Hospice & Palliative Medicine

When contemplating the state of ethical dialogue in our modern world, the philosopher Alasdair MacIntyre had this to say: “I can only answer the question, ‘What am I to do?’ If I can answer the prior question ‘Of what story or stories do I find myself a part?’”¹ That is, our ethics must proceed from our understanding of ourselves, others, and the world. David Hume might scoff, but we do need an “is” to appreciate and grasp our “ought.” This is just as true for medical ethics as it is for the rest of life. Questions about what we should do in medicine should draw us to deeper questions about identity and purpose.

In this issue, Ruskin et al present a tragic case of a man who spent his later years walking the line between life and a self-chosen death.² After enduring the chronic decline of Parkinson disease, he faced a final diagnosis of glioblastoma. The patient enrolled in hospice while considering how he might move elsewhere to avail himself of assisted suicide. Before he had a chance to do that, he was admitted to an inpatient hospice unit where he weakened further. In the throes of what may have been delirium or a last effort to enact his wish of a hastened death, he attempted suicide on the hospice unit. He survived only to die days later from the cancer.

The authors reflect on the complexities of this case, including the distress of a clinician who may want to satisfy a veteran’s wish but cannot due to legal constraints, and the challenges of identifying pathologic suicidal ideation from an earnest and rational desire for a hastened death. How should they handle these conversations? They conclude by suggesting ways clinicians may assess and respond to requests for a hastened death, recognizing that assisted suicide remains illegal within the Veterans Health Administration (VHA).

Clinicians can return to the foundation of our profession to better consider these questions. The case report authors acknowledge this but avoid learning from what the conflict might teach us: “The inability to help veterans achieve their care preferences [to receive a hastened death] conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.” Before feeling like they have failed the veteran, a clinician must ask if it is really within their scope of practice to end someone’s life. While it is true that “the mission of VHA’s [Palliative and Hospice Care] program is to honor veterans’ preferences for care,” this mission exists within a greater context of appreciating that not all preferences can or should be honored.³ An obvious example is when a veteran requests an intervention that is not clinically indicated (eg, antibiotics for a viral infection). Clinicians are not bound to honor this preference; not because there is a law directing the clinicians’ decision making (there is not) but because there is a standard of care that accounts for but can supersede the veteran’s preference.

Is assisted suicide ever clinically indicated? While the answer shifts depending on the jurisdiction, the case report authors acknowledge why the preference for assisted suicide cannot be honored in a VHA facility: it is against the law.⁴ However, as they explain, this is insufficient to assuage the moral distress that might arise for some clinicians who want to fulfill a veteran’s request. They recommend several different strategies for clinicians to consider when receiving a request for assisted suicide. Distress in the form of cognitive dissonance may also arise from the tension that exists between stopping some forms of suicide while assisting in others.

While it is important to assess whether the request for a hastened death is driven by an untreated symptom or mental illness, this will only get a clinician so far when the request is made in earnest with no remediable drivers. While I cannot argue the point here, I accept that there are forms of suicide which are rational. However, that alone is insufficient to justify the act or assist someone with it; we must assess the good that the rational choice seeks to realize.⁵ If suicide can be rational, clinicians should ask whether it is within the goals of medicine to assist in suicide. The authors seem to take it for granted that the distressed clinician in the case hopes to hasten this veteran’s death or at least refer him to someone who could. Perhaps his suicide attempt on the hospice unit was, in part, a consequence of being incapable of offering such assistance. These presuppositions should be considered explicitly to better align one’s practice both with the mission of VHA and with the goals of medicine.

One way to do this is to consider whether we can cast assisted suicide as a medical therapy. Sulmasy proposes the provisional “canons of therapy” which might guide clinicians in assessing medical therapies.⁶ This article distinguishes 3 types of clinically and ethically distinct practices. I have split his first canon (proportionality) into 2 for the sake of clarity.

Priority: Do the benefits outweigh the burdens of the intervention?

The challenge of assessing priority when considering assisted suicide is that we cannot explain any benefits or burdens that might accrue after death; it is beyond our knowledge and informed consent is impossible. While there is always some uncertainty in discerning the benefits and burdens of an intervention, death presents an insurmountable procedural problem for informed consent to assisted suicide.

Fit: Are the means appropriate for the outcome of interest?

The outcomes of interest when considering assisted suicide are many—many—they range from symptom relief or avoidance to reclaiming dignity. In the case described by Ruskin et al, the interdisciplinary team offered the veteran a number of interventions to assuage his symptoms. Dignity therapy may have been employed as a meaningful, useful way of bringing closure to a life.^7,8 Ultimately, however, some distress, particularly existential distress, may be intractable and clinicians must commit, as they did in this case, to doing what they can to remedy other symptoms and not abandon the veteran. Suicide is a tempting option because it may eliminate some of these concerns, but one must first grapple with the ethical question of whether suicide is ever an appropriate way to pursue any of these outcomes. Addressing that question is beyond the scope of this commentary, but both clinicians and patients should consider whether and why suicide should be considered appropriate and whether it is appropriate for the medical profession to assist with it.

Parsimony: Is this the least invasive, least burdensome intervention available?

In US jurisdictions where it is legal, assisted suicide is considered an intervention of last resort. Assisted suicide seems to be neither invasive (it involves taking medications) nor burdensome: the medications usually work quickly and without adverse effects, although there are risks (eg, vomiting). Broadening our view beyond the individual reveals something different.

In a cultural sense, assisted suicide is invasive. It changes how clinicians and patients consider health and medical care. We no longer have the profession of medicine with another intervention in the toolbox; we have a totally different profession which now intends death instead of health for its patients. It changes medicine and society at large profoundly. This makes it culturally invasive.

Furthermore, although the veteran in the case recurrently grappled with the choice of suicide, most people do not. They live by default. Offering assisted suicide, even in broad, general terms, may still leave them deciding to live, but the offer has also taken from them the possibility of living by default. They must justify their choice if only to themselves, considering the reasons they continue to pursue life-prolonging treatment and incur financial, emotional, and physical costs for their family. This is a dangerous cultural burden ironically imposed by the offer of more choices.⁹ Clinicians, by offering assisted suicide even if a patient declines it, also affirm the reasonableness of ending one’s life given the circumstances. That affirmation may be burdensome (eg, “They see my life as not worth living”) rather than validating.¹⁰

Restoration: Will this intervention help to restore the patient overall (even if not immediately)?

It would seem restoration is impossible for someone who is dying. Dying is terrible and so one possibility would be to hasten the process with assisted suicide. If health is in view, though, clinicians could recognize that restoration is always possible as long as someone is alive.

For someone dying, restoration may look like symptom relief (restoring bodily distress) which in turn may restore one’s capacity to sleep or to converse with loved ones. Assisted suicide does not fit in this paradigm. Is it intended to help patients sustain and restore their health, whatever amount they have (this is what the hospice and psychiatric services attempted to do in the case). Or is it intended to help patients pursue whatever goals seem good to the patient even those goals which conflict with health? Happily, most patients want their health sustained or restored so there is usually no conflict. As medical technology advances, though, conflicts arise: Should a clinician prescribe stimulants to enhance a healthy student’s wakefulness during final exams? Should a clinician engineer embryos to provide parents with a particular kind of child? Should a clinician end a patient’s life? Assisted suicide is obviously not aimed at restoration. It is a concession to the intractability of one’s disease and disability and one’s impending death. Without clarity and agreement on the goal of medicine, the default provision of care centers instead on satisfying patient preferences whatever they are.

Holism: Does the intervention prioritize the whole patient (vs prioritizing a part for the sake of the whole)?

Clinicians offering assisted suicide suggest that providing a death on a patient’s own terms restores autonomy and brings coherence to a life narrative that, at its end, is fraught with tragedy. This is what it looks like to honor “the whole patient.” A clinician must scrutinize that judgment to determine whether the patient meets statutory criteria for assisted suicide. The impulse underlying the moral distress described by Ruskin et al and many other clinicians is that a patient’s judgment, once determined to be sound, should trump a clinician’s judgment about what is best for the patient’s health and whether there are limits on what the clinician can do to satisfy a patient’s preferences. Ironically, assisted suicide prioritizes a patient’s judgment about how their life should end above other considerations, namely, that medicine has traditionally sought the patient’s good by sustaining and restoring their health, not by intending and causing their death. Notably, there was no lack of holism in the care provided the veteran in the case both before and after his suicide attempt.

Discretion: What are the limits of the intervention itself? What is the scope of medicine in general? What is the limit of one’s own individual knowledge and skill?

Assisted suicide has a substantial limit: it does not offer relief from suffering because there will be no one left alive to experience relief. Assisted suicide cannot achieve anything for the patient because they are dead by the time they fully receive what has been given. This profound limit makes assisted suicide unlike anything else offered in medicine and should give clinicians pause before adopting it, prompting them to grapple with whether causing a patient’s death is within the scope of medicine. If so, how did this come to be after thousands of years to the contrary across cultures and traditions, and what justifies this change? Finally, clinicians must contend with the limits of informed consent.

This brief reflection on how clinicians should consider medical therapies brings us back to MacIntyre’s exhortation: We cannot decide what to do until we have discerned the story to which we belong. One way of telling the story of medicine is to tell it with the techniques front and center: we prescribe, we operate, we irradiate, make the numbers go in the right direction, cure infections, and shrink masses. We can also tell that story by rejoicing that technology is giving us increasing control over our bodies and we can put that power to whatever use we desire. Often that will align with health, but it may not and that is for many patients increasingly acceptable. There is another, better story to tell: the profession of medicine exists to help people sustain and restore health, whatever bit of it they have and even as they lay dying. All those things just listed may help clinicians in that pursuit or they may not, given the specific context.

Ruskin et al tell a story of clinicians living in the tension of wanting to satisfy the desires their patients bring to them but must settle for the best that medicine can provide. Medical intervention as preference satisfaction is a story we have been living and practicing for 50 years since Beauchamp and Childress described the 4-principle framework for biomedical ethics: respect for autonomy, justice, nonmaleficence, beneficence.

Medicine-as-preference-satisfaction conflicts with the VHA mission to “honor America’s veterans by providing exceptional health care that improves their health and well-being.” VHA does not owe veterans whatever they request. VHA owes them exceptional health care. When a patient comes to a clinician, a clinician owes them a bounded set of things in service to their health. The dissonance a clinician might experience in trying to discern whether a patient’s death can serve that patient’s own health should signal a need to step back and reflect on how they understand the foundations of medical practice.

I do not disagree with the authors in their general approach to how clinicians might discuss this with patients who request a hastened death. I also seek to assuage symptoms, validate emotions, and remain steadfast through someone’s dying. I also affirm my commitment as a physician to care for a person’s health which, while someone is dying, usually entails managing symptoms. It never entails ending someone’s life. The clinicians in the case did an excellent job caring for this veteran and could not have done better by helping him end his life.

When contemplating the state of ethical dialogue in our modern world, the philosopher Alasdair MacIntyre had this to say: “I can only answer the question, ‘What am I to do?’ If I can answer the prior question ‘Of what story or stories do I find myself a part?’”¹ That is, our ethics must proceed from our understanding of ourselves, others, and the world. David Hume might scoff, but we do need an “is” to appreciate and grasp our “ought.” This is just as true for medical ethics as it is for the rest of life. Questions about what we should do in medicine should draw us to deeper questions about identity and purpose.

In this issue, Ruskin et al present a tragic case of a man who spent his later years walking the line between life and a self-chosen death.² After enduring the chronic decline of Parkinson disease, he faced a final diagnosis of glioblastoma. The patient enrolled in hospice while considering how he might move elsewhere to avail himself of assisted suicide. Before he had a chance to do that, he was admitted to an inpatient hospice unit where he weakened further. In the throes of what may have been delirium or a last effort to enact his wish of a hastened death, he attempted suicide on the hospice unit. He survived only to die days later from the cancer.

The authors reflect on the complexities of this case, including the distress of a clinician who may want to satisfy a veteran’s wish but cannot due to legal constraints, and the challenges of identifying pathologic suicidal ideation from an earnest and rational desire for a hastened death. How should they handle these conversations? They conclude by suggesting ways clinicians may assess and respond to requests for a hastened death, recognizing that assisted suicide remains illegal within the Veterans Health Administration (VHA).

Clinicians can return to the foundation of our profession to better consider these questions. The case report authors acknowledge this but avoid learning from what the conflict might teach us: “The inability to help veterans achieve their care preferences [to receive a hastened death] conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.” Before feeling like they have failed the veteran, a clinician must ask if it is really within their scope of practice to end someone’s life. While it is true that “the mission of VHA’s [Palliative and Hospice Care] program is to honor veterans’ preferences for care,” this mission exists within a greater context of appreciating that not all preferences can or should be honored.³ An obvious example is when a veteran requests an intervention that is not clinically indicated (eg, antibiotics for a viral infection). Clinicians are not bound to honor this preference; not because there is a law directing the clinicians’ decision making (there is not) but because there is a standard of care that accounts for but can supersede the veteran’s preference.

Is assisted suicide ever clinically indicated? While the answer shifts depending on the jurisdiction, the case report authors acknowledge why the preference for assisted suicide cannot be honored in a VHA facility: it is against the law.⁴ However, as they explain, this is insufficient to assuage the moral distress that might arise for some clinicians who want to fulfill a veteran’s request. They recommend several different strategies for clinicians to consider when receiving a request for assisted suicide. Distress in the form of cognitive dissonance may also arise from the tension that exists between stopping some forms of suicide while assisting in others.

While it is important to assess whether the request for a hastened death is driven by an untreated symptom or mental illness, this will only get a clinician so far when the request is made in earnest with no remediable drivers. While I cannot argue the point here, I accept that there are forms of suicide which are rational. However, that alone is insufficient to justify the act or assist someone with it; we must assess the good that the rational choice seeks to realize.⁵ If suicide can be rational, clinicians should ask whether it is within the goals of medicine to assist in suicide. The authors seem to take it for granted that the distressed clinician in the case hopes to hasten this veteran’s death or at least refer him to someone who could. Perhaps his suicide attempt on the hospice unit was, in part, a consequence of being incapable of offering such assistance. These presuppositions should be considered explicitly to better align one’s practice both with the mission of VHA and with the goals of medicine.

One way to do this is to consider whether we can cast assisted suicide as a medical therapy. Sulmasy proposes the provisional “canons of therapy” which might guide clinicians in assessing medical therapies.⁶ This article distinguishes 3 types of clinically and ethically distinct practices. I have split his first canon (proportionality) into 2 for the sake of clarity.

Priority: Do the benefits outweigh the burdens of the intervention?

The challenge of assessing priority when considering assisted suicide is that we cannot explain any benefits or burdens that might accrue after death; it is beyond our knowledge and informed consent is impossible. While there is always some uncertainty in discerning the benefits and burdens of an intervention, death presents an insurmountable procedural problem for informed consent to assisted suicide.

Fit: Are the means appropriate for the outcome of interest?

The outcomes of interest when considering assisted suicide are many—many—they range from symptom relief or avoidance to reclaiming dignity. In the case described by Ruskin et al, the interdisciplinary team offered the veteran a number of interventions to assuage his symptoms. Dignity therapy may have been employed as a meaningful, useful way of bringing closure to a life.^7,8 Ultimately, however, some distress, particularly existential distress, may be intractable and clinicians must commit, as they did in this case, to doing what they can to remedy other symptoms and not abandon the veteran. Suicide is a tempting option because it may eliminate some of these concerns, but one must first grapple with the ethical question of whether suicide is ever an appropriate way to pursue any of these outcomes. Addressing that question is beyond the scope of this commentary, but both clinicians and patients should consider whether and why suicide should be considered appropriate and whether it is appropriate for the medical profession to assist with it.

Parsimony: Is this the least invasive, least burdensome intervention available?

In US jurisdictions where it is legal, assisted suicide is considered an intervention of last resort. Assisted suicide seems to be neither invasive (it involves taking medications) nor burdensome: the medications usually work quickly and without adverse effects, although there are risks (eg, vomiting). Broadening our view beyond the individual reveals something different.

In a cultural sense, assisted suicide is invasive. It changes how clinicians and patients consider health and medical care. We no longer have the profession of medicine with another intervention in the toolbox; we have a totally different profession which now intends death instead of health for its patients. It changes medicine and society at large profoundly. This makes it culturally invasive.

Furthermore, although the veteran in the case recurrently grappled with the choice of suicide, most people do not. They live by default. Offering assisted suicide, even in broad, general terms, may still leave them deciding to live, but the offer has also taken from them the possibility of living by default. They must justify their choice if only to themselves, considering the reasons they continue to pursue life-prolonging treatment and incur financial, emotional, and physical costs for their family. This is a dangerous cultural burden ironically imposed by the offer of more choices.⁹ Clinicians, by offering assisted suicide even if a patient declines it, also affirm the reasonableness of ending one’s life given the circumstances. That affirmation may be burdensome (eg, “They see my life as not worth living”) rather than validating.¹⁰

Restoration: Will this intervention help to restore the patient overall (even if not immediately)?

It would seem restoration is impossible for someone who is dying. Dying is terrible and so one possibility would be to hasten the process with assisted suicide. If health is in view, though, clinicians could recognize that restoration is always possible as long as someone is alive.

For someone dying, restoration may look like symptom relief (restoring bodily distress) which in turn may restore one’s capacity to sleep or to converse with loved ones. Assisted suicide does not fit in this paradigm. Is it intended to help patients sustain and restore their health, whatever amount they have (this is what the hospice and psychiatric services attempted to do in the case). Or is it intended to help patients pursue whatever goals seem good to the patient even those goals which conflict with health? Happily, most patients want their health sustained or restored so there is usually no conflict. As medical technology advances, though, conflicts arise: Should a clinician prescribe stimulants to enhance a healthy student’s wakefulness during final exams? Should a clinician engineer embryos to provide parents with a particular kind of child? Should a clinician end a patient’s life? Assisted suicide is obviously not aimed at restoration. It is a concession to the intractability of one’s disease and disability and one’s impending death. Without clarity and agreement on the goal of medicine, the default provision of care centers instead on satisfying patient preferences whatever they are.

Holism: Does the intervention prioritize the whole patient (vs prioritizing a part for the sake of the whole)?

Clinicians offering assisted suicide suggest that providing a death on a patient’s own terms restores autonomy and brings coherence to a life narrative that, at its end, is fraught with tragedy. This is what it looks like to honor “the whole patient.” A clinician must scrutinize that judgment to determine whether the patient meets statutory criteria for assisted suicide. The impulse underlying the moral distress described by Ruskin et al and many other clinicians is that a patient’s judgment, once determined to be sound, should trump a clinician’s judgment about what is best for the patient’s health and whether there are limits on what the clinician can do to satisfy a patient’s preferences. Ironically, assisted suicide prioritizes a patient’s judgment about how their life should end above other considerations, namely, that medicine has traditionally sought the patient’s good by sustaining and restoring their health, not by intending and causing their death. Notably, there was no lack of holism in the care provided the veteran in the case both before and after his suicide attempt.

Discretion: What are the limits of the intervention itself? What is the scope of medicine in general? What is the limit of one’s own individual knowledge and skill?

Assisted suicide has a substantial limit: it does not offer relief from suffering because there will be no one left alive to experience relief. Assisted suicide cannot achieve anything for the patient because they are dead by the time they fully receive what has been given. This profound limit makes assisted suicide unlike anything else offered in medicine and should give clinicians pause before adopting it, prompting them to grapple with whether causing a patient’s death is within the scope of medicine. If so, how did this come to be after thousands of years to the contrary across cultures and traditions, and what justifies this change? Finally, clinicians must contend with the limits of informed consent.

This brief reflection on how clinicians should consider medical therapies brings us back to MacIntyre’s exhortation: We cannot decide what to do until we have discerned the story to which we belong. One way of telling the story of medicine is to tell it with the techniques front and center: we prescribe, we operate, we irradiate, make the numbers go in the right direction, cure infections, and shrink masses. We can also tell that story by rejoicing that technology is giving us increasing control over our bodies and we can put that power to whatever use we desire. Often that will align with health, but it may not and that is for many patients increasingly acceptable. There is another, better story to tell: the profession of medicine exists to help people sustain and restore health, whatever bit of it they have and even as they lay dying. All those things just listed may help clinicians in that pursuit or they may not, given the specific context.

Ruskin et al tell a story of clinicians living in the tension of wanting to satisfy the desires their patients bring to them but must settle for the best that medicine can provide. Medical intervention as preference satisfaction is a story we have been living and practicing for 50 years since Beauchamp and Childress described the 4-principle framework for biomedical ethics: respect for autonomy, justice, nonmaleficence, beneficence.

Medicine-as-preference-satisfaction conflicts with the VHA mission to “honor America’s veterans by providing exceptional health care that improves their health and well-being.” VHA does not owe veterans whatever they request. VHA owes them exceptional health care. When a patient comes to a clinician, a clinician owes them a bounded set of things in service to their health. The dissonance a clinician might experience in trying to discern whether a patient’s death can serve that patient’s own health should signal a need to step back and reflect on how they understand the foundations of medical practice.

I do not disagree with the authors in their general approach to how clinicians might discuss this with patients who request a hastened death. I also seek to assuage symptoms, validate emotions, and remain steadfast through someone’s dying. I also affirm my commitment as a physician to care for a person’s health which, while someone is dying, usually entails managing symptoms. It never entails ending someone’s life. The clinicians in the case did an excellent job caring for this veteran and could not have done better by helping him end his life.

When contemplating the state of ethical dialogue in our modern world, the philosopher Alasdair MacIntyre had this to say: “I can only answer the question, ‘What am I to do?’ If I can answer the prior question ‘Of what story or stories do I find myself a part?’”¹ That is, our ethics must proceed from our understanding of ourselves, others, and the world. David Hume might scoff, but we do need an “is” to appreciate and grasp our “ought.” This is just as true for medical ethics as it is for the rest of life. Questions about what we should do in medicine should draw us to deeper questions about identity and purpose.

In this issue, Ruskin et al present a tragic case of a man who spent his later years walking the line between life and a self-chosen death.² After enduring the chronic decline of Parkinson disease, he faced a final diagnosis of glioblastoma. The patient enrolled in hospice while considering how he might move elsewhere to avail himself of assisted suicide. Before he had a chance to do that, he was admitted to an inpatient hospice unit where he weakened further. In the throes of what may have been delirium or a last effort to enact his wish of a hastened death, he attempted suicide on the hospice unit. He survived only to die days later from the cancer.

The authors reflect on the complexities of this case, including the distress of a clinician who may want to satisfy a veteran’s wish but cannot due to legal constraints, and the challenges of identifying pathologic suicidal ideation from an earnest and rational desire for a hastened death. How should they handle these conversations? They conclude by suggesting ways clinicians may assess and respond to requests for a hastened death, recognizing that assisted suicide remains illegal within the Veterans Health Administration (VHA).

Clinicians can return to the foundation of our profession to better consider these questions. The case report authors acknowledge this but avoid learning from what the conflict might teach us: “The inability to help veterans achieve their care preferences [to receive a hastened death] conflicts with the core mission of palliative care to reduce suffering and respect end-of-life wishes.” Before feeling like they have failed the veteran, a clinician must ask if it is really within their scope of practice to end someone’s life. While it is true that “the mission of VHA’s [Palliative and Hospice Care] program is to honor veterans’ preferences for care,” this mission exists within a greater context of appreciating that not all preferences can or should be honored.³ An obvious example is when a veteran requests an intervention that is not clinically indicated (eg, antibiotics for a viral infection). Clinicians are not bound to honor this preference; not because there is a law directing the clinicians’ decision making (there is not) but because there is a standard of care that accounts for but can supersede the veteran’s preference.

Is assisted suicide ever clinically indicated? While the answer shifts depending on the jurisdiction, the case report authors acknowledge why the preference for assisted suicide cannot be honored in a VHA facility: it is against the law.⁴ However, as they explain, this is insufficient to assuage the moral distress that might arise for some clinicians who want to fulfill a veteran’s request. They recommend several different strategies for clinicians to consider when receiving a request for assisted suicide. Distress in the form of cognitive dissonance may also arise from the tension that exists between stopping some forms of suicide while assisting in others.

While it is important to assess whether the request for a hastened death is driven by an untreated symptom or mental illness, this will only get a clinician so far when the request is made in earnest with no remediable drivers. While I cannot argue the point here, I accept that there are forms of suicide which are rational. However, that alone is insufficient to justify the act or assist someone with it; we must assess the good that the rational choice seeks to realize.⁵ If suicide can be rational, clinicians should ask whether it is within the goals of medicine to assist in suicide. The authors seem to take it for granted that the distressed clinician in the case hopes to hasten this veteran’s death or at least refer him to someone who could. Perhaps his suicide attempt on the hospice unit was, in part, a consequence of being incapable of offering such assistance. These presuppositions should be considered explicitly to better align one’s practice both with the mission of VHA and with the goals of medicine.

One way to do this is to consider whether we can cast assisted suicide as a medical therapy. Sulmasy proposes the provisional “canons of therapy” which might guide clinicians in assessing medical therapies.⁶ This article distinguishes 3 types of clinically and ethically distinct practices. I have split his first canon (proportionality) into 2 for the sake of clarity.

Priority: Do the benefits outweigh the burdens of the intervention?

The challenge of assessing priority when considering assisted suicide is that we cannot explain any benefits or burdens that might accrue after death; it is beyond our knowledge and informed consent is impossible. While there is always some uncertainty in discerning the benefits and burdens of an intervention, death presents an insurmountable procedural problem for informed consent to assisted suicide.

Fit: Are the means appropriate for the outcome of interest?

The outcomes of interest when considering assisted suicide are many—many—they range from symptom relief or avoidance to reclaiming dignity. In the case described by Ruskin et al, the interdisciplinary team offered the veteran a number of interventions to assuage his symptoms. Dignity therapy may have been employed as a meaningful, useful way of bringing closure to a life.^7,8 Ultimately, however, some distress, particularly existential distress, may be intractable and clinicians must commit, as they did in this case, to doing what they can to remedy other symptoms and not abandon the veteran. Suicide is a tempting option because it may eliminate some of these concerns, but one must first grapple with the ethical question of whether suicide is ever an appropriate way to pursue any of these outcomes. Addressing that question is beyond the scope of this commentary, but both clinicians and patients should consider whether and why suicide should be considered appropriate and whether it is appropriate for the medical profession to assist with it.

Parsimony: Is this the least invasive, least burdensome intervention available?

In US jurisdictions where it is legal, assisted suicide is considered an intervention of last resort. Assisted suicide seems to be neither invasive (it involves taking medications) nor burdensome: the medications usually work quickly and without adverse effects, although there are risks (eg, vomiting). Broadening our view beyond the individual reveals something different.

In a cultural sense, assisted suicide is invasive. It changes how clinicians and patients consider health and medical care. We no longer have the profession of medicine with another intervention in the toolbox; we have a totally different profession which now intends death instead of health for its patients. It changes medicine and society at large profoundly. This makes it culturally invasive.

Furthermore, although the veteran in the case recurrently grappled with the choice of suicide, most people do not. They live by default. Offering assisted suicide, even in broad, general terms, may still leave them deciding to live, but the offer has also taken from them the possibility of living by default. They must justify their choice if only to themselves, considering the reasons they continue to pursue life-prolonging treatment and incur financial, emotional, and physical costs for their family. This is a dangerous cultural burden ironically imposed by the offer of more choices.⁹ Clinicians, by offering assisted suicide even if a patient declines it, also affirm the reasonableness of ending one’s life given the circumstances. That affirmation may be burdensome (eg, “They see my life as not worth living”) rather than validating.¹⁰

Restoration: Will this intervention help to restore the patient overall (even if not immediately)?

It would seem restoration is impossible for someone who is dying. Dying is terrible and so one possibility would be to hasten the process with assisted suicide. If health is in view, though, clinicians could recognize that restoration is always possible as long as someone is alive.

For someone dying, restoration may look like symptom relief (restoring bodily distress) which in turn may restore one’s capacity to sleep or to converse with loved ones. Assisted suicide does not fit in this paradigm. Is it intended to help patients sustain and restore their health, whatever amount they have (this is what the hospice and psychiatric services attempted to do in the case). Or is it intended to help patients pursue whatever goals seem good to the patient even those goals which conflict with health? Happily, most patients want their health sustained or restored so there is usually no conflict. As medical technology advances, though, conflicts arise: Should a clinician prescribe stimulants to enhance a healthy student’s wakefulness during final exams? Should a clinician engineer embryos to provide parents with a particular kind of child? Should a clinician end a patient’s life? Assisted suicide is obviously not aimed at restoration. It is a concession to the intractability of one’s disease and disability and one’s impending death. Without clarity and agreement on the goal of medicine, the default provision of care centers instead on satisfying patient preferences whatever they are.

Holism: Does the intervention prioritize the whole patient (vs prioritizing a part for the sake of the whole)?

Clinicians offering assisted suicide suggest that providing a death on a patient’s own terms restores autonomy and brings coherence to a life narrative that, at its end, is fraught with tragedy. This is what it looks like to honor “the whole patient.” A clinician must scrutinize that judgment to determine whether the patient meets statutory criteria for assisted suicide. The impulse underlying the moral distress described by Ruskin et al and many other clinicians is that a patient’s judgment, once determined to be sound, should trump a clinician’s judgment about what is best for the patient’s health and whether there are limits on what the clinician can do to satisfy a patient’s preferences. Ironically, assisted suicide prioritizes a patient’s judgment about how their life should end above other considerations, namely, that medicine has traditionally sought the patient’s good by sustaining and restoring their health, not by intending and causing their death. Notably, there was no lack of holism in the care provided the veteran in the case both before and after his suicide attempt.

Discretion: What are the limits of the intervention itself? What is the scope of medicine in general? What is the limit of one’s own individual knowledge and skill?

Assisted suicide has a substantial limit: it does not offer relief from suffering because there will be no one left alive to experience relief. Assisted suicide cannot achieve anything for the patient because they are dead by the time they fully receive what has been given. This profound limit makes assisted suicide unlike anything else offered in medicine and should give clinicians pause before adopting it, prompting them to grapple with whether causing a patient’s death is within the scope of medicine. If so, how did this come to be after thousands of years to the contrary across cultures and traditions, and what justifies this change? Finally, clinicians must contend with the limits of informed consent.

This brief reflection on how clinicians should consider medical therapies brings us back to MacIntyre’s exhortation: We cannot decide what to do until we have discerned the story to which we belong. One way of telling the story of medicine is to tell it with the techniques front and center: we prescribe, we operate, we irradiate, make the numbers go in the right direction, cure infections, and shrink masses. We can also tell that story by rejoicing that technology is giving us increasing control over our bodies and we can put that power to whatever use we desire. Often that will align with health, but it may not and that is for many patients increasingly acceptable. There is another, better story to tell: the profession of medicine exists to help people sustain and restore health, whatever bit of it they have and even as they lay dying. All those things just listed may help clinicians in that pursuit or they may not, given the specific context.

Ruskin et al tell a story of clinicians living in the tension of wanting to satisfy the desires their patients bring to them but must settle for the best that medicine can provide. Medical intervention as preference satisfaction is a story we have been living and practicing for 50 years since Beauchamp and Childress described the 4-principle framework for biomedical ethics: respect for autonomy, justice, nonmaleficence, beneficence.

Medicine-as-preference-satisfaction conflicts with the VHA mission to “honor America’s veterans by providing exceptional health care that improves their health and well-being.” VHA does not owe veterans whatever they request. VHA owes them exceptional health care. When a patient comes to a clinician, a clinician owes them a bounded set of things in service to their health. The dissonance a clinician might experience in trying to discern whether a patient’s death can serve that patient’s own health should signal a need to step back and reflect on how they understand the foundations of medical practice.

I do not disagree with the authors in their general approach to how clinicians might discuss this with patients who request a hastened death. I also seek to assuage symptoms, validate emotions, and remain steadfast through someone’s dying. I also affirm my commitment as a physician to care for a person’s health which, while someone is dying, usually entails managing symptoms. It never entails ending someone’s life. The clinicians in the case did an excellent job caring for this veteran and could not have done better by helping him end his life.

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Background

Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”¹ Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.² Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).

Aim

The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.

Methods

The Model for Improvement was used for this quality improvement project.³ One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.

Results

Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.

Conclusions

We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.

Background

Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”¹ Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.² Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).

Aim

The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.

Methods

The Model for Improvement was used for this quality improvement project.³ One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.

Results

Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.

Conclusions

We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.

Background

Veterans Health Administration Directive 1004.03(1) (Advance Care Planning) aims to establish a “system-wide, patient-centered and evidence-based approach to Advance Care Planning.”¹ Life-sustaining treatment (LST) orders are documents of patient preference regarding interventions such as mechanical ventilation, CPR, dialysis, artificial nutrition and hydration; and are considered part of an Advance Care Plan. From a bioethics perspective, these orders promote patient autonomy by formalizing patient preferences around LSTs in the medical record, particularly for when a patient lacks capacity and/or cannot make decisions on their own.² Through consensus building, our team defined vague, inactionable, or incorrectly written LST orders as Potentially Problematic Orders (PPO). PPOs which cause confusion at the bedside or lack clarity around preferences can pose serious risks to patient safety and autonomy by exposing patients to inappropriate initiation or withholding of LSTs. Improving the quality of LST orders and reducing the number of PPOs is a crucial element for safe and effective implementation of Directive 1004.03(1).

Aim

The aim of this quality improvement project was to reduce the number of PPOs in a VA Community-Based Outpatient Clinic (CBOC) by 75% by the end of 2025.

Methods

The Model for Improvement was used for this quality improvement project.³ One year of LST orders were audited and thematic analysis identified 7 subtypes of PPO. Some PPO subtypes included clerical errors, potentially mismatched order sets (e.g., Comfort Care order with no associated DNR order) ill-defined or vague orders, and clinically impractical orders (eg, “consents to one shock during CPR”). We defined vague, ill-defined, and impractical orders as the most ethically and clinically challenging given the possibility of confusion or error at the bedside. Initial data were collected from October 2022 to October 2023, and post-intervention data were collected from February 2024 to September 2024. Interventions included process changes (clarifying role responsibility, documentation practices, patient education), regular auditing and feedback from a supervisor, and staff education.

Results

Post-intervention analysis demonstrated that the proportion of PPO remained the same, with 25% of patient charts containing at least one PPO. However, the distribution of PPO in the most ethically and clinically problematic categories (vague, ill-defined, and impractical orders) decreased from 14.7% to <1%.

Conclusions

We successfully reduced the most ethically and clinically challenging PPOs to <1% in our initial intervention. To reduce the overall proportion of PPO, we plan enhancements in process automations, additional physical educational resources, and minor changes in audit criteria. Future projects will aim to address the remaining PPO error types and prepare this project for implementation in other CBOCs.

Background

Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.

Methods

We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.

Results

Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.

Conclusions

We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.

Background

Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.

Methods

We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.

Results

Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.

Conclusions

We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.

Background

Studies show that early referral to Specialty Palliative Care (SPC) can improve patient- reported outcomes among Veterans with cancer; quality metrics include referral within 8 weeks of an advanced cancer diagnosis. In this study, we explored timeliness of specialty referrals and compared various factors.

Methods

We identified our cohort using Department of Veterans Affairs (VA) Corporate Data Warehouse (CDW). Eligibility criteria included active or history of cancer—using a peer-reviewed, in-house list of ICD-9 and ICD-10 codes—between 2013-2023. We stratified our cohort of Veterans using factors including cancer stage, rurality, and care assessment needs (CAN) scores. We performed survival analyses to look at time to SPC from initial diagnosis and peak CAN score. Predictors of utilization were evaluated using multinomial regression and Cox proportional hazards models through R.

Results

Using CDW’s oncology domain, we identified 475,775 Veterans. 28% received SPC. Most received it near the end of their life as evidenced by the mortality rates (79.5%) in the early period following SPC consultation. Median time to SPC was 515 days. There was a significant difference in utilization rates between urban and rural Veterans (Wilcoxon W-statistic = 2.31E+10, p < 0.001). Peak CAN scores ranged from 0 to 0.81, median peak of 0.057 and interquartile range of 0.1. Multinomial regression model indicated statistically significant associations of advanced cancer (Stages 3 and 4) with timing of SPC. Stage 4 cancer showed the strongest association with receipt of palliative care within 60 days of initial diagnosis (OR 4.8, 95% CI: 4.69-4.93, p < 0.001), suggesting higher stage disease increases the likelihood of palliative care referral and accelerates the timing of these referrals.

Conclusions

We found Veterans received SPC from a broad range of peak CAN scores (0 to 0.81), suggesting that absolute CAN scores may not be clinically actionable indicators but perhaps indicative of changes in condition warranting referral. Stage IV cancer at diagnosis was associated with early SPC. The significant differences in utilization rates between urban and rural patients highlight potential access barriers that should be addressed.

Purpose/Background

Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.

Methods

A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.

Results

Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.

Implications/Significance

This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.

Purpose/Background

Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.

Methods

A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.

Results

Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.

Implications/Significance

This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.

Purpose/Background

Palliative care referrals are recommended for patients with advanced or metastatic cancer to enhance patient and caregiver outcomes. However, challenges like delays or lack of referrals hinder implementation. This study identified rate of palliative care referrals at James A. Haley Veterans’ Hospital in Tampa, Florida; explored potential barriers to referral, and implemented targeted interventions to improve referral rates and patient outcomes.

Methods

A Plan-Do-Study-Act (PDSA) cycle was used for this quality improvement project. Data was collected from electronic medical record, focusing on consult dates, patient demographics, and reasons for seeking palliative care. Pre-intervention surveys were administered to Hematology-Oncology fellows at the institution to identify barriers to referral. Following a root cause analysis, a targeted intervention was developed, focusing on educational programs for fellows for streamlined referral processes.

Results

Before the intervention, monthly average for palliative care consults was low (3-8, typically 5). Pre-intervention surveys revealed that fellows lacked knowledge about palliative care resources, which contributed to low referral rates. To address this issue, a didactic session led by a palliative care specialist was conducted for the fellows in the fellowship program. This session provided education on the role of palliative care, how to initiate referrals, and the benefits of early involvement of palliative care teams in oncology patient management. Post-intervention surveys showed a marked improvement in fellows’ confidence regarding identification of patients suitable for palliative care. Following the session, 90% (9/10) of fellows reported being “very likely” to consult palliative care more often and 80% (8/10) indicated they were “very likely” to initiate palliative care discussions earlier in patient’s disease trajectory, with the remaining 20% (2/10) reporting a neutral stance. All fellows (100%) agreed that earlier palliative care involvement improves patient outcomes.

Implications/Significance

This PDSA cycle demonstrated that targeted education for fellows can increase awareness of palliative care resources and improve referral rates. Future work will focus on reassessing usage of palliative care consults post-intervention to evaluate effects of fellows’ education of appropriate palliative care consultation, make necessary interventions based on data and further evaluate the long-term impact on patient outcomes at James A. Haley Veterans’ Hospital.

Background

Early palliative care (PC) has been shown to improve cancer patients’ quality of life, symptom control, disease knowledge, psychological and spiritual health, end-of-life care, and survival, as well as reduce hospital admissions and emergency visits. The American Society of Clinical Oncology and the World Health Organization recommend that every patient with advanced cancer should be treated by a multidisciplinary palliative care team early in the course of the disease and in conjunction with anticancer treatment. Despite the documented benefits and the recommendations, early PC is still not often offered in clinical practice.

Results

Through a retrospective data review from July, August, and September 2023, a low percentage of early PC referrals were identified among Veterans with pancreatic, head and neck, and stage IV lung cancer in the Infusion Clinic. Only 48.5% had an early PC referral, which is a referral made within 8 weeks from the time of diagnosis and 3 or more months before death. A survey conducted among oncology providers suggests that the lack of provider knowledge about the scope of PC, the lack of set criteria/protocol to initiate a referral, and provider discomfort in referring patients were thought to hinder early referrals or cause late or/lack of referrals.

Discussion

This quality improvement project aimed to increase the early PC referral rate among advanced cancer patients in the infusion clinic to improve patient outcomes. An early PC referral toolkit was implemented consisting of (a) provider education about the scope of PC, (b) a script to help providers introduce PC as part of the comprehensive care team, (c) a PC brochure for reference, and (d) an Evidence-Based Five-item Screening Checklist to identify patients needing PC.

Conclusions

Nine months of data monitoring and analysis post-implementation revealed a 100% (n=12) early PC referral rate, and 80% (n=12) of providers reported feeling comfortable referring their patients. The project fostered a culture of comprehensive cancer care while empowering providers to make early referrals that improve patients’ multidimensional outcomes. The toolkit remains available to oncology providers and is shared upon request with other VA centers, as it is replicable in most VA settings that offer PC.

Background

Early palliative care (PC) has been shown to improve cancer patients’ quality of life, symptom control, disease knowledge, psychological and spiritual health, end-of-life care, and survival, as well as reduce hospital admissions and emergency visits. The American Society of Clinical Oncology and the World Health Organization recommend that every patient with advanced cancer should be treated by a multidisciplinary palliative care team early in the course of the disease and in conjunction with anticancer treatment. Despite the documented benefits and the recommendations, early PC is still not often offered in clinical practice.

Results

Through a retrospective data review from July, August, and September 2023, a low percentage of early PC referrals were identified among Veterans with pancreatic, head and neck, and stage IV lung cancer in the Infusion Clinic. Only 48.5% had an early PC referral, which is a referral made within 8 weeks from the time of diagnosis and 3 or more months before death. A survey conducted among oncology providers suggests that the lack of provider knowledge about the scope of PC, the lack of set criteria/protocol to initiate a referral, and provider discomfort in referring patients were thought to hinder early referrals or cause late or/lack of referrals.

Discussion

This quality improvement project aimed to increase the early PC referral rate among advanced cancer patients in the infusion clinic to improve patient outcomes. An early PC referral toolkit was implemented consisting of (a) provider education about the scope of PC, (b) a script to help providers introduce PC as part of the comprehensive care team, (c) a PC brochure for reference, and (d) an Evidence-Based Five-item Screening Checklist to identify patients needing PC.

Conclusions

Nine months of data monitoring and analysis post-implementation revealed a 100% (n=12) early PC referral rate, and 80% (n=12) of providers reported feeling comfortable referring their patients. The project fostered a culture of comprehensive cancer care while empowering providers to make early referrals that improve patients’ multidimensional outcomes. The toolkit remains available to oncology providers and is shared upon request with other VA centers, as it is replicable in most VA settings that offer PC.

Background

Early palliative care (PC) has been shown to improve cancer patients’ quality of life, symptom control, disease knowledge, psychological and spiritual health, end-of-life care, and survival, as well as reduce hospital admissions and emergency visits. The American Society of Clinical Oncology and the World Health Organization recommend that every patient with advanced cancer should be treated by a multidisciplinary palliative care team early in the course of the disease and in conjunction with anticancer treatment. Despite the documented benefits and the recommendations, early PC is still not often offered in clinical practice.

Results

Through a retrospective data review from July, August, and September 2023, a low percentage of early PC referrals were identified among Veterans with pancreatic, head and neck, and stage IV lung cancer in the Infusion Clinic. Only 48.5% had an early PC referral, which is a referral made within 8 weeks from the time of diagnosis and 3 or more months before death. A survey conducted among oncology providers suggests that the lack of provider knowledge about the scope of PC, the lack of set criteria/protocol to initiate a referral, and provider discomfort in referring patients were thought to hinder early referrals or cause late or/lack of referrals.

Discussion

This quality improvement project aimed to increase the early PC referral rate among advanced cancer patients in the infusion clinic to improve patient outcomes. An early PC referral toolkit was implemented consisting of (a) provider education about the scope of PC, (b) a script to help providers introduce PC as part of the comprehensive care team, (c) a PC brochure for reference, and (d) an Evidence-Based Five-item Screening Checklist to identify patients needing PC.

Conclusions

Nine months of data monitoring and analysis post-implementation revealed a 100% (n=12) early PC referral rate, and 80% (n=12) of providers reported feeling comfortable referring their patients. The project fostered a culture of comprehensive cancer care while empowering providers to make early referrals that improve patients’ multidimensional outcomes. The toolkit remains available to oncology providers and is shared upon request with other VA centers, as it is replicable in most VA settings that offer PC.

Background

The goal of hospice and palliative care is to provide comfort and dignity for individuals by honoring autonomy and patient preferences at endof- life. These standards can be difficult to balance when concerns around decision-making capacity and safety arise. The Veteran’s Health Administration has numerous resources to support interdisciplinary teams. We present a case study highlighting conflict between these ethical principles

Case Presentation

Veteran is a 66-year-old male with metastatic neuroendocrine cancer to brain and co-occurring polysubstance use disorder. Veteran agreed to VA inpatient hospice due to functional decline and limited social support at home. Day passes were initially allowed but later restricted due to multiple safety concerns surrounding mental status, smoking on campus and unauthorized passes. Behaviors escalated and veteran removed secure care monitor, left the unit without notifying staff, and erratically drove off campus prompting local police involvement.

Discussion

Patient demonstrated a preference to attend Alcoholics Anonymous meetings in person, to use his vehicle and to live at home. Given the complexity of this case, we turned to the National Center for Ethics in Health Care for input. This included guidance about legal and ethical limitations and recommendations for ongoing assessment and documentation of decisionmaking capacity and use of a surrogate.

Results

As veteran’s mental status declined, veteran no longer demonstrated the capacity to understand the safety risks of driving or living at home. His sister served as his health care agent and was opposed to home discharge due to safety concerns. The interdisciplinary team attempted to focus on respecting veteran’s dignity and autonomy as veteran approached end-oflife. Conflicts arose between the ethical pillars of autonomy, non-maleficence, community safety, and legal risks to institution. Lessons learned included the importance of daily safety huddles, ensuring secure care system functions properly, performing ongoing capacity assessments, and improving pre-admission screening.

Conclusions

Balancing autonomy and patient prefpreferences in VA hospice care demands continuous evaluation and adjustment of care plans. Legal and institutional ethics can be consulted to assist providers in formulating optimal plans and to guide use of ethical pillars within the VA framework.

Background

The goal of hospice and palliative care is to provide comfort and dignity for individuals by honoring autonomy and patient preferences at endof- life. These standards can be difficult to balance when concerns around decision-making capacity and safety arise. The Veteran’s Health Administration has numerous resources to support interdisciplinary teams. We present a case study highlighting conflict between these ethical principles

Case Presentation

Veteran is a 66-year-old male with metastatic neuroendocrine cancer to brain and co-occurring polysubstance use disorder. Veteran agreed to VA inpatient hospice due to functional decline and limited social support at home. Day passes were initially allowed but later restricted due to multiple safety concerns surrounding mental status, smoking on campus and unauthorized passes. Behaviors escalated and veteran removed secure care monitor, left the unit without notifying staff, and erratically drove off campus prompting local police involvement.

Discussion

Patient demonstrated a preference to attend Alcoholics Anonymous meetings in person, to use his vehicle and to live at home. Given the complexity of this case, we turned to the National Center for Ethics in Health Care for input. This included guidance about legal and ethical limitations and recommendations for ongoing assessment and documentation of decisionmaking capacity and use of a surrogate.

Results

As veteran’s mental status declined, veteran no longer demonstrated the capacity to understand the safety risks of driving or living at home. His sister served as his health care agent and was opposed to home discharge due to safety concerns. The interdisciplinary team attempted to focus on respecting veteran’s dignity and autonomy as veteran approached end-oflife. Conflicts arose between the ethical pillars of autonomy, non-maleficence, community safety, and legal risks to institution. Lessons learned included the importance of daily safety huddles, ensuring secure care system functions properly, performing ongoing capacity assessments, and improving pre-admission screening.

Conclusions

Balancing autonomy and patient prefpreferences in VA hospice care demands continuous evaluation and adjustment of care plans. Legal and institutional ethics can be consulted to assist providers in formulating optimal plans and to guide use of ethical pillars within the VA framework.

Background

The goal of hospice and palliative care is to provide comfort and dignity for individuals by honoring autonomy and patient preferences at endof- life. These standards can be difficult to balance when concerns around decision-making capacity and safety arise. The Veteran’s Health Administration has numerous resources to support interdisciplinary teams. We present a case study highlighting conflict between these ethical principles

Case Presentation

Veteran is a 66-year-old male with metastatic neuroendocrine cancer to brain and co-occurring polysubstance use disorder. Veteran agreed to VA inpatient hospice due to functional decline and limited social support at home. Day passes were initially allowed but later restricted due to multiple safety concerns surrounding mental status, smoking on campus and unauthorized passes. Behaviors escalated and veteran removed secure care monitor, left the unit without notifying staff, and erratically drove off campus prompting local police involvement.

Discussion

Patient demonstrated a preference to attend Alcoholics Anonymous meetings in person, to use his vehicle and to live at home. Given the complexity of this case, we turned to the National Center for Ethics in Health Care for input. This included guidance about legal and ethical limitations and recommendations for ongoing assessment and documentation of decisionmaking capacity and use of a surrogate.

Results

As veteran’s mental status declined, veteran no longer demonstrated the capacity to understand the safety risks of driving or living at home. His sister served as his health care agent and was opposed to home discharge due to safety concerns. The interdisciplinary team attempted to focus on respecting veteran’s dignity and autonomy as veteran approached end-oflife. Conflicts arose between the ethical pillars of autonomy, non-maleficence, community safety, and legal risks to institution. Lessons learned included the importance of daily safety huddles, ensuring secure care system functions properly, performing ongoing capacity assessments, and improving pre-admission screening.

Conclusions

Balancing autonomy and patient prefpreferences in VA hospice care demands continuous evaluation and adjustment of care plans. Legal and institutional ethics can be consulted to assist providers in formulating optimal plans and to guide use of ethical pillars within the VA framework.