NURS1137 Palliative Care Assignment: Advanced Care Planning and Ethics

This essay provides a comprehensive analysis of a palliative care case study involving Melissa, a 37-year-old woman with stage 4 bowel cancer. The essay explores the ethical and legal rights of patients, particularly focusing on the right to determine the time and place of death. It delves into the significance of advanced care planning (ACP) in palliative care, highlighting its role in respecting patient autonomy and preferences. The discussion encompasses ethical principles like autonomy, beneficence, justice, and non-maleficence, along with relevant legal frameworks. Challenges faced by palliative care professionals in facilitating discussions about death are examined, along with potential solutions to overcome these obstacles, such as sensitive communication strategies. The essay underscores the importance of ACP in ensuring a dignified end-of-life experience for patients and their families, emphasizing the need for open and honest conversations about end-of-life preferences.

Running head: PALLIATIVE CARE
Palliative care
Name of the student:
Name of the University:
Author’s note

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Introduction:
Palliative care is a specialized area of care, where an interdisciplinary care process is
implemented for patients diagnosed with terminal illness. As most patients at end of life lose
their capacity to make decisions, development of advanced care planning (ACP) haS become
important to respect patient’s choice during event of death or incapacity (Fan & Rhee, 2017).
This essay aims to analyse the case study of Melissa, a 37 year old women with stage 4 bowel
cancer 12 months and a developed liver metastases. Taking cues from the health issues faced by
Melissa at end of life, this essay particularly aims to explore the topic of the right to determine
the time and place to die in relation to Melissa. The essay will discuss about the ethical and legal
rights of patient related to determining the time and place for death and explore the challenges
encountered in engaging palliative care patient in such discussions.
Overview of advanced care planning (ACP) and patient’s preferred place of death at end of
life:
ACP is a critical part of palliative which involves using person centred communication
process to facilitate understanding and discussion related to goal and patient’s preference for
future care. The main significance of ACP is that it gives patient the opportunity to exercise their
right to choice of treatment even during end of life. ACP has been associated with compliance
with patient’s preferences and choices related to end of life and improvement in patient
satisfaction level (Walczak et al., 2017). It facilitates health care professional to promote care
that is consistent with patient’s values and preferences. It involves discussion not only regarding
treatment preferences at end of life but also about choices related to place of death. As the likely
timing of death can now be predicted by physicians, it gives them more chances to plan for death

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(Swerissen & Duckett, 2015). Brighton and Bristowe (2016) supports those discussions on end
of life before the end of life is a foundation of good care and such discussion increases
concordance with patient reported goals of care. However, the challenge in palliative care
practice currently is that there are many obstacles to improving the quality of dying because of
limited conversation regarding plan of death (Swerissen & Duckett, 2015).
Melissa is a patient with advanced stage of cancer. She has two children, a 15 year old
son Joshua and a 12 year old daughter, Emma. She has separated from her husband Daniel.
However, they manage shared care of her children. Despite this, following her current illness,
she is worried about her children and ongoing care. Another issue for Melissa is that Daniel’s
parents have estranged from her because of breakdown in relationship with Daniel. Following
several frank conversation with her oncologist and other specialist, she is now aware of her poor
prognosis.. Her preference to engage in ACP suggests the need to take her preference related to
place of death too. Assessing her choices over where her death occurs is significant to provide
good death to her. Arnold, Finucane and Oxenham (2015) gives the evidence regarding the
recording of patient preferred place of death in ACP. The review of ACP decisions related to
place of death also gives the evidence that majority of patients prefer to die at home instead of
hospitals. Even of patient prefer hospital as a choice of death, this depends on the patient’s
familiarity with the hospice environment and its staff (Pollock, 2015). Although taking patient
preference place of death choice is ethically challenging, however not taking such preference
also violates dignity and respect of patient. For example, people who do not give any information
about a preferred place of death are more likely to be ambivalent about dying and they are more
likely to die in hospitals. However, evidence based research suggest that patient can be open to

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receiving such palliative care services if staffs handle such communication sensitively (Arnold,
Finucane & Oxenham, 2015). Hence, similar arrangement can be made for Melissa too.
Ethical and legal values related to the right to determine the time and place to diet
As Melissa has been diagnosed with stage 4 bowel cancer last year, her death is very
much predictable as stage IV colon cancer patients are very likely to die before five years.
According to NCCI (2019), survival rate for metastatic cancers at one year of diagnosis is 49%.
Hence, this is the right time to start discussions regarding her death and take steps to ensure she
has good death. Accurate discussion regarding timing and place of death is relevant with the
ethical values shaping end-of-life care decisions. Key ethical principles surrounding end of life
or palliative care includes autonomy, beneficence, justice and non-maleficence (NHMRC, 2011).
Autonomy is the right to patient’s determination and giving patient the authority to take
decisions on their own even when they lose decision making capacity (Wilkinson, Truog &
Savulescu, 2016). This right of patient is fulfilled through ACPs. However, violation of this
ethical principle is seen when physicians contact family members instead of patient to discuss
about death and treatments at end of life (Nguyen et al., 2017). Therefore, based on ethical
values of patient autonomy, involving Melissa in discussion related to death and preferred place
of dying is important.
The ethical rights of beneficence mandate doing what is good or beneficial for the
patient. Hence, discussion related to dying is also part of beneficence activity as it preserve’s
patient’s best interest related to achievement of preferred place of death. ACP is an approach to
fulfil the same wish of patient. The beneficence associated with this activity is that it facilitates

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management of a good death for palliative care patient. The legislations rated to the Consent to
Medical Treatment and Decisions Act 2016 also makes it mandatory for health care
professionals to preserve individual right to decision making at the end of life. The Act mandates
health practitioners to care for people who do have decision making capacity and provide clear
environment for patient to talk about death and dying (State Government of Victoria, 2019).
However, despite legal obligation, the choice over place of death is debatable due to diverse
meaning associated with the choice of dying at home or hospital. For example, situational,
interpersonal and organizational factor may underpin the preferences about the place of death
(Russell, 2017). By having honest and open conversation with Melissa related to the timing and
place of dying, the ethical principle of justice and fidelity is addressed too. This is said because
by having such discussion, truthfulness and fairness during palliative care delivery is maintained.
Challenges associated with discussions related to death
Although discussion related to time and place of death respect patient autonomy even
during death, however actual implementation of such discussion is a challenging task for
palliative care professional. Palliative care professionals mostly avoid such discussions because
of it psychological effect on patient. Many fear to approach patients for such discussion because
of prognostic challenges, fear of causing distress to patient and being unprepared for discussions
(Nguyen et al., 2017). As reported by Brighton and Bristowe (2016), the key reason for staffs to
avoid such discussion is their confusion regarding the linguistic and stylistics features that can be
preferred by patient. The ideal way for death related communication is to show empathy instead
of pity. However, too much phrasing can lead to patient and family distress and indirect phrasing
can lead to miscommunication. Hence, lack of confidence on sensitive end of life related

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communication is a major drawback that impedes palliative care staffs to actively take patient’s
preferences related to place of death.
In context of Melissa, discussing about timing and place of death is paramount as she has
two children and there is a possibility that she may want to be surrounded by her family during
that time. Discussion related to timing is crucial to provide dignified death to patient and avoid
overuse of invasive treatments. This may be influenced by cultural values of patient too. For
example, Kennedy (2016) reveals that based on cultural and religions factors, individual patient’s
interpretation about dying with dignity may differ. When the palliative care staffs and nurse will
proceed with the decision to have a conversation with her regarding her timing of death, many
challenges can be encountered for them too. There may be conflicting opinions or hesitancy in
starting the conversation. This is said based on several evidence regarding challenges faced by
palliative care staffs. Hold (2017) opines that major ethical dilemma facing nurses is not being
able to actualize a good death for patients. Frustration has been voiced by nurses because of
unsuccessful negotiations related to end of life decisions among family members. In addition,
Carr and Luth (2017) gives the evidence that there are concerns regarding the effectiveness of
ACP tools. However, health care professionals must be made aware about the benefits associated
with a successful completion of ACP. This involves reducing use of invasive treatments,
increasing sense of decision making control and facilitating the likelihood of dying at home
instead of hospitals.
Solution to facilitate discussion related to timing and place of death:
ACP related to timing and place of death can be a very protective tool for Melissa to
fulfil her cultural and personal values related to dying. To ensure that such communication is

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started with Melissa in a sensible and transparent manner without causing her any distress, it is
necessary to handle such communication very sensitively. This is because it will offer choices to
patient and staff to express their choice without causing distress (Arnold, Finucane & Oxenham,
2015). The oncology staffs has already discussed about poor prognosis of Melissa. They can now
openly explain to her that as part of ethical obligations, taking her preference regarding place of
death is important. She can be made aware about legal legislations in Australia that givers her the
right to exercise her choice. Such form of professional discussion with evidence regarding
professional obligation can help Melissa understand the benefits for her in exercising her choice.
Such type of sensible communication will empower her to select appropriate place of death
instead of being depressed about it.
In the context of Melissa, she is not going to die very soon. However, still there is a need
to have meaningful conversation related to preferred place of death. This is because similar
conversation cannot take place when her progresses and affects her communication related
capabilities. Initiating such conversation will also reduce any regrets for her family members as
seen for most families who regret about missing the opportunities to heart patient after the
patient die (Clark, 2017). The review of evidence regarding communication strategies used by
experienced doctors and palliative care can also help to find solution to start difficult
conversation related to death and dying. According to Pino et al. (2016), instead of directly
asking patient about dying, the end of life conversation can begin by responding to patient’s cues
and including talk about death after elaboration of something. For example, elaboration
solicitation during conversation with patient can be initiated by asking questions like ‘Do you
feel anxious about things Melissa?’ and ‘You know that means, people can then die’. With such
kind of conversation, direct confrontation of death is avoided, yet patients are introduced to the

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fact about dying and giving their choice related to place of death. Hence, such communication
strategy can enable palliative care staffs to enable patients to bring up the topic of dying
themselves and recording preferred place of death accordingly.
Another solution to successful record Melissa’s preference related to place of dying is to
ensure that discussions are implemented considering the context and preparedness of patient for
such discussion. Optimal time to discussion must be identified to avoid contradiction with
supportive nature of palliative care and avoid staff’s fear of being perceived as uncaring or rude
by patients. This consideration can help to avoid initiating the discussion too early (Fields,
Finucane & Oxenham, 2013). Hence, overall it can be concluded that having a sensitive and
timed discussion related to preferred place of death is crucial to prevent adverse outcomes and
achieve psychological benefits for patient. For staffs that lack the skills to engage in successful
end of life discussion, such discussions in palliative care of Australia can be recorded as a form
of training resource for new palliative care staffs.
The essay explored the topic of discussions related to timing and place of death
considering the case scenario of Melissa, a patient with advanced metastatic cancer. The essay
summarized about the benefits of preferred place of death discussion in ACP, the ethical and
legal values associated with the discussion, the challenges faced by palliative care professional in
taking such preference from patient and the solution to successfully initiate dying related
conclusion. The review of the communication strategies suggest that use of elicitation strategy
along with timed and sensitivity conversation is the solution to addressing obstacles in engaging
in dying related discussions.

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