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Ethical considerations for hospice


Hospice is a care concept aiming to provide comfort and support to patients and their families when a life-limiting illness no longer responds to cure-oriented treatments. The mission of home-based hospice is to provide medical care and support to terminally ill patients and their families, helping people who are dying remain comfortable. Patients and family members are assisted in transitioning from a high-tech medical environment focused on a cure to a home-like environment focused on comfort. Even though the number of hospices has grown rapidly in the last 20 years, still less than 25% of dying patients in the United States access hospice services. Many elderly patients approach their end of life in isolation. Rural hospice care providers have identified several barriers to the provision of hospice services in their communities, such as shortage of nurses, aides, and social workers, insufficient reimbursement, and restrictive regulatory definitions of service areas based on mileage and driving time rather than quality-of-care outcomes.

The American Telemedicine Association has produced a set of clinical guidelines for the deployment of home-based telehealth applications. These guidelines refer to patients, healthcare providers, and technology criteria. Patient criteria involve a set of recommendations, such as the need for informed written consent obtained from patients, selection of patients able to handle the equipment, and training. Healthcare provider criteria entail the need for plans of action, training issues, and after-hours support.  

Criteria relate to the operation and maintenance of equipment, establishment of clear procedures and safety codes, protection of patient privacy, and security of records. While these guidelines are meant to serve as practical tips for the proper utilization of telehealth systems, they do address some of the ethical considerations associated with this model of care delivery and can assist nursing administrators in the decision-making process as they consider the adoption of telehealth technology by the home care or hospice agency. It becomes clear that when aiming to utilize telehealth technologies in the home environment, one needs to determine the appropriateness of the innovation. 

Several factors must be considered by nurse practitioners when determining whether the use of technology is appropriate for a particular patient. These include the patient’s stability of disease processes, his or her level of functional limitations, infrastructure at the patients home and the housing condition in general, the patient’s mental state, attitude toward the system, willingness to provide informed consent, and availability of a support mechanism (technical support, a network of friends, or informal caregivers). On the basis of the patient’s primary diagnosis, stability, and ability to use the system, nurses should determine the type of virtual visit and the visit pattern. Patients challenged by medication compliance or at risk of adverse drug reactions, for example, might benefit from a home-based telehealth application that provides frequent monitoring and different types of medication reminders, as well as assists in the retrieval of relevant educational materials regarding their diagnosis and nutrition. On the other hand, individuals in need of strong emotional or psycho-social support may need the benefits of human touch and a virtual visit may not be appropriate.