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Clinical Decision-Making in Palliative Care 

Clinical Decision-Making in Palliative Care
Chapter:
Clinical Decision-Making in Palliative Care
Source:
Hospice and Palliative Medicine and Supportive Care Flashcards
Author(s):

Eduardo Bruera

DOI:
10.1093/med/9780190633066.003.0003

Question 3.1

A 65-year-old male with locally recurrent and metastatic adenocarcinoma of the colon comes to the clinic with a 2-day history of increasing abdominal pain, nausea, and vomiting. For the past 3 weeks, the patient has become progressively less active and now spends most of the time in bed. The patient has refused surgery for his colon cancer in the past, and the oncology team believes that there is no more indication for chemotherapy. The X-rays today show mechanical bowel obstruction. The clinical team must decide whether to recommend surgical consultation for the possibility of a colostomy, admission to the acute care facility for symptomatic treatment, or discharge home with hospice and symptomatic treatment.

What information is necessary to make an appropriate decision for this patient?

  1. A. Disease stage, previous treatment, and planned treatment

  2. B. Comorbidities, severity, and management

  3. C. Life prognosis

  4. D. Performance status

  5. E. All of the above

Answer 3.1

The correct answer is (E)

Palliative care decision-making differs from that of many other disease-oriented specialties. Palliative care clinical teams focus on personhood and family care rather than on disease management. Therefore, palliative care clinicians require a combination of disease, patient, and family information before decisions can be made. The following are important items required: (a) disease stage, previous treatment, and planned treatment; (b) comorbidities, severity, and management; (c) life prognosis; (d) performance status; (e) physical, emotional, and spiritual symptom burden; (f) patient current living arrangements; and (g) family structure and function (family may or may not be related to the patient, and the patient’s perception of the role of the family in his or her present or future care needs to be recorded); (h) patient’s decision-making preference (active, passive, or shared) with regard to his or her clinical team and family; (i) financial barriers to care and financial resources; and (j) spiritual support and spiritual pain. The majority of this information can be obtained after one single visit with the patient and interaction with the primary caregiver.

Further Reading

Bakitas M, Kryworuchko J, Matlock DD, Volandes AE. Palliative medicine and decision science: The critical need for a shared agenda to foster informed patient choice in serious illness. J Palliat Med. 2011;14(10):1109–1116.Find this resource:

Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.Find this resource:

Question 3.2

Which one of the following statements is incorrect regarding appropriate decision-making for a palliative care intervention?

  1. A. Delineate potential problems and adverse effects of the clinical problem that may be influencing the patient’s quality of life.

  2. B. Rank the discomfort associated with a specific problem within the patient’s overall complex of symptoms.

  3. C. Balance the overall advantages and disadvantages of the intervention versus no intervention for the patient.

  4. D. Symptomatic management is more appropriate than identification and correction of the clinical abnormality.

Answer 3.2

The correct answer is (D)

When specific palliative care decisions need to be made, the following five steps are important:

  1. Step 1: Delineate potential problems and adverse effects of the clinical program that may be influencing the patient’s quality of life. In the case discussed in Question 3.1, these include mechanical bowel obstruction causing nausea, vomiting, and abdominal pain.

  2. Step 2: Rank the discomfort associated with a specific problem within the patient’s overall complex of symptoms. In the case of the patient discussed in Question 3.1, abdominal pain, nausea, and vomiting may be completely or partially relieved by medications or may lose priority when other problems such as delirium or dyspnea occur.

  3. Step 3: Identify the way to correct the clinical abnormality diagnosed in Step 1 and potential problems associated with the correction of such abnormality: A painful postoperative period for a patient with a short life span. The inconvenience of an acute hospital bed for a patient who prefers to stay at home.

  4. Step 4: Balance the overall advantages and disadvantages of the intervention versus no intervention for the patient.

  5. Step 5: Reach consensus between the clinical team, the patient, and the family regarding the most appropriate course of action. This may require multiple discussions or even a family conference to clarify particularly complex situations.

Further Reading

Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.Find this resource:

Question 3.3

A 65-year-old male with locally recurrent and metastatic adenocarcinoma of the colon comes to the clinic with a 2-day history of increasing abdominal pain, nausea, and vomiting. For the past 3 weeks, the patient has become progressively less active and now spends most of the time in bed. The patient has refused surgery for his colon cancer in the past, and the oncology team believes that there is no more indication for chemotherapy. The X-rays today show mechanical bowel obstruction.

Using the evidence-based clinical decision-making process in palliative care, the most appropriate management decision by the clinical team is which of the following?

  1. A. Proceed with surgery consultation for colostomy to relieve obstruction

  2. B. Admission to acute care for symptomatic treatment

  3. C. Discharge home with hospice and symptomatic treatment

  4. D. None of the above

Answer 3.3

The correct answer is (C)

In the case presented, if the patient and family are reluctant for the patient to be admitted to the hospital to undergo surgical evaluation and potential surgical treatment, a good potential palliative alternative might involve opioids and antiemetics as well as hydration, all administered subcutaneously at home with the family with reassessment after a few days.

Further Reading

Bakitas M, Kryworuchko J, Matlock DD, Volandes AE. Palliative medicine and decision science: The critical need for a shared agenda to foster informed patient choice in serious illness. J Palliat Med. 2011;14(10):1109–1116.Find this resource:

Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: A review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.Find this resource:

Question 3.4

Excellent patient–clinician communication is critical for provision of quality palliative care. Which of the following elements are important to achieve this goal?

  1. A. It is important to determine decision-making preferences (active, passive, or shared) by the patient.

  2. B. The use of empathetic statements has to be learned and practiced.

  3. C. It is important to involve other team members for particularly difficult communication issues.

  4. D. In cases in which communication is particularly challenging and distressing for a palliative care clinician, it is completely appropriate to ask for help and even transfer the care of a patient and/or family to other members of the team.

  5. E. All of the above.

Answer 3.4

The correct answer is (E)

Communic ation with the patient and family requires palliative care clinicians to acquire sophisticated clinical skills. Didactic learning, role playing, bedside teaching, and monitored practice are all important components of communication training.

Palliative care clinicians need to be familiar with protocols for breaking bad news. In addition, they need to be familiar with the organization and conduct of family meetings. It is important to determine decision-making preferences (active, passive, or shared) by the patient regarding family and the clinical team. The use of empathetic statements has to be learned and practiced.

Mindfulness may help palliative care physicians recognize emotionally charged conversations and appropriately respond to patients and families.

Palliative care physicians need to identify private settings in which these meetings can be conducted and be aware of the importance of adopting the appropriate posture (sitting vs. standing), the use of open-ended questions to initiate the conversations, and involving other team members for particularly difficult communication issues.

In cases in which communication is particularly challenging and distressing for a palliative care clinician, it is completely appropriate to ask for help and even transfer the care of a patient and/or family to other members of the team in order to reduce the risk of burnout.

Further Reading

Pollak KI, Arnold RM, Jeffreys AS, et al. Oncologist communication about emotion during visits with patients with advanced cancer. J Clin Oncol. 2007;25:5748.Find this resource:

Von Gunten CF, Ferris FD, Emanuel LL. The patient–physician relationship. Ensuring competency in end-of-life care: Communication and relational skills. JAMA. 2000;284:3051.Find this resource:

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