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Ethics of Death and Dying

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Chapter 7- Ethical Problems of Death and Dying: Option 1
A 45-year-old man with metastatic lymphoma cancer has decided to try palliative chemotherapy because "otherwise I might just as well roll over and give up." After the first cycle chemo, he requires hospitalization for fever and neutropenia (a complication of the chemotherapy). You stop by for a visit, and he says he feels terrible and wonders "if the chemo is worth all this", but that he's too scared to stop. WHAT DO YOU TELL YOUR PATIENT?-

Patients with cancer and depression experience more physical symptoms, have poorer quality of life, and are more likely to have suicidal thoughts, or a desire for hastened death. The association between cancer and suicidal behavior is neither unusual nor surprising. Depression, pain, debility, hopelessness and a sense of being a burden to others have been identified as key risk factors for suicidal behavior in cancer patients (Rosenstein, 2011, p. 101). In this scenario the issue of when medical care might be considered futile, meaning, when the continuation of a particular treatment might have the anticipated medical effect and yet not be beneficial to the patient any longer rises an must be addressed accordingly. Chemotherapy and other medications used in cancer treatment (glucocorticoids, narcotics, benzodiazepines, antihistamines, and antibiotics) often lead to adverse effects that mimic depression. For example, dopamine-blocking antiemetic’s such as metoclopramide (Reglan), prochlorperazine (Compazine), and promethazine (Phenergan) cause akathisia, which may in turn be misdiagnosed as an anxious or agitated depression (Rosenstein, 2011, p. 108). Clinicians are then faced with the task of differentiating from symptoms that masquerade as depression from a superimposed syndromal depression that complicates the treatment course of the lymphoma. The pharmacotherapy of depression in patients with advanced cancer should be guided by a palliative care approach. It should be focused on symptom reduction, regardless of whether the patient meets diagnostic criteria for major depression (Rosenstein, 2011, p. 108). I truly believe earlier and more intensive supportive care for patients with cancer reduces symptom burden and may prolong life for patients with advanced disease. The patient in this case should be examined and treated for his depression issues first. The patient’s clinical depression in this example is caused by a concern out of fear for future loss of control and of dignity. Healthcare professionals should comfort when it is needed, especially in cases where no healing is possible. However, it is never appropriate to dictate medical treatments (Baillie, McGeehan, Garrett, & Garrett, 2013, p. 180-183). Even when certain treatments are denied because of undue risk of harm, respectful discussions are always necessary. Viable choices must be offered within the realm of good patient care. Physicians are not obligated to provide treatments they believe are ineffective or harmful to patients. Physicians have a fiduciary obligation, and have taken a professional oath, to “first do no harm.” If harms of treatment are excessive, physicians risk maleficence. Physicians must exercise clinical judgment when declaring treatments futile. They need to clarify between specific treatments that are medically ineffective, yet might still provide perceived benefits to patients. The patient must be guaranteed palliation, pain control, respect of his dignity, and reassurance that the medical team will never abandon his care even when specific treatments are deemed futile (Baillie et al., 2013, p. 174-180). This situation is very difficult. It is important to explain futility to families. If practitioners feel there is essentially no chance of meaningful recovery, this needs to be stated explicitly to the family. Most families do not care to see their loved ones suffer, and are relieved when physicians offer guidance about withdrawing aggressive treatments from their loved one. Families always hope their loved one will improve, even when the prognosis is bleak. If practitioners know that at best, the status quo will be maintained until further decline naturally ensues, physicians need to empathically yet concisely state this, which is what I would attempt to do if this were my patient. Then I would allow families’ time to process this information before steadfastly recommending withdrawal or withholding aggressive treatments.

References
Baillie, H. W., McGeehan, J., Garrett, T. M., & Garrett, R. M. (2013). Health Care Ethics (6 ed.). Boston: Pearson.
Rosenstein, D. L. (2011, march 13,2011). Depression and end-of-life care for patients with cancer. Dialogues Clinical Neuroscience, 13, 101-108. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181973/

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