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Ethics have been long talked about in health care in the United States. Ethics suggests that every decision made has a right or wrong action. This sense of right or wrong, however, could be subjective to different experiences in one’s life. Ethics are influenced by many different factors like culture, climate, and morals (Kreitner & Kinicki, 2016). This creates grey areas in ethical policy regarding end-of-life issues.
Ethics are defined as beliefs, ideas, or values that are foundations of why actions are considered good or bad (Petrovic-Lazarevic, 2004). The United States healthcare system has tried to set up a rule of ethics regarding end-of-life issues. The central themes that will be discussed are the history of the policy regarding end-of-life issues, alternatives, ideas surrounding science and politics, the success of the current policy, implementation, involvement with the public health problem, and areas for improvement.
The purpose of this paper is to discuss policies surrounding end-of-life issues. The analysis of ethics in health care will also be discussed, as well as how this issue could be handled differently and the moral principles that should be considered when reviewing this policy.
To start, an ethical climate is the standard behavior that is clearly communicated and followed by all leaders in any organization. Creating this ethical climate in health care is essential in finding issues and addressing them (Kreitner & Kinicki, 2016). Effective leadership, one that carries out these practices, is the key to creating a clear ethical climate in health care. Applying ethical practices to end-of-life issues will be reviewed in this paper.
How it works
The history of the policy (why the problem was identified as worthy of a policy solution and how the policy was formulated).
In 1980, an economist by the name of Eli Ginzberg introduced the term “the high cost of dying,” which surrounded the fact that, as notice of GDP spending increased starting in the 1960s, there was a large number of resources being spent on the terminally ill and last few months of patients’ lives. Conversations began on whether these costs should continue and how to best cut costs. In 2005, researchers wanted to collect data to support the idea that end-of-life policy was needed due to the increased spending in this area of care and to discuss ways to control those costs (Scitovsky, 2005). Not only was it hypothesized that there were increased costs in care to patients at the end of their life, but that many of these people ended up dying in pain and alone (Wiener & Tilly, 2003).
End-of-life policy includes advanced directives, hospice usage, death location, specialized services for end-of-life, use of prescriptions that regulate pain, and availability of care professionals. The main sources of funding for end-of-life issues come from Medicare, Medicaid, and private insurance. Specific end-of-life policy attention should be focused on hospice in Medicare and Medicaid. Restrictions on policy included payment, benefits, eligibility, and quality assurance in hospice. (Wiener, & Tilly, 2003).
When formatting the policy, three actions were taken. One was specifying who this policy would be geared towards and what was defined as patients who had illnesses that prohibited the advancement of life. The second action was creating guidelines to regulate ethical therapeutic interventions. The last action included improving the quality of care these patients received at the last leg of their life, with physicians effectively communicating procedures and a timeline to the patient and loved ones (Myatra et al., 2014).
Current practices like hospice and palliative care were deemed what best serves at the end of life care, but other methods, which will be discussed in more detail, include still emerging practices like death midwives, death doulas, death with dignity acts, and different end-of-life guides (Henkel, 2017). Death midwives “provide holistic, non-medical, emotional, spiritual, and practical support for the dying and their families” (The death midwife, 2018). Death midwives are meant to work with medical staff and fill in the gaps to provide heart-oriented and community-like care during one’s final passage in life (The death midwife, 2018). There is an International End of Life Doula Association (INELDA) that assists the dying and their families. It is a nonprofit organization whose mission is to “transform the end-of-life experience, so it brings greater meaning and sacredness to a dying person and their loved ones” (INELDA, 2017). Both excel in the emotional aspect of the end of life to give support during the process rather than provide medical attention.
End Life Symptom Management Order was a protocol to use opiate medication for palliation during the end of life. An issue with this protocol was that many physicians believed that it started too late in end-of-life care. While most physicians thought of the protocol as useful, it was not enough to stand alone in end-of-life care. Dealing with emotional pain from both the patient and family members, as well as patients being in physical pain during their last leg of life, showed that other measures needed to take place for a successful end-of-life policy (Walling et al., 2008).
Death with dignity is another alternative that has had many controversial actions regarding end-of-life directions. Death with dignity, in short, is for terminally ill patients who can choose to die on their own terms. The Death with Dignity National Center is a nonprofit organization that promotes education and the creation of laws stemming from the Oregon Death with Dignity Act. This act in Oregon made so that there are strict guidelines of who qualifies, but under a physician, the state has legalized medical aid in dying for a terminally ill patient. The Death with Dignity National Center, along with similar organizations, has pushed for policy reform regarding end-of-life issues in many states (History, 2018). The U.S. has not quite reached the whole acceptance of a person being able to medically aid themselves in their decision to die, but some individuals believe this might grow to be a more permanent part of the end-of-life policy in the future.
Science and evidence-based work are the backbones of politics. The medical science that goes into end-of-life issues was needed before the policy could take place. Most politics, however, take certain scientific data and statistics to spin it in aid their specific end goal. Some even fabricate false scientific evidence that, unless fact-checked, will be deemed as true. On the other end of the spectrum, some know factual scientific information and still choose to discredit findings to collaborate with their goal. This leads to scientific information not always being the decision-making factor. It can most certainly start and fuel a discussion, but “public opinion, electoral contests, [and] fiscal priorities” will also always be considered by the government (King, 2016). Scientists speaking to the right people in politics with the right words will only be a slow track to policy reform with end-of-life issues.
How ethics fits into the tradeoff between science and politics is also important to review. For science to be authentic, ethical data needs to be obtained. Scientists are thus forced to perform with high expectations of their moral values on how they obtain information and present it. Immoral tradeoffs begin when scientists have political motives. While, as stated above, scientific data is not the only factor in policy, it still holds weight in politics (Zohoor, 2003).
The success of the end-of-life policy relies heavily on physicians successfully predicting how many months a patient has left to live. After all, end-of-life issues should only span the final leg of a person’s life as deemed appropriate. Hospice has a strict 6-month or less rule that needs to be verified by a physician for Medicare to fund it (Scitovsky, 2005). If a physician deems someone terminally ill, they can continue to receive funds even after being in hospice for over six months (Cancer.Net Editorial Board, 2018). Once hospice is initiated, Medicare no longer pays for medication to cure the illness, only to monitor pain. Predicting death is a difficult, near-impossible task, even for the most seasoned physicians (Scitovsky, 2005). This creates an issue and makes the policy not as successful as it could be.
In one study comparing decedents to survivors, decedents have more hospital use, expenditures, and reimbursements made than the survivors. This shows that the ‘cost of dying’ has been around for a long time (dating back to data from 1961), and this cost is just as high, if not higher, than what is used on survivors. The takeaway from the study is that even though these statistics are available, they do not provide enough evidence to single out a certain group to modify the type of care for cost containment. The impact hospice has on end-of-life care is the right move for many terminally ill patients. End-of-life care, rather than continuous treatments, is sometimes the best move for many individuals. A more accurate prognosis when debating if hospice is the best decision should also continue to be researched to continue a positive impact (Scitovsky, 2005).
The policy came about by developing guidelines for limiting inappropriate care for people with a terminal illnesses and improving the quality of end-of-life care. Physicians practice avoiding inappropriate interventions for fear of being accused of providing low-quality care. Hospice was implemented to be used during the last leg of someone’s life by allowing care and relieving pain for someone terminally ill. This care does not just stem to the patient but also to his or her family and friends. Quality end-of-life care is a human right to provide the best end-of-life care to an individual. Physicians, who are needed, deem a person as having a life-limiting disease which, after practical treatments have been exhausted, will ask hospice to fill gaps in the last months of a person’s life (Myatra et al., 2014). The Centers for Medicare Services are who regulate the actions and care of hospice to oversee appropriate care is being met (Hospice funding: What you need to know, 2018).
Currently, the policy can and usually does, use hospice and palliative care together, which helps fill gaps that could be created in end-of-life care (Henkel, 2017). The four principles of medical ethics include social justice, autonomy, nonmalfeasance, and beneficence, all of which, to some degree, get put into perspective surrounding end-of-life policy in the United States (Wiener & Tilly, 2003). The policy, for the most part, though, is fragmented, with limited use of rules surrounding hospice and having deficit care when hospice is involved (Wiener & Tilly, 2003). When speaking specifically about the challenges in end-of-life care, there are four challenges for policy. This includes general knowledge surrounding care, cultural and ethical beliefs, reimbursement for services, and what the public currently knows about end-of-life care. In this case, steps are being taken to solve end-of-life issues by identifying the issues and working toward solutions (Schreibeis-Baum et al., 2016).
What one considers a ‘good death’ varies depending on whom you ask. Discussing end-of-life care could thus have many different outlooks. Therefore, ethics plays an important part in creating end-of-life policies. 70% of patients say they want to die at home but only about 25% use hospice. The rest die in an ICU, hospital, or nursing home. This means that 75% of dying patients do not use the end-of-life care policy regarding hospice care (Fine, 2004). This causes the end-of-life policy to be unsuccessful when only 25% of dying patients use it.
With Medicare and Medicaid being the dominant sources of financing for end-of-life care, they could focus their market power on changing how an individual spends the last months of their life. More data would be needed on the specifics of Medicare and Medicaid beneficences during their end-of-life issues to push policies. The first step would be for makers to recognize issues that need modifying and then look for better solutions. More government involvement in funding palliative care to allow more pain medication to be available earlier could also improve the policy. Along the same lines of managing care, finding a better way to measure the pain that the individual experiences would also improve the policy. The current policy surrounding end-of-life issues in hospice should be relooked at specifically with how many months left a physician needs to declare so that hospice can come in and provide care at an appropriate time (Wiener & Tilly, 2003). The first step to improving the policy is working from what is already in place and making it better so that it can span to more individuals who need it and to better benefit those whole it currently serves.
The second thing that should be reviewed to improve the policy is to look back at the alternatives and research to see if one or more of those could be introduced to fill in the gaps not filled by the first action. According to Henkel, even though hospice and palliative care fill gaps in end-of-life care, the drive for improvements should not stop there (2017). Creating more death-with-dignity acts could be one way to give control back to those who are terminally ill. This move, however, would cause some ethical dilemmas, and a political movement would need to first be initiated in Washington.
To most people, death will not be sudden. Death, to most, is a process, starting with possibly one chronic condition and adding additional conditions until the end (Institute of Medicine, 2015). Having a successful end-of-life policy is a crucial part of overall health care as every single human at one point in their life will need end-of-life care. The ethics surrounding how best to proceed with this issue is messy, with many different views on what should occur during a patient’s final leg of their life. Excluding certain cultures that believe no intervention is a way of passage, many would believe that excruciating pain and feeling of aloneness during the final days and months should not occur. Therefore, reviewing end-of-life care and its success is important to its policy.
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