Case study: Patient-Centered Care: Case Studies on End of Life in elderly

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Background
Ms. L is an 87-year-old African American woman who was diagnosed with vulvar cancer at the beginning of 2017. She is also HIV-positive. By the time Ms. L engaged in care, the cancer had proliferated quite quickly in the setting of a compromised immune system. Upon discovery of the Stage 4 cancer, doctors recommended a dose of radiation and chemotherapy. However, during the course of this episode Ms. L was struggling with substance use. During her hospitalization, she tested positive for a number of substances, including heroin and cocaine. As a result, care providers had many discussions about pain management and which pain medications could be given to her. She was not on methadone treatment maintenance at first, so she was self-medicating to address her pain. While Ms. L wanted to seek help for her addiction to substances, some of the traditional models were not appropriate given the magnitude of her physical issues. There were expectations that she would get into outpatient treatment but she did not follow through, primarily because it was difficult for her to tolerate being in groups for long periods. (Given the location of her cancer, she could not sit upright for long periods or on the bus for transportation.) Ultimately, Lawanda Williams, Director of

Housing Services at Health Care for the Homeless in Baltimore, Maryland, and her team were able to provide Ms. L with transportation and cab vouchers so she could access the full course of radiation that doctors had recommended. Her pain was never well controlled, because her physician refused to prescribe her any pain medications, due to the magnitude of her substance use. The radiation center gave her Percocet while she was there but would not give her anything that could not be directly supervised. After treatment, they sent her home with prescriptions for Tylenol and instructions to return and follow up with pain management teams, which she was unable to do because of her difficulties with transportation and sitting. Ms. L completed radiation and is in a period of holding to assess effectiveness of the initial course of radiation, but she still does not have a prescription for her significant pain and, as a result, continues to use substances to manage her pain. Ms. Williams observes, “I have been able to see how managing withdrawal and managing substance abuse in the context of a palliative care treatment plan does not always exist for patients experiencing homelessness. She does not fit very neatly into any mainstream treatment model.”

 

CASE STUDY CHALLENGE:
1. Harm reduction: How can care providers best advocate for a harm reduction approach while seeking to deliver palliative care services, including hospice care?
2. What ethical arguments can you make base on the case study?
3. Why do you think that long-term care and palliative care insurance lacks of popularity among older Americans.

 

Sample Solution

Harm reduction:

Harm reduction is an approach to substance use that focuses on reducing the negative consequences of drug use, rather than on eliminating drug use altogether. This approach is often used with people who are unable or unwilling to stop using drugs, and it can be an effective way to improve their health and well-being.

In the case of Ms. L, a harm reduction approach would involve providing her with the medications she needs to manage her pain, while also working with her to reduce her substance use. This could involve providing her with counseling and support, and helping her to access treatment for her addiction.

There are a number of ways that care providers can advocate for a harm reduction approach. They can educate themselves about harm reduction principles, and they can talk to their colleagues about the benefits of this approach. They can also advocate for policies that support harm reduction, such as needle exchange programs and naloxone distribution.

Ethical arguments:

There are a number of ethical arguments that can be made in favor of a harm reduction approach. First, harm reduction is based on the principle of respecting patient autonomy. This means that patients have the right to make their own decisions about their health care, even if those decisions are not in line with the provider’s recommendations.

Second, harm reduction is based on the principle of beneficence. This means that providers have a duty to do good for their patients. In the case of Ms. L, providing her with the medications she needs to manage her pain would be doing good for her, even if it does not lead to her stopping her substance use.

Third, harm reduction is based on the principle of non-maleficence. This means that providers should do no harm to their patients. In the case of Ms. L, denying her pain medication could actually harm her by causing her to suffer unnecessarily.

Lack of popularity of long-term care and palliative care insurance:

There are a number of reasons why long-term care and palliative care insurance lacks popularity among older Americans. One reason is that these types of insurance can be expensive. Another reason is that many people are not aware of the benefits of these types of insurance. Additionally, some people may be reluctant to purchase long-term care or palliative care insurance because they do not want to think about their own mortality.

Here are some of the things that can be done to increase the popularity of long-term care and palliative care insurance:

  • Make these types of insurance more affordable.
  • Educate people about the benefits of these types of insurance.
  • Make it easier for people to purchase long-term care or palliative care insurance.
  • Reduce the stigma associated with long-term care and palliative care.

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