The director of one of the local hospice programs approached the nurse manager of the inpatient oncology unit and asked if they could discuss an ethical situation that has occurred related to developing a hospice plan of care for an oncology patient.

Jenny Mason is a 65-year-old female, divorced, has no children, and has a long-term history of mental illness, which manifests as depression, with intermittent schizoid features. Two years ago, Ms Mason presented to the emergency department with back pain and an inability to walk. Her workup revealed numerous pathological fractures, including a femur and both humeri. She was diagnosed with widely metastatic renal carcinoma and treated with chemotherapy and radiation with stabilization of her disease.

During the past year, Ms Mason's cancer reoccurred, and she elected to receive second-line chemotherapy. Last month, she was hospitalized on the inpatient oncology unit for side effects from the chemotherapy and had documented progressive disease. Subsequently, the patient elected to have no further treatment and to be admitted to a hospice program. Ms Mason is currently awaiting discharge. During her preadmission assessment by the hospice nurse, Ms Mason identified that her primary goal was to return home. Thus, the hospice team has begun to investigate options on how to make this goal a reality.

Ms Mason has the physical limitations that one would expect with her advanced disease, plus the added challenges related to her mental illness. Some members of the hospice team feel that she has an unrealistic view of life and does not see any need to plan for the future. She continues to insist that "things just always work out." She greatly desires to be autonomous and in control of her life and resents any attempt to help her.

One of the obstacles to her being able to receive home hospice is her high acuity level. She is bed bound and dependent for all of her care needs. She receives scheduled and PRN intravenous pain medications and has diabetes, both of which require frequent monitoring and pharmacological intervention. Hiring nurses who can address this degree of acuity may be difficult and significantly more costly than staying at the extended care facility.

When notified of the cost issue, Ms Mason told the case manager, "That really isn't a problem. I inherited $1.5 million when my Aunt Helen died, I have no living relatives, and I might just as well spend this money doing what I want." At this week's interdisciplinary hospice team meeting, the case manager pointed out that although Ms Mason had a solid financial foundation for supporting 24/7 home care. However, the lack of a dedicated family care provider was a significant problem since the potential exists for Ms Mason to be left alone if a scheduled provider were to be late or absent. Ms Mason is unable to understand why this could be a problem. She claims to have several friends to whom she could turn for help. However, these friends turn out to be known only by their first names, and although they might be able to help in an emergency, they are not able to commit to a prearranged schedule.

This is an unusual case, so the hospice team is trying to think outside the box when identifying options. During her many hospital admissions, Ms Mason seems to have established many friendships with various members of the healthcare team. During a brain-storming session, the oncologist suggested, "The oncology nursing staff is genuinely fond of Ms Mason and definitely qualified to provide her care. Why not offer the nurses say [horizontal ellipsis] double their salary to work with Ms Mason in her home on their day(s) off?"a

The nurse manager agreed that this request encompassed a variety of ethical questions that could benefit from a team approach. Thus, consultations were sought from the hospital ethicist, palliative care clinical nurse specialist, and nursing administrator.

^aThis case is based on an actual patient care situation, but facts have been changed to protect confidentiality. [Context Link]