JOURNAL OF PALLIATIVE MEDICINE Volume 17, Number 11, 2014 ª Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2014.0289
Letters to the Editor
A Reflection on ‘‘Death as Harm’’ Deborah Way, MD, CMD, FAAHPM1 and William D. Smucker, MD, CMD 2
Dear Editor: We read with interest Dr. MacKintosh’s letter about death as harm.1 Our response is meant to reframe ‘harm’ associated with anticipated death. For instance, harm may come to patients with advanced disease when they are not invited into well-timed discussions about prognosis, unmet needs, and wishes for future care. We initially assumed that the phrase ‘‘Death as harm’’ referenced the common ‘error’ of omission of appropriate palliative care. This ‘error’ can result in many different harms, including care choices that do not improve quality of life or change outcomes, avoidance or delay of discussions about goals of care, lack of assessment of spiritual and emotional needs, and lack of appropriate palliative care or referral to hospice. Dr. MacKintosh’s patient had two potentially fatal conditions and a rapid decline. Her relatives arranged transfer to a palliative care unit for end-of-life care. The narrative lacked details about what harm, beyond death, this patient suffered. Dr MacKintosh implies that the harm the patient experienced might fit within the definition of error used in a study by Smucker et al.: A patient safety incident in hospice care is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient, unnecessary harm to a family member.or unnecessary disruption of the natural dying process for a patient with a terminal illness.2
tom management, shared decision making, preparation for death, acknowledgement of spirituality, resolving conflicts, contributing to the well-being of others, and care that affirms the whole person.3 Even the most loving, functional patients and their families may benefit from the expertise provided by a palliative care team. Often the biggest need is preparation—timing a shift from continued investigation and treatment to concentration on aligning treatment with stated goals of care. We submit that another way to think of ‘death as harm’ is when timely discussions and palliative plans do not result in a good death. References
1. MacKintosh D: Death as ‘‘harm’’ when it is an anticipated outcome in palliative care—or anywhere. J Palliat Med 2014;17:502. 2. Smucker DR, Regan S, Elder NC, Gerrety E: Patient safety incidents in home hospice care: The experiences of hospice interdisciplinary team members. J Palliat Med 2014;17: 540–544. 3. Steinhauser KE, Clipp EC, McNeilly M, et al.: In search of a good death: Observations of patients, families, and providers. Ann Intern Med 2000;132:825–832.
We suggest that this patient with cancer and COPD would have been harmed if she had not received palliative care. She may have benefited from an earlier discussion of her prognosis, wishes, and unmet needs. The MacKintosh case narrative implies these discussions had not occurred. Most people desire a good death. This is unique to each person, but common characteristics include pain and symp-
1 2
Address correspondence to: William D. Smucker, MD, CMD Family Medicine Center of Akron Summa Health System Akron, OH 44304 E-mail: [email protected]
Palliative Care Services, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. Family Medicine Center of Akron, Summa Health System, Akron, Ohio.
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Letters to the Editor
A Reflection on ‘‘Death as Harm’’ Deborah Way, MD, CMD, FAAHPM1 and William D. Smucker, MD, CMD 2
Dear Editor: We read with interest Dr. MacKintosh’s letter about death as harm.1 Our response is meant to reframe ‘harm’ associated with anticipated death. For instance, harm may come to patients with advanced disease when they are not invited into well-timed discussions about prognosis, unmet needs, and wishes for future care. We initially assumed that the phrase ‘‘Death as harm’’ referenced the common ‘error’ of omission of appropriate palliative care. This ‘error’ can result in many different harms, including care choices that do not improve quality of life or change outcomes, avoidance or delay of discussions about goals of care, lack of assessment of spiritual and emotional needs, and lack of appropriate palliative care or referral to hospice. Dr. MacKintosh’s patient had two potentially fatal conditions and a rapid decline. Her relatives arranged transfer to a palliative care unit for end-of-life care. The narrative lacked details about what harm, beyond death, this patient suffered. Dr MacKintosh implies that the harm the patient experienced might fit within the definition of error used in a study by Smucker et al.: A patient safety incident in hospice care is an event or circumstance that could have resulted, or did result, in unnecessary harm to a patient, unnecessary harm to a family member.or unnecessary disruption of the natural dying process for a patient with a terminal illness.2
tom management, shared decision making, preparation for death, acknowledgement of spirituality, resolving conflicts, contributing to the well-being of others, and care that affirms the whole person.3 Even the most loving, functional patients and their families may benefit from the expertise provided by a palliative care team. Often the biggest need is preparation—timing a shift from continued investigation and treatment to concentration on aligning treatment with stated goals of care. We submit that another way to think of ‘death as harm’ is when timely discussions and palliative plans do not result in a good death. References
1. MacKintosh D: Death as ‘‘harm’’ when it is an anticipated outcome in palliative care—or anywhere. J Palliat Med 2014;17:502. 2. Smucker DR, Regan S, Elder NC, Gerrety E: Patient safety incidents in home hospice care: The experiences of hospice interdisciplinary team members. J Palliat Med 2014;17: 540–544. 3. Steinhauser KE, Clipp EC, McNeilly M, et al.: In search of a good death: Observations of patients, families, and providers. Ann Intern Med 2000;132:825–832.
We suggest that this patient with cancer and COPD would have been harmed if she had not received palliative care. She may have benefited from an earlier discussion of her prognosis, wishes, and unmet needs. The MacKintosh case narrative implies these discussions had not occurred. Most people desire a good death. This is unique to each person, but common characteristics include pain and symp-
1 2
Address correspondence to: William D. Smucker, MD, CMD Family Medicine Center of Akron Summa Health System Akron, OH 44304 E-mail: [email protected]
Palliative Care Services, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania. Family Medicine Center of Akron, Summa Health System, Akron, Ohio.
1196
