The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

More documents

Recommendations

Info

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 17: Ethical IssuesCONCLUSION■ Determining when physicians should violate their patient’s interest in confidentiality or whenphysicians26 picascan and should administer high doses of sedating medication to dying patients arechallenging and complex matters that require sound clinical comprehension of the patient’scondition, good ethical judgment, and an understanding of the ideals and principles that havebeen discussed. Although certainly not definitive, the discussion of these cases has shown howthe theoretical ideals of palliative medicine inform certain fundamental ethical principles, whichin turn provide guidance in clinical cases.These cases and the principles they illustrate are not the only ones relevant to the ethics ofpalliative medicine. We have not discussed a number of issues that raise important ethical problemsfor palliative care physicians, such as issues that surround decisions to withdraw or withholdmedical interventions. To be sure, the principles that we have discussed in this chapter arerelevant to these issues. For example, according to the rule of double effect, a physician shouldnot withhold food and fluids from his patient as a means to hasten the patient’s death. Nonetheless,she could withhold or withdraw feeding tube treatment from a patient whose medical conditionhad made him unable to eat if the treatment were disproportionately burdensome, even ifthis would forseeably (but unintentionally) shorten the lifespan of the patient. We have notattempted to provide a full discussion of these issues here.The cases that we have discussed in detail, however, are particularly important for several reasons.Studies indicate that ineffective communication between physicians and their dying patientsis a major cause of inappropriate care for dying patients. 6 Likewise, uncertainty over therule of double effect has been cited as a key factor in the inadequate control of distressingsymptoms in terminally ill patients. 23 And—for HIV and AIDS patients in particular—the issueof patient confidentiality remains a vital one as physicians struggle to honor the dignity andpromote the well-being of their patients as they approach death. 38, 39 With respect to each ofthese pressing issues, a good understanding of the considerations discussed in this chapter isessential if health care providers are to respond adequately to the difficult ethical challengesthey now confront, and will continue to confront, in treating AIDS patients.362U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 17: Ethical Issues26 picasREFERENCES1. Manfredi PL, Morrison RS, Morris J, Goldhirsch SL, Carter JM, Meier DE. Palliative care consultations:how do they impact the care of hospitalized patients? J Pain Symptom Manage 20:166-73, 2000.2. Doyle D, Hanks G, MacDonald N, eds. Oxford Textbook of Palliative Medicine. New York: Oxford UniversityPress, 1998.3. Velleman D. A right to self-termination? Ethics 109:606-28, 1999.4. Chapman RC, Garvin J. Suffering: the contributions of persistent pain. Lancet 353:2233-6, 1999.5. Cassell E. The Nature of Suffering and the Goals of Medicine. New York: Oxford University Press, 1991.6. Emanuel EJ. What is the great benefit of legalizing euthanasia or physician-assisted suicide?Ethics 109:629-43, 1999.7. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognosesand preference outcome and risks of treatments (SUPPORT). The SUPPORT principle investigators.JAMA 274:1591-8, 1995.8. Brock D. Life and Death: Philosophical Essays in Biomedical Ethics. Cambridge: Cambridge UniversityPress, 1995.9. Emanuel L, Emanuel EJ. Four models of the doctor-patient relationship. JAMA 267:2221-6, 1992.10. Kuczewiski M. Reconceiving the family: the process of consent in medical decision making. The HastingsCenter Report 26:30-37, 1996.11. Jansen LA. Deliberative decision making and the treatment of pain. J Pain Symptom Manage 4: 23-30, 2001.12. Beauchamp TL, Childress JF. The Principles of Biomedical Ethics, 4 th ed. New York: Oxford University Press,1994.13. Sulmasy DP, Pellegrino ED. The rule of double effect: clearing up the double talk. Arch Intern Med 159:545-50, 1999.14. Jansen LA, Sulmasy DP. Sedation, alimentation, hydration and equivocation: careful conversation about careat the end of life. Ann Intern Med. 136; 11:845-9, 2002.15. Quill TE, Dresser R, Brock DW. The rule of double effect: a critique of its role in end of lifedecision making. N Engl J Med 337:1768-71, 1997.16. Sherman DW, Ouellette S. Physicians reflect on their lived experiences in long-term AIDS care.J Palliative Med 3:275-86, 2000.17. Ward A, Goldberg N, Miller-McCauley V, et al. Patient-related barriers to the management of cancer pain.Pain 52:319-24, 1993.18. Steinbrook R, Lo B, Moulton J, Saika G, Hollander H, Volberding PA. Preferences of homosexual menwith AIDS for life-sustaining treatment. N Engl J Med 325: 457-60, 1986.19. Wilson IB. End of life care in HIV disease: let’s talk. J Gen Intern Med 12:784-6, 1998.20. Kohut N, Sam M, O’Rourke K, MacFadden DK, Salit I, Singer PA. Stability of treatment preferences:although most preferences do not change, most people change some of their preferences.J Clin Ethics 8:124-35, 1997.21. Jones W, Rimer B, Kinman J. Cancer patient’s knowledge and beliefs regarding control regimens:implications for educational programs. Patient Educ Couns 5:155-64, 1984.22. Bratman ME. Intentions, Plans and Practical Reason. Cambridge: Harvard University Press, 1987.23. Meier D, Morrison S, Cassel CK. Improving palliative care. Ann Intern Med 127: 225-30, 1997.XVIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 363
Page 4 and 5:
DedicationA Clinical Guide to Suppo
Page 6 and 7:
Lynn A Jansen, RN, PhDAssistant Res
Page 9 and 10:
TABLE OF CONTENTSPart IChapter 1Cha
Page 11 and 12:
IChapter 1.26 picasHIV and Palliati
Page 13:
IA Clinical Guide to Supportive and
Page 16 and 17:
A Clinical Guide to Supportive and
Page 18 and 19:
Page 20 and 21:
Page 22 and 23:
Page 24 and 25:
Page 26 and 27:
Page 28 and 29:
Page 30 and 31:
Page 32 and 33:
Page 34 and 35:
Page 36 and 37:
Page 38 and 39:
Page 40 and 41:
Page 42 and 43:
Page 44 and 45:
Page 47 and 48:
IIIChapter 3.Assessment of Physical
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68:
Page 69 and 70:
Page 71 and 72:
Page 73 and 74:
Page 75 and 76:
Page 77 and 78:
Page 79 and 80:
Page 81 and 82:
Page 83 and 84:
Page 85 and 86:
Page 87 and 88:
Page 89 and 90:
Page 91 and 92:
Page 93:
Page 96 and 97:
Page 98 and 99:
Page 100 and 101:
Page 102 and 103:
Page 104 and 105:
Page 106 and 107:
Page 108 and 109:
Page 110 and 111:
Page 112 and 113:
Page 114 and 115:
Page 116 and 117:
Page 118 and 119:
Page 120 and 121:
Page 122 and 123:
Page 124 and 125:
Page 126 and 127:
Page 128 and 129:
Page 130 and 131:
Page 132 and 133:
Page 134 and 135:
Page 136 and 137:
Page 138 and 139:
Page 140 and 141:
Page 142 and 143:
Page 145 and 146:
Chapter 6.26 picasPulmonary Symptom
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165:
Page 168 and 169:
Page 170 and 171:
Page 172 and 173:
Page 174 and 175:
Page 177 and 178:
Chapter 8.26 picasOral ProblemsDavi
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Chapter 9.26 picasDermatologic Prob
Page 189 and 190:
Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
Page 199 and 200:
Page 201 and 202:
Page 203 and 204:
Page 205 and 206:
Page 207 and 208:
Page 209 and 210:
Page 211 and 212:
Page 213 and 214:
Page 215 and 216:
Page 217 and 218:
Chapter 10.26 picasPsychiatric Prob
Page 219 and 220:
Page 221 and 222:
Page 223 and 224:
Page 225 and 226:
Page 227 and 228:
Page 229 and 230:
Page 231 and 232:
Page 233 and 234:
Page 235 and 236:
Page 237 and 238:
Page 239 and 240:
Page 241 and 242:
Page 243 and 244:
Page 245 and 246:
Page 247 and 248:
Page 249 and 250:
Page 251 and 252:
Page 253 and 254:
Page 255 and 256:
Page 257 and 258:
Page 259 and 260:
Page 261 and 262:
Page 263 and 264:
Chapter 11.26 picas Substance Use P
Page 265 and 266:
Page 267 and 268:
Page 269 and 270:
Page 271 and 272:
Page 273 and 274:
Page 275:
Page 278 and 279:
Page 280 and 281:
Page 282 and 283:
Page 284 and 285:
Page 286 and 287:
Page 288 and 289:
Page 290 and 291:
Page 292 and 293:
Page 294 and 295:
Page 296 and 297:
Page 298 and 299:
Page 300 and 301:
Page 302 and 303:
Page 304 and 305:
Page 306 and 307:
Page 308 and 309:
Page 311 and 312:
Chapter 14.26 picasCulture and Care
Page 313 and 314:
Page 315 and 316:
Page 317 and 318:
Page 319 and 320:
Page 321 and 322: A Clinical Guide to Supportive and
Page 325 and 326: Chapter 15.26 picasSpecial Populati
Page 337: A Clinical Guide to Supportive and
Page 359 and 360: Chapter 17.26 picasEthical IssuesLy
Page 375 and 376: Chapter 18.26 picasLegal and Financ
Page 397 and 398: Chapter 19.Palliative 26 picas Care
Page 422 and 423:
Page 424 and 425:
Page 426 and 427:
Page 428 and 429:
Page 430 and 431:
Page 432 and 433:
Page 434 and 435:
Page 436 and 437:
Page 438 and 439:
Page 441 and 442:
Chapter 21.26 picas Patient-Clinici
Page 443 and 444:
Page 445 and 446:
Page 447 and 448:
Page 449 and 450:
Page 451 and 452:
Page 453 and 454:
Page 455:
Page 458 and 459:
Page 460 and 461:
Page 462 and 463:
Page 464 and 465:
Page 466 and 467:
Page 468 and 469:
Page 470 and 471:
Page 472 and 473:
Page 474 and 475:
Page 476 and 477:
Page 478 and 479:
Page 480 and 481:
Page 482 and 483:
Page 484 and 485:
Page 486 and 487:
Page 489 and 490:
Chapter 23.26 picas Medical Care in
Page 491 and 492:
Page 493 and 494:
Page 495 and 496:
Page 497 and 498:
Page 499 and 500:
Page 501:
Page 504 and 505:
Page 506 and 507:
Page 508 and 509:
Page 510 and 511:
Page 512 and 513:
Page 515 and 516:
Chapter 25.26 picas Prevention of S
Page 517 and 518:
Page 519 and 520:
Page 521 and 522:
Page 523 and 524:
Page 525 and 526:
Chapter 26.26 picasResourcesMagda B
Page 527 and 528:
Page 529 and 530:
Page 531 and 532:
Page 533 and 534:
Page 535 and 536:
Page 537 and 538:
Page 539 and 540:
Page 541 and 542:
Page 543 and 544:
Page 545 and 546:
Page 547 and 548:
Page 549 and 550:
Page 551 and 552:
Page 553 and 554:
Page 555 and 556:
Page 557:
Page 560 and 561:
Page 562 and 563:
Page 564 and 565:
Page 566 and 567:
Page 568 and 569:
Page 570 and 571:
Page 572 and 573:
Page 574 and 575:
Page 576 and 577:
Page 578 and 579:
Page 580 and 581:
Page 582 and 583:
Page 584 and 585:
Page 586 and 587:
Page 588 and 589:
Page 590 and 591:
Page 592 and 593:
Page 594 and 595:
Page 596 and 597:
Page 598 and 599:
Page 600 and 601:
Page 602 and 603:
Page 604 and 605:
Page 606 and 607:
DRUGS AND THERAPIES INDEXNOTES: Ent
Page 608 and 609:
Page 610 and 611:
Page 612:
show all

The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

Create successful ePaper yourself

Delete template?

Save as template?