Policy Paper on End-of-Life Issues in the United States - Coursework Example

Policy Paper on End-of-life Issues in the United s Policy Paper on End-of-life Issues in the United s Introduction: The Social Problem Terri Schiavo collapsed on February 25, 1990, never to regain her consciousness (Montero, 2011). She died fifteen years later on March 31, 2005 in a Florida hospice. Terri Schiavo’s death was preceded by a heated debate and a protracted legal battle. The debate elicited passionate reactions from the general public, government officials and the professionals who deal with end-of-life matters – physicians, nurses and social workers. The legal battle, on the other hand, pitted Terri’s husband, Michael Schiavo on the one hand against her mother and siblings. Terri’s husband pushed for her feeding tube to be removed and, in so doing, her life be terminated. On their part, Terri’s mother and siblings advocated continued medical treatment for her. In the end, Michael Schiavo won the case. In many respects, Terri’s case was one morality versus legality: her husband felt that he had the legal responsibility and right to “assist” his wife to die. By contrast, Terri’s mother and siblings felt obliged to preserve her life until her natural death. Issues of end-of-life are investable in the career of the social worker(Montero, 2011). This paper examines the United States’ policy on end-of-life issues with the view of proposing alternatives. Political Perspectives “Death panel” is a political term that has its roots in the 2009 debate about the then proposed health care legislation that was aimed at covering uninsured Americans(Peppercorn , Smith , & Helft, 2011). It was Sarah Palin, the former Republican Governor of Alaska who coined the term when she alleged that the proposed law would create a “death panel” comprising bureaucrats that would determine whether some Americans, such as the elderly, were fit for medical care. Through her spokesperson, Palin cited Section 1233 of the then Patient Protection and Affordable Care Bill (now PPACA). The section would have paid physicians for offering voluntary counseling to patients on Medicare about end-of-life options, advance directives and living wills. Democrats dismissed the claim as baseless. However, Palins statement seems to have had some influence on the final PPACA. The rather contentious provision to pay physicians for providing end-of-life options advice was struck out(Peppercorn, Smith, & Helft, 2011). In its 2011 statement, the American Society of Clinical Oncology regretted the politicization of the issue(Peppercorn, Smith, & Helft, 2011). Norms, Values and Attitudes Euthanasia In 1947, five in ten Americans supported a terminally ill patient’s right to terminate their life(Montero, 2011). Beginning 1977, public support for voluntary active euthanasia (VAE) grew, with six in ten Americans supporting it. Come 1991, seven in ten Americans supported VAE. By 2005, 75% of Americans supported euthanasia, though that figure dropped to 70% in 2007. Physician-Assisted Suicide (PAS) Between 2003 and 2006, only 54% of Christian Americans supported PAS, compared to 84% of Americans with no religious affiliations(Montero, 2011). Besides religion, the second sharpest division, as far as the support for PAS is concerned, was reported between black and white Americans. Six in ten white Americans supported PAS, compared to four in ten blacks. Moral Acceptability of PAS Between 2001 and 2011, Americans’ moral acceptance of PAS remained fairly stable (Montero, 2011). The lowest support was registered in 2003 and 2011 at 45% while the highest support of 53% was recorded in 2004. The support was regardless of whether or not participants thought PAS should be legalized. Public attitudes toward the Terri Schiavo Case, 2006-2007 When asked about the move to remove Schiavo’s feeding tube, 52% of Americans supported the move(Montero, 2011). When asked about Congress’ involvement in the case, the majority of Americans disapproved of it; only twenty percent of Americans supported the move. By contrast, significantly more Americans (33%) approved of the manner in which President George W. Bush handled the case. History of Policy on End-of-life Issues Controversy over end-of-life decisions such as euthanasia (popularly known as “mercy killing”) and physician-aided suicide (PAS) has persisted in the United States since the beginning of the twentieth century, but became more heated in the last decade of the twentieth century (Altilio & Otis-Green , 2011). The federal Patient Self-Determination Act (PSDA) came into force in 1990. The Act required all Medicare participating health facilities to furnish their patients with legal documents (also known as the advance directive) through which the patients would express their end-of-life care decisions(Montero, 2011). The main goal of advance directives is to empower patients gain control over the life-prolonging treatment given to them(Giovanni, 2012). Current health policy often fails patients in this area as families can override patients’ decisions on the basis that they were not well-informed or have been overtaken by time and events(Giovanni, 2012). Also, there could be delays in producing the documents signed by the patient or, if produced, the documents may not be executed. While it was well-intended, PSDA perpetuated confusion and led to near-voluntary, sporadic completion of advance directives by patients and their families(Giovanni, 2012). In 1991, Derek Humphry, a journalist and founder of the Hemlock Society published Final Exit, a resource that gives terminally ill patients elaborate directions on how to commit suicide. In the same year, Jack Kevorkian had his licence to practice medicine revoked by the Michigan Board of Medicine after the physician assisted three patients end their lives(Montero, 2011). Whereas the Patient Self-Determination Act had attempted to provide a national framework for patients to express their end-of-life care wills, it was silent on the pertinent issue of euthanasia. Thus, in a bid to fill the gap, states grappled with the question of euthanasia. In 1994, Oregon voters voted in favor of the Death with Dignity Act. The legislation allowed Oregon residents, under specified circumstances, to request a lethal dose of medication from their physicians. The US Supreme Court upheld the legislation in 2006. By enacting the Act, Oregon had set the stage for other States to follow suite. In 1998, Washington allowed PAS. In 2010, Montana was the third state to legalize PAS. In 2013, Vermont State passed the Patient Choice at the End of Life Act (PCEOLA), becoming the fourth state to legalize PAS(Tucker, 2014). The Act is modeled after Oregon’s, but is less restrictive (Tucker, 2014). Current healthcare policy is silent on end-of-life care and related issues (Giovanni, 2012). The closest the federal government came to developing a policy on end-of-life issues was the enactment of the Patient Protection and Affordable Care Act (PPACA) of 2010. The provisions of the Act that would have addressed end-of-life care were struck out in the early stages of enacting the law on the basis they would have created the “death panel”(Giovanni, 2012). As currently constituted, a minor sections of PPACA touch on end-of-life care, in a very peripheral manner. The result is that the special needs of the terminally ill population in the United States remain poorly addressed by the health care system (Giovanni, 2012). Perhaps, one of the most disturbing facts is that the type of end-of-life care is rarely the one chosen by the patient or their family (Giovanni, 2012). In the absence of a national policy on end-of-life matters, the National Association of Social Workers (NASW) has developed a policy statement to help social workers dealing with terminally ill patients make better end-of-life decisions that are in the interest of patients(Montero, 2011). The policy statement was first adopted in 2003 then improved in 20008. NASW believes that social workers have a critical role in explaining end-of-life options to patients and their families without coercion(Montero, 2011). Self-determination is an important value for social workers. To this end, patients, with the help of their families, should be left to make their decisions after all the options available to them have been explained. It is worth noting that NASW has no official position on matters touching on end-of-life; the organization, and its members are more concerned about care for the patient during this critical stage in their life(Montero, 2011). Effectiveness of the Policy Very little is known about the effectiveness of NASW’s policy statement as it appears to have received little scholarly research attention(Montero, 2011). However, the association claims that the policy statement is the product of its systematic approach to policy development(Montero, 2011). The policy statement’s effectiveness lies in the extent to which social workers make efforts to familiarize themselves with end-of-life issues. Besides NASW’s policy statement, there are several other resources from which social workers can draw(Montero, 2011). For instance, in 2009, the University of Washington’s School of Medicine released guidelines that stipulate the duties and responsibilities of physicians as far as end-of-life issues are concerned. The National Hospice and Palliative Care Organization also has a range of resources that are useful to social workers. Even as social workers become knowledgeable in end-of-life issues, it must be clear to them that the decision to withdraw life support machines, for instance, lies with health professionals. Ethically, the role of the social worker is to refer patients and their families to healthcare professionals that specialize in these matters. Alternative Policy and Possible Obstacles The American Academy of Hospice and Palliative Medicine and the National Quality Forum among other experts have recommended that the Patient Order for Life Sustaining Care (POLST) be rolled out nationally(Giovanni, 2012). POLST was the program adopted by the Oregon legislature at around the same time PSDA was enacted. The goal of the program was to enforce adherence to patients’ end-of-life care wishes by enhancing the communication of those wishes across health care settings. Effectively, POLST transforms a patient’s preferences into orders that must be carried out. Several studies have confirmed the ability of POLST to help patients self-determine their end-of-life preferences(Giovanni, 2012). Some barriers to the rolling out of POLST nationally exist. The most cited barriers are the detailed specifications for out-of-hospital orders that vary across states(Giovanni, 2012). Moreover, in 23 states, health care providers and professionals are barred from withdrawing life-sustaining treatments from patients. Where a patient’s preference is that they be removed from such treatments, there would be a legal-moral conflict. Still, 12 states require witnessing for out-of-hospital patient wishes. The other significant barrier is access to end-of-life care services(Giovanni, 2012). Access includes awareness of the availability of those services, their acceptability on cultural and religious grounds and affordability. There exist significant inequalities in access palliative care in the United States. The uptake of hospice services, on the other hand, remains low despite their importance. If these challenges can be addressed, a national POLST will go a long way toward enhancing access to quality, patient-responsive end-of-life care in the country. References Altilio, T., & Otis-Green, S. (2011). Oxford textbook of palliative social work. New York: Oxford University Press. Giovanni, L. (2012). End-of-Life Care in the United States: Current Reality and Future Promise – A Policy Review. Nursing Economic$, 30 (3), 127-134. Montero, D. (2011). End-of-Life Issues in the United States after Terri Schiavo: Implications for Social Work Practice. Advances in Social Work, 12(2), 164-180. Peppercorn, J., Smith, T., & Helft, P. (2011). American Society of Clinical Oncology Statement: Toward Individualized Care for Patients With Advanced Cancer. Journal of Clinical Oncology, 29(6), 755-60. Tucker, K. (2014). Vermont’s Patient Choice at End of Life Act: A Historic “Next Generation” Law Governing Aid In Dying. Vermont Law Review, 38(687), 687-699. Read More