Author: Jo Allen, RN, GradDipEth&Law
Abstract
Acute Resuscitation plans (ARP) were introduced into Queensland Health hospitals in 2010. Despite the benefits of the ARP which include engaging the patient and their family in their prognosis to discussion treatment options there are still doctors who do not complete ARPs for elderly hospital inpatients. There are many reasons for this which include the Doctor’s experience, personal values, religious and cultural beliefs and avoidance of conflict as many patients and families can have unrealistic expectations of medical treatments. The main benefits of ARPs from both a distributive justice and medical prospective is they reduce the incidence of futile treatments that contribute to moral conflict and they raise awareness and promote open discussion about end of life issues. Mandatory ARPs for inpatients 80 years of age and older is recommended to address distributive justice within the health care system.
Background
Dying in hospital is an inevitable source of conflict for health care organisations, medical staff and individuals. According to the Australian Bureau of Statistics (2016) many people can reasonably expect to live to 80-94 years of age. This is the result of many factors which include, improved health care systems and sanitation, pharmaceutical advances, medical imaging, better surgical techniques, rapid advances in technology and diagnostic equipment. Ultimately, people are living longer because many conditions can be diagnosed earlier and treated more effectively. The downside is that many elderly people do not discuss end of life issues with their family or health care provider. This lack of end of life planning can place a burden on the finite resources of a health care system and is a major source of moral conflict for patients, families, and medical staff. Acute Resuscitation Plans (ARP) were implemented by Queensland Health in 2010 as one way to address this issue.
The underlying concept of this initiative was to shift the focus away from a ‘Do-Not-Resuscitate’ order which was often recorded as a brief note in a patient’s medical record. This no longer accepted practice in today’s health care environment where people are invited to discuss their needs, goals and wishes in relation to their health care (Australian Commission on Safety and Quality in Health Care, 2015). An ARP encourages open communication between patients and their doctor before an acute or terminal event occurs. In this model, discussions are focused around prognosis and interventions that will produce the best outcome or cause the least harm should a person’s condition deteriorate in hospital (Queensland Health, 2009).
ARPs & Distributive Justice
Distributive justice relates to the ‘fairness’ and equitable distribution or allocation of outcomes (Nabatchi, Blomgren Bingham, & Good, 2007). The National Health Hospitals Reform Commissions identified principles for the Australian Health System which cover equity, accessibility for all regardless of background, value for money and efficient governance, shared public responsibility which involves accepting responsibility for personal lifestyle choices, and strengthening and promoting wellness (National Health Hospitals Reform Commission, 2008).
The other factor that needs to be considered is that health care resources are finite. This means that whilst patients should expect to receive a high standard of care, this does not necessarily mean that they should receive the type of care that they expect or demand (National Health Hospitals Reform Commission, 2008).
Although the principles of distributive justice should prevail in a health care setting, the reality is when patients and their family are faced with highly emotional decisions, asking them to be objective and consider their situation from a ‘distributive justice’ perspective is both unrealistic and unreasonable. Conflict is inevitable when there is a disparity between the expectations of treatment that can (or could) be provided when compared with the ability or obligation of the health service to meet this expectation. Queensland Health (2009) explains this concept in the following paragraph,
“high respect for the value of life does not necessarily mean there should be a duty to always give life-sustaining medical treatment. Prolonging life at any cost, while supported by many institutions in our society, may not always be consistent with good medical practice, particularly if it pays no regard to the quality of a person‘s life or the burdens of their treatment. “
It is also important to mention that the Australian Commission on Safety and Quality in Health Care (2015) claims that doctors are not legally obliged to provide treatments that, ‘will not offer a reasonable hope of benefit or improve the patient’s quality of life’.
Moral conflict
Although many doctors will complete an ARP if one is not already in place, there are still instances where a doctor will avoid or defer completing one. There are many reasons for this which can include the doctor’s training and experience, personal values, cultural background, religious beliefs and avoidance of potential conflict. There can also be the belief that the death of a patient equates to a failure on the part of the Doctor (Hayes, 2012; Lawrence, Willmott, Milligan, Winch, & Parker, 2012).
Unfortunately, when patients do not discuss their end of life issues with their family the burden of health care decisions fall on them. The family can experience moral conflict when they are obliged to make decisions on the patient’s behalf. In one case, which highlights the moral dilemma that can ensue, a family member of a 100-year-old patient was quoted as saying, ‘if there is any chance she may survive with treatment, then I don’t want to be the one to say no to it’ (Murray, 2009, p. 79).
The problem inherent in this approach for elderly patients is many ‘treatments’ used in an attempt to save them are extremely traumatic and cause harm, for example, cardiopulmonary resuscitation (CPR). Without an ARP or Advance Health Care directive to guide medical staff, resuscitation may commence whether it is in the best interest of the patient or not. In many cases CPR not only results in broken ribs for an elderly patient, if they actually survive the experience there is often a severe reduction in their quality of life (Crealy, 2014; Murray, 2009).
When CPR is unsuccessful the resulting death is traumatic for the patient and medical staff involved (Murray, 2009). This situation causes moral conflict in cases where medical staff are cognisant of the fact that aggressive emergency treatment is not always consistent with good medical practice (Lawrence, Willmott, Milligan, Winch, & Parker, 2012; Queensland Health, 2009). It is no surprise that this moral conflict has been identified as one of the factors that contributes to emotional exhaustion and burnout in nurses (Murray 2009).
ARP advantages
The advantages of an ARP from an organisational perspective are clear as the patient and their family are involved in major health decisions. Even in the example of the 100-year-old patient, it seems extremely unlikely the patient would want CPR to be performed if they were fully aware of the risks and negative aspects involved as it is not in their best interest. In comparison, when a patient is fully informed of the risks and is adamant they still would want CPR, the moral conflict and subsequent distress is diminished as medical staff are acting in accordance with the wishes and interests of the patient.
Another advantage is that an ARP can highlight situations where the patient or family need additional support, particularly if their expectations of treatment that can be provided are unrealistic or incongruent with their medical condition. It is another way of encouraging and promoting discussion with our elderly patients about end of life issues with their family or through formal planning (e.g. Advance Health Directives) (Queensland Health, 2009).
Resolving the conflict
A solution that would improve ARP compliance which would in turn influence distributive justice is to make the completion of ARPs mandatory for hospitalised patients aged 80+ where there is no prior ARP or Advance Health Directive. This would create a level of equity and consistency within health care systems and improve resource management as futile treatments place an unnecessary financial burden on the finite resources of our health care system.
Regular audits of ARPs and identification can identify impediments and sources of conflict for doctors. This data could then be used to provide additional resources, support and education for medical staff on the advantages of ARPs and encourage discussion on end of life issues.
Conclusion
ARPs provide a forum that allows ongoing discussions between doctors and patients about their prognosis and appropriate treatments that can be tailored for their age and physical condition. They raise awareness and promote open discussion about end of life issues. The main advantage of ARPs is they can reduce the incidence of futile treatments that contribute to moral conflict. A reduction in futile treatments is a step towards maintaining distributive justice within the finite resources of our health care system.
References
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