Letting Go of the Rope — Aggressive Treatment, Hospice Care, and Open Access
Dana-Farber Cancer Institute, Boston, USA.New England Journal of Medicine (Impact Factor: 55.87). 08/2007; 357(4):324-7. DOI: 10.1056/NEJMp078074
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- "In essence, cancer patients must forego disease-specific treatments regardless of intent (e.g., maintenance, prolonged survival, palliation) in order to access comprehensive palliative care services offered by hospice programs (Wright & Katz, 2007). Although some large hospice organizations labeled " open access " enroll patients who continue cancer-directed therapies, these programs remain the exception (Wright & Katz, 2007). Many hospices still adhere to a rule of complete cessation of disease-specific treatment and acceptance by the patient of his or her terminal condition (Connor, 2010). "
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ABSTRACT: Disease-directed therapy near death is a growing trend among persons living with late-stage cancer. As a sociocultural phenomenon, cancer-directed therapy (e.g., chemotherapy) when given for very advanced disease is a process that offers questionable benefits and portends further suffering, but also suggests potential for growth and transcendence. Theories and concepts drawn from cultural anthropology, sociology, and existentialism illustrate how contextual factors contribute to the creation of a “liminal space”; the latter part of the cancer trajectory where living and dying can overlap. When applied to clinical practice, this theoretical framework gives the patient, family, and health care provider a way of “unmasking” a period of transition during terminal illness when aggressive disease-directed care continues to be provided. The liminal space may function as an existential plane; a gateway or threshold with inherent potential for psychospiritual development during the final stage of life.
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- "These apparatus can be seen in the interface that has been very dominant and offered great promise and that has been constructed between the modern hospice movement and the traditional Western healthcare system, modelled on disease-focused actions and continuous, persistent practices until the end of life. Indeed, after initially occupying a somewhat outcast position, the hospice movement now operates , in ever-closer partnership with this system, whether by means of an increasingly more frequent formation of palliative care teams in general hospitals , or by the growth of hospices (Wright & Katz, 2007; Doyle, 2007–2008). It is precisely in this new scenario, however, that criticisms arise regarding the practices developed by the hospice movement. "
ABSTRACT: This article investigates some of the criticisms that have been directed at the hospice movement in the process of interaction with the traditional Western healthcare system, such as those relative to its routinization and medicalization. It also aims to review some of the consequences of this process of institutionalisation for the field of end-of-life care: surveillance and control over the process of dying, at the expense of decisions preferably based on the patient and that patient's ability to decide how to die, with the loss of wider objectives originally established by the movement, such as unconditional reception for the patient. Based on these criticisms, some considerations are made regarding the moral implications and risks related to this specific mode of action, the hospice way of care.
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ABSTRACT: Limitation of treatment decisions remain problematic despite both ethical and legislative endorsement of the patient's right to choose a course of treatment. There is broad variation in public knowledge and attitudes about what is and is not possible at the margin between life and death. There is an illusion of efficacy of cardiopulmonary resuscitation (CPR). Originally proposed for witnessed collapse of circulation in the Operating Room, CPR is now applied regardless of the circumstances through a presumption of consent. Do Not Resuscitate (DNR) orders occupy a unique niche in medical orders. They are orders to withhold that specific intervention. Discussing the option not to resuscitate or to limit treatment can be difficult for patient, family, and caregiver alike. If patients are unable to make their own decisions, a proxy or surrogate decision-maker needs to be identified which adds another level of complexity, particularly if the patients never discussed their wishes with their surrogate. Some practical suggestions are made to facilitate communication about these difficult choices. It must be clear that a DNR order by itself is not an order to withhold other treatments and is not a death sentence. It is a choice for dignity, respect, and comfort if other treatments fail.