps to learn your strengths and weaknesses, and to actively seek whatever will nurture you – in or out of medicine. A strategy of detachment may not serve you well in the long run. There are indeed rewards for physicians who care for the dying, but as a Zen master once observed of a bingo game, “you must be present to win.”