Improving the Transition to End-of-Life Care
New Book by NewYork-Presbyterian/Weill Cornell's Dr. Joseph Fins Helps Clinicians, Patients, and Family Members Make the Transition
In the wake of the Terry Schiavo case, many are becoming aware of the importance of planning for end-of-life medical care. A new book, A Palliative Ethic of Care: Clinical Wisdom at Life's End (Jones and Bartlett Publishers) offers clinicians, medical students, patients, and family members a practical guide to the subject. Written by a world-renowned authority on medical ethics and end-of-life care, Dr. Joseph J. Fins of NewYork-Presbyterian Hospital/Weill Cornell Medical Center, the book helps ease the transition from curative to palliative care, with practical advice on issues like formulating goals of care.
"The average length of stay in a hospice is only a few weeks. This is often too little, too late. In fact, many patients deserving of a comfortable and dignified death aren't even given the option, whether in a hospice or hospital setting," says Dr. Fins. He is Chief of the Division of Medical Ethics at Weill Medical College of Cornell University, where he serves as Professor of Medicine, Professor of Public Health, and Professor of Medicine in Psychiatry. In addition, he is Director of Medical Ethics at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.
Over the last 15 years, palliative care has come into its own, with more hospices and specialty-trained physicians than ever before; yet, outside the specialty, there is still a considerable lack of understanding by medical practitioners about end-of-life care and ways to help patients make this often tricky transition, says Dr. Fins.
The conversation can be a difficult one to bring up for both the patient and physician. When considering end-of-life care, the patient sometimes feels they do not want to disappoint the doctor; or they feel they are obligated to exhaust every treatment available; or they fear being abandoned. Physicians also can dismiss the patient's desire for death as symptomatic of depression.
In response to these challenges, Dr. Fins' book offers a singular and empirically based system called GCAT (Goals of Care Assessment Tool) to help clinicians be better advocates for patients and their families.
"GCAT is specifically designed to ensure that the patient's goals drive their therapy instead of the therapy driving the goals," says Dr. Fins.
Formulating goals takes the form of advance care planning including a living will, which outlines treatment choices; and advance directives that designate a health-care proxy and guidelines for a DNR (do-not-resuscitate) order.
The book stresses that patients must be reassured that they are free to change their goals of care at any time, and that their care will continue beyond hope of a cure.
According to Dr. Fins, physicians and patient advocates, including family members, must be very attentive to cues that the patient may want to discuss goals of care. When a patient asks, for example, "How many more rounds of chemo will I need to go through?" this should be a red flag.
GCAT is designed to help clinicians formulate a care plan that respects a patient's autonomy, dignity, and personhood. Says Dr. Fins: "The goal is to help people have a better quality of life and, when the time comes, quality of death."
"My intention is to help foster needed reforms, and I am confident that continued improvements are possible," says Dr. Fins, whose work as an ethics consultant and professor at Weill Cornell for more than 15 years informs the book.
The book additionally provides a historic overview of end-of-life care in the United States beginning with the rise of informed consent in the early part of the 20th century through the recent national debate surrounding the Schiavo case.
Dr. Joseph J. Fins
Dr. Joseph J. Fins is Chief of the Division of Medical Ethics at Weill Medical College of Cornell University, where he serves as Professor of Medicine, Professor of Public Health, and Professor of Medicine in Psychiatry. In addition, Dr. Fins is Director of Medical Ethics at New York-Presbyterian Hospital/Weill Cornell Medical Center, Associate for Medicine at The Hastings Center, and a member of the Adjunct Faculty of The Rockefeller University.
Dr. Fins is the author of more than 150 publications in medical ethics and health policy. He has lectured widely in the United States, Europe, and Latin America. His current scholarly interests include ethical issues in brain injury and disorders of consciousness; palliative care; research ethics in neurology and psychiatry; medical education; and methods of ethics case consultation. He is a member of the Editorial Board of the Journal of Pain and Symptom Management, Cambridge Quarterly of Health Care Ethics, and The Oncologist.
Dr. Fins has been a Visiting Professor in Medical Ethics at The Complutense University in Madrid, and is a recipient of a Soros Open Society Institute Project on Death in America Faculty Scholars Award, and a Woodrow Wilson National Fellowship Foundation Visiting Fellowship. In July 2000, Dr. Fins was appointed by President Clinton to the White House Commission on Complementary and Alternative Medicine Policy.
A diplomate of the American Board of Internal Medicine, Dr. Fins is a graduate of Wesleyan University and Weill Cornell Medical College (then Cornell University Medical College). He completed his residency in Internal Medicine and Fellowship in General Internal Medicine at NewYork-Presbyterian/Weill Cornell.
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