Supportive Care in Cancer

, Volume 3, Issue 1, pp 28–36 | Cite as

Ethical dilemmas in hospice and palliative care

  • Barry M. Kinzbrunner
Review Article

Abstract

In order to understand some of the ethical dilemmas that face hospice programs in the United States, one must understand the Medicare Hospice Benefit, which is the model by which hospice programs provide palliative care to terminally ill patients in the United States. Unlike palliative care programs outside the United States, patients must have a prognosis of 6 months or less to receive hospice care under the Medicare Hospice Benefit. Care is reimbursed on a per diem basis, and inpatient care is restricted to pain and symptom management that cannot be managed in another setting. Ethical dilemmas that face physicians referring patients to hospice programs include the ability of clinicians to predict accurately a patient prognosis of 6 months or less, and to what extent hospice programs and clinicians are obligated to provide patients with full information about their illness, as the Medicare Hospice Benefit requires that patients sign an informed consent in order to elect the hospice benefit. There are ethical dilemmas that affect day-to-day patient management in palliative care programs including physician concern over the use of morphine because of possible respiratory depression in the advanced cancer patient, the question of providing enteral or parenteral nutritional support to patients who refuse to eat near the end of life, and the question of providing parenteral fluids to patients who are unable to take fluids during the terminal phases of illness. A final ethical dilemma concerns the methodology for quality of life research in palliative care. By following current research dogma, and only considering patient-generated data as valid, the patient population that most needs to be studied is excluded. A new methodology specifically for palliative care research is needed to provide information on the patients who are cognitively or physically impaired and unable to provide input regarding their needs near the end of life.

Key words

Hospice Palliative care Ethical dilemmas 

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References

  1. 1.
    Addington-Hall JM, MacDonald LD, Anderson HR (1990) Can the Spitzer quality of life index help to reduce prognostic uncertainty in terminal care? Br J Cancer 62:695–699Google Scholar
  2. 2.
    American College of Physicians (1989) Parenteral nutrition in patients receiving cancer chemotherapy. Ann Intern Med 110:734Google Scholar
  3. 3.
    American College of Physicians (1990) Harm is net result of TPN in cancer. Pharmacy Pract News, JanuaryGoogle Scholar
  4. 4.
    Apilanez RV, Gonzalez de Langarica LR, Arribas EG (1987) Terminal illness syndrome. In: Fourth European Conference on Clinical Oncology and Cancer Nursing, Madrid, Federation of European Cancer Societies, p 193Google Scholar
  5. 5.
    Baines M (1988) Nausea and vomiting in the patient with advanced cancer. J Pain Symptom Manage 3:81–85Google Scholar
  6. 6.
    Bayer R, Feldman E (1982) Hospice under the medicare wing. Hastings Cent Rep 12:5–6Google Scholar
  7. 7.
    Billings JA (1985) Comfort measures for the terminally ill. Is dehydration painful? J Am Geriatr Soc 33:808–810Google Scholar
  8. 8.
    Brennan MF (1981) Total parenteral nutrition in the management of the cancer patient. Annu Rev Med 32:233–243Google Scholar
  9. 9.
    Brescia FJ (1993) Specialized care of the terminally ill. In: DeVita VT, Hellman S, Rosenberg SA (eds) Cancer, principles and practice of oncology, 4th edn. Lippincott, Philadelphia, pp 2501–2508Google Scholar
  10. 10.
    Brescia FJ, Adler D, Gray G, et al (1990) Hospitalized advanced cancer patients: a profile. J Pain Symptom Manage 5:221–227Google Scholar
  11. 11.
    Brody H, Lynn J (1984) The physician's responsibility under the new Medicare reimbursement for hospice care. N Engl J Med 310:920–921Google Scholar
  12. 12.
    Bruera E (1990) Ambulatory infusion devices in the continuing care of patients with advanced diseases. J Pain Symptom Manage 5:287–296Google Scholar
  13. 13.
    Bruera E, MacDonald RN (1988) Nutrition in cancer patients: an update and review of our experience. J Pain Symptom Manage 3:133–140Google Scholar
  14. 14.
    Bruera E, Roca E, Cedaro L, et al (1985) Action of oral methylprednisolone in terminal cancer patients. Cancer Treat Rep 69:751–754Google Scholar
  15. 15.
    Bruera E, Macmillan K, Kuehn N, et al (1990) A controlled trial of megestrol acetate on appetite, caloric intake, nutritional status, and other symptoms in patients with advanced cancer. Cancer 66:1279–1282Google Scholar
  16. 16.
    Bruera E, Macmillan K, Pither J, MacDonald RN (1990) Effects of morphine on the dyspnea of terminal cancer patients. J Pain Symptom Manage 5:341–344Google Scholar
  17. 17.
    Bruera E, MacEachern T, Ripamonti C, Hanson J (1993) Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med 119:906–907Google Scholar
  18. 18.
    Burge FI (1993) Dehydration symptoms of palliative care cancer patients. J Pain Symptom Manage 8:454–464Google Scholar
  19. 19.
    Burge FI, King DB, Willison D (1990) Intravenous fluids and the hospitalized dying: a medical last rite? Can Fam Physician 36:883–886Google Scholar
  20. 20.
    Burt ME, Gorschboth CM, Brennan MF (1982) A controlled prospective randomized trial evaluating the metabolic effects of enteral and parenteral nutrition in the cancer patient. Cancer 49:1092–1105Google Scholar
  21. 21.
    Byrne P, Dunstan GR, Jakobovits I (1991) Hospice care: Jewish reservations considered in a comparative ethical study. Palliat Med 5:187–200Google Scholar
  22. 22.
    Campbell-Taylor I, Fisher RH (1987) The clinical case against tube feeding in palliative care in the elderly. J Am Geriatr Soc 35:1100–1104Google Scholar
  23. 23.
    Casseleith BR, Lusk EJ, Miller DJ, et al (1985) Psychosocial correlates of survival in advanced malignant diseases. N Engl J Med 312:1551–1555Google Scholar
  24. 24.
    Centeno-Cortes C (1994) Questioning diagnosis disclosure in terminal cancer patients: a prospective study evaluating patients' responses. Palliat Med 8:39–44Google Scholar
  25. 25.
    Ciocon JO, Silverstone FA, Graver LM, Foley CJ (1988) Tube feedings in elderly patients. Indications, benefits, and complications. Arch Intern Med 148:429–433Google Scholar
  26. 26.
    Collaud T, Rapin CH (1991) Dehydration in dying patients: study with physicians in French-speaking Switzerland. J Pain Symptom Manage 6:230–240Google Scholar
  27. 27.
    Corless IB (1983) The hospice movement in North America. In: Corr CA, Coor DM (eds) Hospice care, principles and practice. Springer, Berlin Heidelberg New York, pp 335–351Google Scholar
  28. 28.
    Cowcher K, Hanks GW (1990) Longterm management of respiratory symptoms in advanced cancer. J Pain Symptom Manage 5:320–330Google Scholar
  29. 29.
    Demer C, Johnston-Anderson AV, Tobin R, et al (1992) Cost of hospice care: late versus early entry (abstract). Proc Am Soc Clin Oncol 11:392Google Scholar
  30. 30.
    Dunn SM, Patterson PU, Butow PN, et al (1993) Cancer by another name: a randomized trial of the effects of euphemism and uncertainly in communicating with cancer patients. J Clin Oncol 11:989–996Google Scholar
  31. 31.
    Emanuel EJ, Emanuel LL (1994) The economics of dying. The illusion of cost savings at the end of life. N Engl J Med 330:540–544Google Scholar
  32. 32.
    Ettinger AB, Portenoy RK (1988) The use of corticosteroids in the treatment of symptoms associated with cancer. J Pain Symtom Manage 3:99–103Google Scholar
  33. 33.
    Evans C, McCarthy, M (1985) Prognostic uncertainty in terminal care: can the Karnofsky Index help? Lancet 1:1204–1206Google Scholar
  34. 34.
    Evans WK, Nixon DW, Daly JM, et al (1987) A randomized study of oral nutrition support versus ad lib nutritional intake during chemotherapy for advanced colorectal and non-small-cell lung cancer. J Clin Oncol 5:113–124Google Scholar
  35. 35.
    Farr WC (1990) The use of corticos-steroids for symptom management in terminally ill patients. Am J Hospice Care 7:41–46Google Scholar
  36. 36.
    Forster LE, Lynn J (1988) Predicting life span for applicants to inpatient hospice. Arch Intern Med 148:2540–2543Google Scholar
  37. 37.
    Forster LE, Lynn J (1989) The use of physiologic measures and demographic variables to predict longevity among inpatient hospice applicants. Am J Hospice Care 6:31–34Google Scholar
  38. 38.
    Forty-two Code of Federal Regulations (1993) Part 418. Medicare Hospice RegulationsGoogle Scholar
  39. 39.
    Hanks GE, Myers CE, Scardino PT (1993) Cancer of the prostate. In: DeVita VT Jr, Hellman S, Rosenberg SA (eds) Cancer: principles and practice of oncology, 4th edn. Lippincott, Philadelphia, pp 1073–1113Google Scholar
  40. 40.
    Harris JR, Morrow M, Bonadonna G (1993) Cancer of the breast. In: DeVita VT Jr, Hellman S, Rosenberg SA (eds) Cancer: principles and practice of oncology, 4th edn. Lippincott, Philadelphia, pp 1264–1332Google Scholar
  41. 41.
    Heber D, Byerley LO, Chi J, et al (1986) Pathophysiology of malnutrition in the adult cancer patient. Cancer 58:1867–1873Google Scholar
  42. 42.
    Kane RL, Wales J, Bernstein L, et al (1984) A randomised controlled trial of hospice care. Lancet I:890–894Google Scholar
  43. 43.
    Kaye P (1990) Notes on symptom control in hospice and palliative care. Hospice Education Institute, Essex, Conn, pp 27–29Google Scholar
  44. 44.
    Kidder D (1988) The impact of hospice on the health care costs of terminal cancer patients. In: Mor V, Greer D, Kastenbaum R (eds) The hospice experiment. Johns Hopkins, Baltimore, pp 48–68Google Scholar
  45. 45.
    Kidder D (1992) The effects of hospice coverage on Medicare expenditures. Health Serv Res 27:195–217Google Scholar
  46. 46.
    Kinzbrunner BM (1994) Hospice: what to do when anti-cancer therapy is no longer appropriate, effective, or desired. Semin Oncol (in press)Google Scholar
  47. 47.
    Klein S (1993) Clinical efficacy of nutritional support in patients with cancer. Oncology 7 [Suppl]:87–92Google Scholar
  48. 48.
    Klein S, Simes J, Blackburn GL (1986) Total parenteral nutrition and cancer clinical trials. Cancer 58:1378–1386Google Scholar
  49. 49.
    Koretz RL (1984) Parenteral nutrition: is it oncologically logical? J Clin Oncol 2:534–538Google Scholar
  50. 50.
    Lack S (1983) The hospice concept — the adult with advanced cancer. In: Corr CA, Coor DM (eds) Hospice care, principles and practice. Springer, Berlin Heidelberg New York, pp 42–54Google Scholar
  51. 51.
    Levy MH, Catalano RB (1985) Control of common physical symptoms other than pain in patients with terminal disease. Semin Oncol 12:411–430Google Scholar
  52. 52.
    Light RW, Muro JR, Sato RI, et al (1989) Effects of oral morphine on breathlessness and exercise tolerance in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 139:126–133Google Scholar
  53. 53.
    Loprinzi CL (1993) Pharmacologic management of cancer anorexia/cachexia. Oncology 7 [Suppl]:101–103Google Scholar
  54. 54.
    Loprinzi C Ellison NM, Schaid DJ, et al (1990) Controlled trial of megestrol acetate for the treatment of cancer anorexia and cachexia. J Natl Cancer Inst 82:1127–1132Google Scholar
  55. 55.
    Loprinzi CL, Goldberg RG, Su JQ, et al (1993) Randomized double-blind placebo controlled trial evaluating hydrazine sulfate in patients with newly diagnosed non-small cell lung cancer (abstract). Proc Am Soc Clin Oncol 12:337Google Scholar
  56. 56.
    Loprinzi CL, Michalak JC, Schaid DJ, et al (1993) Phase III evaluation of four doses of megestrol acetate therapy for patients with cancer anorexia and/or cachexia. J Clin Oncol 11:762–767Google Scholar
  57. 57.
    Lubitz JD, Riley GF (1993) Trends in Medicare payments in the last year of life. N Engl J Med 328:1092–1096Google Scholar
  58. 58.
    McCullough LB (1992) A primer on bioethics. In: McCullough LB, Bauer J, Kindig D, Schenke R (eds) Review course for the ABMM examination. American College of Physician Executives, Boston, pp 1–20Google Scholar
  59. 59.
    McCusker J (1984) The terminal period of cancer: definition and descriptive epidemiology. J Chronic Dis 37:377–385Google Scholar
  60. 60.
    Micetich KC, Steinecker PH, Thomasma DC (1983) Are intravenous fluids morally required for a dying patient? Arch Intern Med 143:975–978Google Scholar
  61. 61.
    Miller RJ (1991) Predicting survival in the advanced cancer patient. Henry Ford Hosp Med J 39:81–83Google Scholar
  62. 62.
    Mor V (1987) The cost of hospice. In: Mor V (ed) Hospice care systems, structure, process costs, and outcomes. Springer, Berlin Heidelberg New York, pp 177–212Google Scholar
  63. 63.
    Mor V (1987) Quality of life outcomes. In: Mor V (ed) Hospice care systems, structure, process, costs, and outcomes. Springer, Berlin Heidelberg New York, pp 125–176Google Scholar
  64. 64.
    Mor V, Masterson-Allen S (1990) A comparison of hospice vs conventional care of the terminally ill cancer patient. Oncology 4:85–91Google Scholar
  65. 65.
    Mor V, Laliberte L, Morris JN, et al (1984) The Karnofsky Performance Status Scale, an examination of its reliability and validity in a research setting. Cancer 53:2002–2007Google Scholar
  66. 66.
    Mor V, Greer DS, Goldberg R (1988) The medical and social service interventions of hospice and nonhospice patients. In: Mor V, Greer D, Kastenbaum R (eds) The hospice experiment. Johns Hopkins, Baltimore, pp 88–108Google Scholar
  67. 67.
    Morris JN, Sherwood S, Wright SM, Gutkin CE (1988) The last weeks of life: does hospice care make a difference? In: Mor V, Greer D, Kastenbaum R (eds) The hospice experiment. Johns Hopkins, Baltimore, pp 109–132Google Scholar
  68. 68.
    Mullen JL (1981) Complications of total parenteral nutrition in the cancer patient. Cancer Treat Rep 65 [Suppl 5]:107–113Google Scholar
  69. 69.
    Needs and responses — the hospice approach (1983) In: Corr CA, Coor DM (eds) Hospice care, principles and practice. Springer, Berlin Heidelberg New York, pp 1–4Google Scholar
  70. 70.
    Nelson KA, Walsh TD (1993) Metoclopramide in anorexia caused by cancer-associated dyspepsia syndrome (CADS). J Palliat Care 9:14–18Google Scholar
  71. 71.
    Nelson KA, Walsh D, Sheehan FA (1994) The cancer anorexia-cachexia syndrome. J Clin Oncol 12:213–225Google Scholar
  72. 72.
    NHO Newsline (1993) 1992 stats show continued growth in programs and patients. NHO Newsline 3:1–2Google Scholar
  73. 73.
    Nixon DW (1986) The value of parenteral nutrition support. Chemotherapy and radiation treatment. Cancer 58:1902–1903Google Scholar
  74. 74.
    Oliver D (1993) Ethical issues in palliative care — an overview. Palliat Med 7 [Suppl 2]:15–20Google Scholar
  75. 75.
    Ovesen L, Allingstrup L, Hannibal J, et al (1993) Effect of dietary counseling on food intake, body weight, response rate, survival, and quality of life in cancer patients undergoing chemotherapy: a prospective, randomized study. J Clin Oncol 11:2043–2049Google Scholar
  76. 76.
    Parkes CM (1972) Accuracy of predictions of survival in later stages of cancer. Br Med J II:29–31Google Scholar
  77. 77.
    Phillips PA, Rolls BJ, Ledingham JGG, et al (1984) Reduced thirst after water deprivation in healthy elderly men. N Engl J Med 311:753–759Google Scholar
  78. 78.
    Portenoy RK, Coyle N (1990) Controversies in the long-term management of analgesic therapy in patients with advanced cancer. J Pain Symptom Manage 5:307–319Google Scholar
  79. 79.
    Printz LA (1988) Is withholding hydration a valid comfort measure in the terminally ill? Geriatrics 43:85–88Google Scholar
  80. 80.
    Reuben DB, Mor V (1986) Dyspnea in terminally ill cancer patients. Chest 89:234–236Google Scholar
  81. 81.
    Reuben DB, Mor V, Hiris J (1988) Clinical symptoms and length of survival in patients with terminal cancer. Arch Intern Med 148:1586–1591Google Scholar
  82. 82.
    Rhymes J (1990) Hospice care in America. JAMA 264:369–372Google Scholar
  83. 83.
    Rogers DF, Barnes PG (1989) Opioid inhibition of neurally mediated mucous secretion in human bronchi. Lancet I:930–931Google Scholar
  84. 84.
    Rosenthal MA, Gebski VJ, Kefford RF, et al (1993) Prediction of life-expectancy in hospice patients: identification of novel prognostic factors. Palliat Med 7:199–204Google Scholar
  85. 85.
    Rousseau PC (1991) How fluid deprivation affects the terminally ill. RN, January, pp 73–76Google Scholar
  86. 86.
    Santiago TV, Edelman NH (1985) Opioids and breathing. J Appl Physiol 59:1675–1685Google Scholar
  87. 87.
    Saunders CM (1983) The last stages of life. In: Corr CA, Coor DM (eds) Hospice care, principles and practice. Springer, Berlin Heidelberg New York, pp 5–11Google Scholar
  88. 88.
    Schonwetter RS, Teasdale TA, Storey P, Luchi RJ (1990) Estimation of survival time in terminal cancer patients: an impedance to hospice admissions? Hospice J 6:65–79Google Scholar
  89. 89.
    Scott AG (1994) Nasogastric feeding in the management of severe dysphagia in motor neurone disease. Palliat Med 8:45–49Google Scholar
  90. 90.
    Smith DH, Granbois JA (1982) The American way of hospice. Hastings Cent Rep 11:8–10Google Scholar
  91. 91.
    Souba WW, Copeland EM (1989) Hyperalimentation in cancer. CA Cancer J Clin 39:105–113Google Scholar
  92. 92.
    Stuart SP, Tiley EH, Boland JP (1993) Feeding gastrostomy: a critical review of its indications and mortality rate. South Med J 86:169–172Google Scholar
  93. 93.
    Tchekmedyian NS, Hickman M, Siau J, et al (1990) Treatment of cancer anorexia with megestrol acetate: impact on quality of life. Oncology 4:184–192Google Scholar
  94. 94.
    Von Roenn JH, Cleeland CS, Gonin R, et al (1993) Physician attitudes and practice in cancer pain management. A survey from the Eastern Cooperative Oncology group. Ann Intern Med 119:121–126Google Scholar
  95. 95.
    Wallston KA, Burger C, Smith RA, Baugher RJ (1988) Comparing the quality of death for hospice and nonhospice cancer patients. Med Care 26:177–182Google Scholar
  96. 96.
    Woodcock AA, Gross ER, Gellert A, et al (1981) Effects of dihydrocodeine, alcohol, and caffeine on breathlessness and exercise tolerance in patients with chronic obstructive lung disease and normal blood gases. N Engl J Med 305:1611–1616Google Scholar
  97. 97.
    Yates JW, Chalmer B, McKegney FP (1980) Evaluation of patients with advanced cancer using the Karnofsky performance status. Cancer 45:2220–2224Google Scholar
  98. 98.
    Ziegler TR, Young LS, Benfell K, et al (1992) Clinical and metabolic efficacy of glutamine-supplemented parenteral nutrition after bone marrow transplantation. Ann Intern Med 116:821–828Google Scholar

Copyright information

© Springer-Verlag 1995

Authors and Affiliations

  • Barry M. Kinzbrunner
    • 1
  1. 1.Clinical Research and DevelopmentVitas Healthcare CorporationMiamiUSA

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