Palliative and hospice care as part of the ethics of life

Palliative and hospice care ethics as part of life Every year, several tens of millions of people die around the world. Some newborns die after only a few minutes, hours, or days of life, while others die in old age, after many decades since birth. Death can take many forms; it may be caused by an acute illness, an unexpected traffic accident, wartime events, it may result from chronic illness, or long-term physical decline in later life. We all must die. However, most of us do not choose the way of our death.

Care for terminally ill patients is certainly not an easy task, whether it is provided at home, in a palliative care ward, or in a hospice. At all times, the most important factor is a humane “ethical-moral” approach within human ethics and morality. Encountering death is not easy, especially for a person who is not prepared for it. This experience can be frightening the first time, and each person lives it differently. Some people need professional help, some confide in their closest ones, but in the end everyone develops their own view and attitude toward death.

It is appropriate to look for new and effective ways to reduce a patient’s suffering and help them work through fear of death. At present, palliative and hospice care appears to us as the best solution, and this care should naturally include the ethics of life. A home-care solution is the most comprehensive option for caring for terminally ill people, but there are many cases where a person is in such a situation and family members or loved ones cannot care for them for various reasons. In such circumstances, palliative and hospice care in dedicated institutions is the most suitable alternative. In human society, especially in international contexts, this question resonates very strongly. In our case, however, the establishment of palliative and hospice care facilities is stagnant, or even essentially not being implemented at all. It is important to talk and provide information about the purpose and role of these institutions in our society, because through care they provide the client and their family an immeasurable wealth in the form of respect, concern, and dignity. Caring for terminally ill people enriches us as well. Although demanding, the interest and love we give to a person are returned to us many times over in the form of joy that we have helped make the remaining moments of life more comfortable and of better quality.

Questions related to the end of human life have occupied people since time immemorial. The concern for a good death and life after death was addressed by the oldest human communities. The concern for a good death appears together with concern for a good and successful life, for the search for the meaning of life, satisfaction, and happiness. Questions of life and death have not become easier for modern people, nor less meaningful, than they were for generations before us. Although illness, bodily suffering, pain, mental affliction, death, and dying were, for a time, pushed to the margins of human concern.

In the postwar period, practices of care for the sick or dying person were already known. We refer to professional care in hospital institutions, so-called institutional care. In these institutions, people often died alone, without loved ones, and sometimes without dignity. We do not question the medical perspective, but it was certainly missing at that time emotional support, strengthening the social status of the patient, and even psychological help. It is encouraging that in modern times attention is being paid to palliative and hospice care, in which the emphasis is placed especially on human dignity, even at the time of dying.

The field of palliative care, which mainly addresses the final phase of human life, is currently seen as a growing area of social work. It is here that social workers have the opportunity to use their professional skills, both in assessment and analysis and in intervention, with the aim of improving the quality of care for the dying based on ethical and moral principles.

Palliative care is a special kind of medical (hospital and outpatient) care for patients in advanced stages of illness when a diagnosis has been made, causal treatment exhausted, and only symptom-relieving treatment is applied. Author M. Svatošová (2001) explains that the term palliative care is derived from the Greek word palliat—a covered mantle. It focuses on an individual’s comfort with emphasis on the medical model, and often starts and sometimes remains in an acute-care institution. We can state that palliative care deals with the treatment of patients with active, advanced disease in the terminal stage. Palliative care is active, comprehensive care for patients at a time when their illness no longer responds to further treatment. The aim of treatment and care is the quality of their life. The most important part is pain treatment, symptom control, as well as dealing with the psychological, social, and spiritual problems of patients.

Palliative care is not care only in terminal stages. It is intended for a large group of clients who suffer as a result of malignant disease. It is provided simultaneously with active anti-tumor treatment, or it may be provided independently. H. Haškovcová (2000) says that “palliative care is palliative medicine, comforting, pain-relieving, representing a coherent and hopeful system of help for the dying and their families,” which should have the ethics of life in mind.

Palliative care represents a specific type of both health and social care. Its goal is not only pain relief or stabilization of health status, but mainly the improvement of the best possible quality of life for the client up to their death, where the humane “ethical” approach plays a major role. It includes not only support, but also help for the client and their family.

Hospice care is understood, within general principles, similarly to palliative care. Differences are observed in the complexity of understanding the needs of the dying person, for example with regard to their environment, social relationships, and the needs of loved ones.

According to the World Health Organization (Hanzlíková et al., 2006, p. 266), hospice care is an “integrated form of medical, social, and psychological care, provided to clients in all indication, diagnostic, and age groups, where the attending physician estimates life expectancy at less than six months.” Within hospice care, only palliative treatment is provided. Draganová et al. (2006, p. 89) emphasize that hospice care does not belong among social institutions. In their view, it is “care for the dying and incurably ill person in terminal stages of disease, who needs nursing care and treatment to alleviate suffering.” The goal of hospice care is to accompany severely ill people in the final phase of life and to help their relatives too cope with difficult farewell moments.

Most people mistakenly think that a hospice is a house of death. It is, however, a very simplified and above all incorrect characterization of hospices, where palliative and hospice care is provided. The hospice idea, in fact, arises from respect for life and respect for the human person, which is in line with the ethics of life and its principles. According to Štefko (2003), hospice is a movement whose basic idea is based on respect for life and for the person as a unique and unrepeatable being. It is service to the person who needs it.

Regardless of where hospice or palliative care is provided, it is always important that care be comprehensive and all needs of the client be met. This type of comprehensive care cannot be provided without applying the so-called holistic approach. It is a philosophy applied in care for a dying person in palliative care. It is comprehensive care for a person understood as a bio-psycho-social unity. This care does not include only care for the patient, but also for their family, their mutual relationships, needs, and problems. It is care that respects the needs of body, mind, and spirit.

A person’s right to a dignified death is the basis of ethical principles that no one can dispute. Every person is a unique personality, different from other people in individual characteristics, aspects, components, and structures of personality. In essence everyone is different, whether biologically, psychologically, or socially, and this also applies to the quality and especially ethics of life.

The issue of the ethics of life in palliative and hospice care of the individual currently belongs among the most debated questions of today’s society. It is often identified with people’s lives, is a rewarding theme for the media, but above all it is the social reality of life for every single person. “From the nature and tasks of life, as well as from the person’s relationship to life, the highest principles of the ethics of life are justified, namely a consenting attitude toward life, respect for life, and the final principle is love of life” (Laca, 2008, p. 10). By ethical principle we mean a basic starting point and rule from which we derive ethical laws and norms required in palliative and hospice care. All these principles presuppose the value of human life and its transcendent dimension extending to divine Transcendence.

The first principle is a consenting attitude toward life, which follows from a basic positive right and from a person’s relationship to life, in which the person does not aprioristically reject life but, on the contrary, opens to life fundamentally despite all dangers and obstacles often connected with suffering coming from different sources. In this way, the value of life is confirmed—something that cannot be replaced by anything. The second principle in the issue of the ethics of life is the principle of respect for life, for which reverence for life is characteristic. To this principle A. Schweitzer (In: Slipko, 1998, p. 28) arrived, based on the assumption that “the most immediate reality to us is the experience expressed by the claim that I am life, which I want to live in the midst of life that wants to live ...” For this reason, life cannot be limited to mere vegetating; rather, it must be improved, because respect for life expresses itself in the acknowledgment of the flourishing of all beings, to which diverse goods also belong. And this applies to all people, regardless of whether they are sick or healthy. Thus, respect for life contains everything we know as love, devotion, shared suffering, shared joy, and shared effort.

The final possible principle of the ethics of life is the principle of love of life. Since life comes from God, it is worthy of love as well, because “its most basic attribute is love” (KKC 735). In this understanding, God reveals himself in our mind and heart as trinitarian absolute love with the fullness of divine Life. This life of the Trinity is the paradigm for all other areas of life, which, like everything that exists outside God, derives from it. Human life as a created being is the foundational likeness to God in love, from which arises the objective ontological value of life. And therefore, “love of life in this understanding becomes the unifying factor of life, which mobilizes the person to ethical action” (Laca, 2008, p. 11).

The ethics of life in palliative and hospice care becomes fundamentally important in coordinating ethical attitudes and coexistence according to validated principles of the common good, solidarity, and subsidiarity for everyone. The ethicality of “life” continues from moral experience, which depends on conscience formation in accordance with knowledge, freedom, and especially responsibility. Ethics of life, in close relation to and continuity with moral philosophy, should focus on changing mentality, reforming production structures in line with law, reforming education with the aim of creating a culture of peace and love in a planetary sense, and revitalizing solidarity among all people in society. In this fulfillment, ethics will develop and apply in practice the principles and tenets of all areas of the ethics of life and, in particular, of human life.

Conclusion

Every person is an original, and each individual situation, every moment, and every instant that is lived is unique. No one can write the script of their life in advance, and certainly no one else can do that for them, because no one knows what awaits them. The only certainty is this: death spares none of us. People say in various situations that there is one justice in this world, namely that everyone must die. Yet there are great differences in dying. Just as every human being is unique, so the ending of life has millions of forms. For terminally ill patients who cannot be helped, whose final spark of hope has been extinguished, and who themselves experience this severely, hospice and palliative care can be a solution.

A severely ill or dying person needs a different, more “human” environment than that offered by ordinary hospitals. An environment in which no strict regimen and precisely scheduled program applies. The overall approach to the patient must be more sensitive and take into account their physical and especially psychological state. It is exactly this kind of approach that hospice palliative care provides, where the ethics of life and its principles play a significant role. For this reason, we should pay greater attention to this final stage of life. Preserving the ethics of life to the end of life, making the end of life peaceful, bringing peace and love into everyday life, easing physical pain with appropriate medication, reducing social isolation—these are the main goals of palliative and hospice care, which directs all its attention to helping terminally ill patients and their families.

The quality of services provided to severely ill and incurable people is a criterion of the moral advancement of every human society. Quality care cannot do without comprehensive understanding and meeting the needs of the sick person and their family, which must include certain ethical and moral laws.

Author: PaedDr. Slavomír Laca, PhD. Vysoká škola zdravotníctva a sociálnej práce sv. Alžbety, Bratislava

List of bibliographic references

[1] DRAGANOVÁ, H. et al. 2006. Sociálna starostlivosť. Martin : Osveta, 2006. 196 s. ISBN 978-80-8063-240-3. [2] HAŠKOVCOVÁ, H. 2000. Thanatológie. Náuka umíraní a smrti. Praha : Galén, 2000. 191 s. ISBN 80-7262-034-7. [3] HANZLÍKOVÁ, A. et al. 2006. Komunitné ošetrovateľstvo. Martin : Osveta, 2006. 280 s. ISBN 80-8063-213-8. [4] Katechizmus Katolíckej cirkvi. 1993. Trnava: SSV, 1993, 918 s. ISBN 80-7162-259-1. [5] LACA, S. 2008. Etika života a interrupcia, Prešov : Kušnír, 2008, s. 105, ISBN 978-80-969984-70. [6] ŠTEFKO, A. 2003. Dôstojnosť človeka v starobe, chorobe a zomieraní. Bratislava : Teologická fakulta Trnavskej univerzity, 2003. 145 s. ISBN 80-7141-429-8. [7] SVATOŠOVÁ, M. 2001. Hospic – umenie sprevádzať. Bratislava : Lúč, 2001. 157 s. ISBN 80-7114-335-9.

The lecture was delivered at the international scientific conference Applied ethics in social work and other helping professions, which took place on October 20–21, 2010 in Piešťany, and was published in the proceedings of that conference: MÁTEL, A. – SCHAVEL, M. – MÜHLPACHR, P. – ROMAN, T. 2010. Aplikovaná etika v sociálne práci a ďalších pomáhajúcich profesiách. Zborník z medzinárodnej vedeckej konferencie. Bratislava : VŠZaSP sv. Alžbety. 413 s. ISBN 978-80-89271-89-4.

Author's publications: PaedDr. Slavomír Laca, PhD

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Selected chapters from ethics for social and health-care professions - At present we can state that there is a significant growth of accumulating scientific knowledge about the human being as a rational individual at the level of the human population, up to varied issues. More and more increasingly obvious and complex ethical questions concerning human life are coming to the forefront.