Palliative care's role grows in solving end-of-life conflicts

A 58-year-old Russian man with advanced esophageal cancer was admitted to a U.S. comprehensive cancer center with decreased oral intake and failure to thrive. The man's family insisted on initiating parenteral nutrition, but the physician and other health professionals involved in his care saw that as medically contraindicated.

The family of Russian immigrants insisted. They told of their struggles with food shortages in the old country and refused to consider what they saw as allowing their loved one to “starve to death.” The clinicians eventually asked for an ethics consultation to help resolve the matter. But as is happening in a rising number of cases, it was the involvement of palliative care that helped broker an acceptable resolution.

During multiple meetings, doctors explained the disproportionate burdens of parenteral nutrition — infections, blood clots, potential liver failure — given the slim benefits for the patient. And it was the palliative care team that helped address the family's concern by giving the patient intravenous glucose while starting comfort care, thus avoiding parenteral nutrition.

“The ethics consultants were critical in helping doctors understand why the family was so adamant that the man not be starved to death, and palliative care was essential in allowing for the death to happen as painlessly as possible,” said Andrew G. Shuman, MD, a head and neck surgical oncologist and ethics consultant at Memorial Sloan-Kettering Cancer Center in New York.

This kind of teamwork on hard-to-resolve, end-of-life care cases appears to be happening more frequently, Dr. Shuman said. He is the lead author of a recent study of more than 200 cases at two comprehensive cancer centers in which ethics consultations were requested. In 41% of those cases, palliative-care consultations also were requested, said the study, published June 18 in the Journal of Oncology Practice.

“We identified an overlap in many cases of the palliative-care consultant and the ethics consultation,” Dr. Shuman said. “In certain cases, both palliative care and ethics consultation may be necessary.”

About half the time, the palliative-care consult happened before the ethics team was called upon. The other half of the time, the case went to ethics before the palliative-care specialists were consulted, the study said.

An increased presence at hospitals

The trend seen at these two cancer centers could reflect the growing presence of palliative care teams in hospitals. Nearly two-thirds of hospitals with 50 or more beds now have palliative care teams, according to an October 2011 report by the Center to Advance Palliative Care in New York. That represented a 19% growth in the penetration of hospital palliative care since the previous report in 2008.

At some hospitals, the tie between palliative care and ethics services is even tighter, said Kayhan Parsi, PhD, a professor of bioethics at Loyola University Chicago Stritch School of Medicine's Neiswanger Institute for Bioethics. He said that at Loyola University Medical Center in Maywood, Ill., one of the members of the ethics consultation service is a palliative care physician. The relationship between specialists in palliative care and clinical ethics is “almost symbiotic,” he added.

“We're both often dealing with very sick, critically ill people and talking about changing goals of care, improving communication, shifting from an aggressive treatment regimen to more comfort care and a palliative care kind of approach,” Parsi said.

Difficulty with communication continues to drive requests for ethics consultation, the Journal of Oncology Practice study found. Lapses in communication were identified in 45% of the cases.

Meanwhile, disagreements or other kinds of conflicts were involved in 51% of ethics-consult cases. In half of these cases, the conflict was among staff and family, while a quarter of the cases involved conflicts among family members. The most common issues prompting ethics consultation were code status, advance directives, surrogate decision-making and medical futility.