Who is Responsible for Discussing End-of-Life Treatment Options?

[tnbutterfly - Mary, BSN]

Who is responsible for discussing end-of-life treatment options with the patient.......the physician? The nurse? In most instances it is the physician's responsibility to initiate discussion and determine a plan of treatment. But what if the patient is not given information on all the options? What if the nurse does not think the patient and family have been given adequate information or disagrees with the physician?

According to the ANA Code of Ethics, "The nurse's primary commitment is to the patient, whether an individual, family, group, or community." How does this come onto play with regard to end-of-life care? What happens when the desires of the patient are in conflict with the desires of the physician? Or what if the physician's plan of care seems more aggressive or unrealistic to the nurse in light of the patient's condition or prognosis?

One of the primary roles of the nurse is that of patient advocate. Nurses need to be prepared to advocate for the patient when conflicts arise between the patient's wishes and the wishes of the physician and/or family members. Although it is the physician who prescribes the plan of treatment, the nurse must be ready to assist the patient in exploring options for end-of-life care. No matter what setting you practice in--hospital, long-term care facility, clinic, or home--it is of utmost importance to address the patient's comfort needs as the patient sees them. This is particularly true in providing quality end-of-life care, allowing the patient to prepare for and face death on his or her own terms.

For other articles by this author, go to Body, Mind, and Soul

[shrinky]

This happened recently in a case here, like 2 days ago. I was asked by the Hospitalist to speak to the patient and family about Hospice at home, he was in the hospital at the time. All was going well until he went for his initial radiation tx and the doc there told him to hold off on Hospice. Seems that doc wanted the man to go to the rehab unit to increase his mobility, man has NSCLC and is short of breath when talking. So how is he going to go through the rigors of rehab? I simply discussed options with Hospice and notified the hospitalist who ordered a PT consult. Turns out the man decides he wants to go home with Hospice. He realized that he could not endure the rehab while doing rad txs. He knew his limitations and knew they needed support. That was an easy one. Usually the docs wait until the patient has 2 weeks or less to live then refer, they really have a difficult time discussing EOL care .

[tnbutterfly - Mary, BSN]

shrinky said:

Usually the docs wait until the patient has 2 weeks or less to live then refer, they really have a difficult time discussing EOL care .

Some physicians do have a difficult time as they feel they have failed. It is difficult for them to deliver bad news to patients and families. It is often much easier for them to continue pursuing an unlikely cure than to have a difficult conversation about death. But the wise physician knows when to transition from cure to palliation.

[Medic09, BSN, RN, EMT-P]

Might there also be a role here for someone in spiritual care - chaplain, the patient's spiritual guide (minister or whatever). For some individuals and cultures, this gets to be a point where there are some moral or religious choices to be made. It seems to me that is one of the things the nurse needs to offer, as well as educating the family and patient concerning the pragmatic options.

[marachne]

Medic09 said:

Might there also be a role here for someone in spiritual care - chaplain, the patient's spiritual guide (minister or whatever). For some individuals and cultures, this gets to be a point where there are some moral or religious choices to be made. It seems to me that is one of the things the nurse needs to offer, as well as educating the family and patient concerning the pragmatic options.

This is why a palliative care team is a team, and the good ones include physicians, rn's APNs, SWs, chaplains (specially trained in EOL), and when they're really lucky, a psych person.

It's about exploring values and goals as well as prognosis and options.

That said, nurses are the ones who spend the most time with patients, who often are the best known and trusted by pts & families. We are often, in many ways, good generalists, and approach care from a holistic perspective -- mind, body, and spirit.

I feel it is a nurse's duty to share her/his knowledge, wisdom, and experience with a pt or family if the physician is doing a disservice to the patient in not sharing full information about what the options are, and what the (likely) consequences/outcomes of certain decision paths. The problem is that the system often leaves nurses feeling intimidated and afraid to speak up.

[PostOpPrincess, BSN, RN]

I worked in ICU for 12 years and whenever the conversation came up (especially if trust has been established) about EOL choices, I always spoke from the heart and from my experience. I would tell the truth as gently as possible; and sometimes with more bluntness when the situation called for it. When you are in a position of trust, truth should always be the option. I think it's the only realistic thing to do.

[truern]

As a new grad I had to deal with this issue. My patient trusted me..and confided in me regarding her last wishes. I had to take on the doctor AND her family, but dangit I fought tooth and nail to see that her wishes were respected. Sometimes WE are all they have on their side.

[nerdtonurse?, BSN, RN]

I cannot tell you how many times I have seen patients sent home without ever knowing that their cancer's back, it's mets'd; the internal med doc will say it's for the surgeon to tell them, the surgeon will say it's the oncologist's responsibility, who will dump it back on the internal med doc that's seeing him in the hospital. The patient's asking us what's going on, we can't tell them (they fired a nurse on another floor for telling a patient that he should get his affairs in order, quickly -- didn't tell him the cancer had mets'd to his liver and brain, or that he had profound lymph node involvement, just that he should quickly get his affairs in order. Patient jumped the doc the next morning, doc jumped the DON, who fired the one person who was being faithful to the patient....).

[jbudrick, MSN]

I have grappled with this dilemma many times as a home care nurse. I generally provide the information that I have that leads me to believe the patient is dying within the next six months to the physician. If he agrees that it is more likely than not that the patient will die within the next six months, he gets to choose who tells the patient and family. There are times when it is clearly obvious that the patient is dying but the physician chooses not to pursue alternative care or discuss the matter with the family. I suspect insurance issues or the physician's assessment of the family situation play a role in this decision. I send in a social worker no matter what the outcome and, if possible, I refer to hospice home care. There are times the patient or family prefers to continue with our agency and we continue to provide care until the end. It is very difficult to provide end of life care when the family is in denial.

[Ginger's Mom, MSN, RN]

Nursing often has the best relationship with the patient and family. Often times the family will seek the nurse's advice. The best is to have the discussion as a team.

[Mommy_of_3_in_AL..RN]

First of all, i never give the patient a diagnosis that the physician hasnt discussed with them. If i know that cancer has mets..i do not tell them that, and if directly asked i simply say that we havent been given those test results, so they would have to ask the dr. As far as if a patient or family chooses to speak with me about end of life choices, i will speak with them, comfort them, but make it clear that, although these are your options, the decision is up to you and your family, and needs to be discussed with your physician. Usually, if a doctor speaks with the family, while i am there, about something like code status, and the family says something like "we have to discuss it, and let you know", we nurses are then allowed to speak with them, and when they make a decision, we can write down the wishes (like no code, no intubation, etc), then call the physician, let them know what wishes the family made known to us,and the doctor will verbal the order for us to write on the chart. Ends up saying something like

mom would accept CPR for a short perioud of time, No meds, no intubation. I speak with the doc and then he has me to write the order to change the code status from full code to no code. this is all dependadnt on the family wishes, and they individual wishes .

[lamazeteacher]

tnbutterfly said:

Some physicians do have a difficult time as they feel they have failed. It is difficult for them to deliver bad news to patients and families. It is often much easier for them to continue pursuing an unlikely cure than to have a difficult conversation about death. But the wise physician knows when to transition from cure to palliation.

If physicians have that difficulty, nurses can mention Hospice to family members, assuring them that treatment can continue while in that program, and that the experts on pain relief practise with those agencies. You'll find out quickly who's not ready, if the patient or family objects to being seen by someone from Hospice, just to explain that service, "in case they need it at some time". :loveya: