Decision Making at the End of Life

Abstract

Palliative care is becoming an increasingly accepted approach to care when cure is no longer possible. Decision making during the palliative phase of any illness call be complex, involving integration of knowledge, legal & ethical considerations, & excellent Communication skills for healthcare professionals, patients and.. where appropriate, their family/carers. This decision making process may become even more challenging as the focus of care changes from uncertainty in terms of survival or time to progression of disease to the often highly charged emotional terminal stage of the illness. Patient participation is increasingly purported as a goal in end of life care (Clover et al 2004), and research suggests that most patients prefer a collaborative role in decision making (Pattison 2004). However there is a paucity of information about how those nearing the end of life can actively engage with healthcare professionals & family members to achieve this in such diverse areas as personal care (Clarke & Seymour 1999); symptom management; hydration & nutrition; advance directives (Scanlon 2003); compliance with medical advice; and place of end of life care (McCall & Rice 2004). The patient's right to self-determination is evidenced in the increasing use and possible questionable legality of advance directives, both written & documented oral statements, and in the ongoing current debate regarding physician-assisted Suicide (Scanlon 2003). Traditional decision making roles are changing and the paternalistic medical model, which has previously led much end of life care, is having to be modified, challenging professional caregivers to help the decision making process to be more collaborative. This chapter aims to explore the psychology of decision making in end-of-life care where competency to make decisions may be threatened by changes in cognitive ability due to advancing disease, the unique psychosocial stressors related to terminal illness, or altered judgement related to the use of high dose drugs in symptom management.