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A Family’s Decision and Questions They Ask: Are Opioids Necessary and Do They Hastened Death for Patient Receiving Hospice Care? a Literature Review

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A Family’s Decision and Questions They Ask: Are Opioids Necessary and Do They Hastened Death

for Patient Receiving Hospice Care? A Literature Review

Damonica Gomez-Samuel

Eastern Michigan University


The word hospice may bring stress and a feeling of failure or giving up. To some hospice means death and these grieving emotions can cause a cascade of confusion. As stated by Baumrucker (2015) “hospice is often misunderstood and many associate hospices with dying.” (p.706). A negative perspective continues about hospice despite all the well-known benefits. As told by Baumrucker (2015) “hospice is an appropriate option that strives to assist the patient in maintaining as much quality of life as possible.” (p.706). The promotion of quality of life is the main feature of most hospices.

To qualify for hospice there are many factors to be considered. Eligibility is based on a standard tool set by Medicare. Jones (2013) “the need to meet specific eligibility criteria for hospice admission requires careful consideration. Criteria mandates that a person must have a prognosis of a six-month life expectancy. And must have two physicians certify that this patient is terminally ill” (p.114-115). The social security act provides the statutory requirements for the certificate of terminal illness.” With so much involved with eligibility, it is flabbergasting to consider not signing on to hospice if eligible. Carrion (2011) stated “often an individual’s decision not to enroll at a hospice is predicated on a distrust of conventional medical care, an inability to navigate the medical systems, and the lack of culturally competent providers” (p. 4).

End of life decisions

As stated by Karikari-Martin et al. (2015) “decisions to use hospice and other services at the end of life are complex and not unique” (p. 543) With these facts in mind and heart, families find themselves in a dilemma. A quandary as it were. Patients are transferred back and forth to the hospital as if the ER and ICU is their medical last rights. This routine of treating the chronically and terminally ill has prolonged life for many with unnecessarily. And sometimes the patient has a written advance directive that clearly states what the patient’s wishes are, but it seems to be ignored, and the cycle continues. As said by Karikari-Martin et al. (2015) “most individuals wait too long before enrolling in hospice to take full advantage of the services” (p. 542).

Families continue to transport their loved ones to the emergency department despite multiple surveys suggesting that most people would like to die at home. As stated by Baumrucker (2015) “75%” end up dying in a hospital. Carrion (2011) stated, “as a result of this disparity, older black and Asian patients are more likely to receive high-intensity care at the end of life, including prolonged frequent hospitalizations, admissions to ICU, and are more likely to die in the hospital” (p.1).

When death is probable, a world wind of cascading emotions are sparked. Common reactions may include fear, shock, anger, guilt. Carson et al. (2016) stated “protocol-based informational and emotional support meetings with palliative care specialists did not improve anxiety or depression symptoms among family surrogate decision makers at 3 months” (p.57-58) The ability to decide between hope and despair is tested during this difficult time. For example, the mother of a pending hospice patient began to relate the experience of her late husband that died while under hospice care. She felt that signing on to hospice was the worst thing that her family could ever do, even though her husband’s diagnosis was terminal. He had pain, weakness, lethargy, difficulty breathing and was bedbound. She convinced him not to sign on to hospice that day. Two days the family frantically called the hospice agency, urgently requesting for her dear husband to be signed on immediately. When the nurse arrived at the home, it was already too late, he died.

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The hope for a cure of a terminal illness drive many seek other options besides the obvious, which may not be what the patient wants. Baumrucker (2015) “Some may consider a 10% chance of tumor shrinkage too low to struggle through a therapy, while others may consider a 1% chance enough to clinch to. The final say in accepting or refusing any therapy is always the patient’s” (p.708).  In a case study by Baumrucker (2015) “a 38-year-old female with metastatic cervical cancer. There were extra pelvic metastases on presentation. The oncologist recommended third-line salvage chemotherapy with stating ‘‘there is a chance that this will prolong the patient’s life’’ The patient and family decided to defer hospice admission. She had leukocytosis requiring admission on this regimen and died after an episode of sepsis and respiratory failure requiring intensive care unit” (p.703). In addition, Baumrucker (2015) stated “when discussing choices for potentially ‘‘life-prolonging’’ treatment versus no treatment, the conversation begins to focus on the patient’s desire and definition of quantity and quality of life. The individual and unique circumstance of each patient life is ultimately what drives this decision” (p.706)

Health literacy is considered to be the understanding of information about healthcare and the ability to use this information for care when needed. This fact may help explain what Karikari-Martin (2015) stated “in comparison to whites, treatment decisions for blacks were significantly more likely to be based on the desire to provide all care possible in order to prolong life” (p.542). In addition, Carrion (2011) added “studies indicate that as a result of health disparities throughout the life cycle, older black and Asian patients with advanced cancer are less likely than whites to enroll at a hospice for care” (p.4). And Carrion (2011) stated, “studies have noted an increased use of hospice services among racial/ethnic minorities in the United States however, overall, many racial/ethnic groups continue to underuse these hospice services despite the benefits they offer” (p.2). Some cultures use hospice less. However, Karikari-Martin et al. (2015) stated “the odds of hospice use were more than twice as great for individuals with any cancer diagnosis compared to individuals without a cancer diagnosis” (p.539).

Pain and opioids

The lack of effective treatments for chronic pain has left many elderlies to suffer unnecessarily. One of the questions from Teno et al. (2006) highlights the elderly pain issues and the survey asked “Do you ever have pain or discomfort that prevents you from going to sleep or wakes you from sleeping? With “45.4%” answering yes, they have gone to sleep in pain.” (p.579).  Many elderlies may not share this information with family members. Teno et al. (2006) relates the survey results “for example, one in five persons with pain at night stated that they did not tell the nurse when they had pain that kept them from sleeping.” (p.580) When pain is assessed during the hospice information visit, the family may be surprised to learn that their loved one has pain. Some members may continue to deny that pain is present. In a case study, a hospice patient was bedbound and contracted.  He moaned and yelled out loud when turned in bed. When the discussion of pain management was initiated with the primary care giving, her response was that he did not have pain. The patient was not cognitively able to answer subjective assessment questions about his pain, but objectively he was clearly in pain.  The family denied any treatment and even refused over basic counter pain medications for the patient. Their focus of denial highlights the need for pain education for families, and the use of opioids is considered compassionate pain management.

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