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Year:: 2019
Contributor:: Dressler, Gabrielle (Author); Garrett, Sarah B (Author); Hunt, Lauren J (Author); Thompson, Nicole (Author); Mahoney, Katherine (Author); Sudore, Rebecca (Author); Ritchie, Christine S (Author); Harrison, Krista L (Author); Brown University. Alpert Medical School. Scholarly Concentration Program. Non-Scholarly Concentrator (research program)
Subject:: Hospice care; Terminal care; Bioethics; Palliative treatment

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Abstract:: Background: Hospice organizations increasingly admit patients who are full code and/or desire other “aggressive” treatments, such as chemotherapy, dialysis, and total parenteral nutrition, while on hospice. Yet remarkably little is known about how hospice clinicians engage with these types of requests. Methods: We conducted semi-structured in-depth interviews with employees at four non-profit hospices in the US. Data were coded in Atlas.ti and analyzed by an interdisciplinary team using the constant comparative method and informed by theories of bioethics. Results: Of 51 participants, 61% of participants were clinicians (23 nurses, 21 social workers, 7 physicians and 2 chaplains; two had multiple degrees/disciplines) 25% executive leaders, and 14% administrative staff. Participants described challenges encountered when discussing EOL care preferences, including patient/family preferences for remaining full code or for what participants termed “aggressive” treatment. Specific strategies to engage with such patient/family preferences included clarifying misconceptions about DNRs, educating about likely outcomes of aggressive treatment, and employing graphic language (e.g., “break their ribs). Participant narratives evinced a tension between three central tenets of the hospice philosophy: relieving suffering, avoiding harm, and respecting patient/family choices. Participants engaged with this ethical dilemma in three ways: accepting patient/family preferences for aggressive treatment or remaining full code, attempting to shift preferences, and holding out hope that these preferences would change. Conclusions: Patient/family preferences for “aggressive” treatment or remaining full code contribute to an ethical dilemma that complicates already difficult end-of-life conversations. Communicating effectively about such preferences remains challenging for hospice clinicians and we observed opportunities for improvement. Future work should explore how hospice organizations can better support clinicians in these discussions.
Notes:: Scholarly concentration: Non-Scholarly Concentrator

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Dressler, Gabrielle, Garrett, Sarah B., Hunt, Lauren J., et al., "“Too intimate, too close, too hot:” Discussing Death, “Aggressive” Treatment, and Being Full Code in Hospice" (2019). Warren Alpert Medical School Academic Symposium. Brown Digital Repository. Brown University Library. https://repository.library.brown.edu/studio/item/bdr:957181/

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Warren Alpert Medical School Academic Symposium

The Warren Alpert Medical School Academic Symposium is an annual event at Warren Alpert Medical School of Brown University that provides Year II medical students a venue to present their summer research in a poster format. Participation in the Symposium …
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“Too intimate, too close, too hot:” Discussing Death, “Aggressive” Treatment, and Being Full Code in Hospice