End-of-life care decision making carries paramount importance due to the advancements in medical sciences. Since medical science has evolved over the time and now has a potentiality to reshape the circumstances during death and in turn prolong lives, various ethical issues surround end-of-life care.

These Best Practice Guidelines on Publication Ethics describe Blackwell Publishing's position on the major ethical principles of academic publishing and review factors that may foster ethical behavior or create problems. The aims are to encourage discussion, to initiate changes where they are needed, and to provide practical guidance, in the form of Best Practice statements, to inform these changes. Blackwell Publishing recommends that editors adapt and adopt the suggestions outlined to best fit the needs of their own particular publishing environment. Background Academic publishing depends, to a great extent, on trust. Editors trust peer reviewers to provide fair assessments, authors trust editors to select appropriate peer reviewers, and readers put their trust in the peer-review process. Academic publishing also occurs in an environment of powerful intellectual, financial, and sometimes political interests that may collide or compete.

Good decisions and strong editorial processes designed to manage these interests will foster a sustainable and efficient publishing system, which will benefit academic societies, journal editors, authors, research funders, readers, and publishers. Good publication practices do not develop by chance, and will become established only if they are actively promoted. These Best Practice Guidelines on Publication Ethics have been written to offer journal editors a framework for developing and implementing their own publication ethics policies and systems. In some sectors, notably medicine, the debate about publication ethics is moving rapidly. In response, and at suitable intervals, we will update our guidance.

The general principles of publication ethics are grouped and discussed under broad themes. Statements of principle are followed by factors that may affect them. The order of the sections does not imply a hierarchy of importance. Best Practice: Authorship and acknowledgment The International Committee of Medical Journal Editors (ICMJE) provides a definition of authorship that is applicable beyond the medical sector (). Blackwell Publishing recommends that journal editors consider adopting the ICMJE authorship criteria as part of their editorial policy. The ICMJE authorship criteria state ‘authorship credit should be based on 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published.

Authors should meet conditions 1, 2 and 3.’ Blackwell Publishing recommends that editors ask authors to submit a short description of all contributions to their manuscript. Each author's contribution should be described in brief.

Authors of research papers should state whether they had complete access to the study data that support the publication. Contributors who do not qualify as authors should also be listed and their particular contribution described.

This information should appear as an acknowledgment. Sample authorship description/acknowledgment Drs A, B and C designed and conducted the study, including patient recruitment, data collection, and data analysis.

Dr A prepared the manuscript draft with important intellectual input from Drs B and C. All authors approved the final manuscript.

[Insert name of organization] provided funding for the study, statistical support in analyzing the data with input from Drs A, B and C, and also provided funding for editorial support. Drs A, B and C had complete access to the study data. We would like to thank Dr D for her editorial support during preparation of this manuscript. The Blackwell Publishing Exclusive License Form, the OnlineOpen Form, or the Copyright Assignment form, one of which must be submitted before publication in any Blackwell journal, requires the corresponding author to state that written authorization for publication of the article has been received by the corresponding author from all co-authors. Best Practice: Collecting authorship information For research papers, authorship should be decided at the study launch.

Policing authorship is beyond the responsibilities of an editor. Editors should demand transparent and complete descriptions of who has contributed to a paper. Editors should employ appropriate systems to inform contributors about authorship criteria (if used) and/or to obtain accurate information about individuals’ contributions. Blackwell Publishing can advise Blackwell editors about how best to do this, and the Blackwell Publishing electronic submission system can be used to explain authorship criteria, and to collect and manage authorship information efficiently.

Editors should ask authors to submit, as part of their initial submission package, a statement that all individuals listed as authors meet the appropriate authorship criteria, that nobody who qualifies for authorship has been omitted from the list, and that contributors and their funding sources have been properly acknowledged, and that authors and contributors have approved the acknowledgment of their contribution. Best Practice: Attributing authorship to a group The International Committee of Medical Journal Editors (ICMJE) provides guidance for instances where a number of authors report on behalf of a larger group of investigators (). This guidance is applicable outside the medical sector. Blackwell Publishing recommends that editors adopt the ICMJE policy.

ICMJE guidance states: ‘When a large, multi-center group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript. These individuals should fully meet the criteria for authorship defined above When submitting a group author manuscript, the corresponding author should clearly indicate the preferred citation and should clearly identify all individual authors as well as the group name.’ The individual authors who accept direct responsibility for the manuscript should list the members of the larger authorship group in an appendix to their acknowledgments.

Best Practice: Redundant (multiple) publication Journal instructions should clearly explain what is, and what is not, considered to be prior publication. Abstracts and posters at conferences, results presented at meetings (for example, to inform investigators or participants about findings), results databases (data without interpretation, discussion, context or conclusions in the form of tables and text to describe data/information where this is not easily presented in tabular form) are not considered by Blackwell Publishing to be prior publication. Journals may choose to accept (i.e. Consider ‘not redundant’) the re-publication of materials that have been accurately translated from an original publication in a different language. Journals that translate and publish material that has been published elsewhere should ensure that they have appropriate permission(s), should indicate clearly that the material has been translated and re-published, and should indicate clearly the original source of the material. Editors may request copies of related publications if they are concerned about overlap and possible redundancy.

Re-publishing in the same language as primary publication with the aim of serving different audiences is more difficult to justify when primary publication is electronic and therefore easily accessible, but if editors feel that this is appropriate they should follow the same steps as for translation. Editors should ensure that sub-group analyses, meta- and secondary analyses are clearly identified as analyses of data that have already been published, that they refer directly to the primary source, and that (if available) they include the clinical trial registration number from the primary publication. The Blackwell Publishing Exclusive License Form, the OnlineOpen Form, or the Copyright Assignment form, one of which must be submitted before publication in any Blackwell journal, requires signature from the corresponding author to warrant that the article is an original work, has not been published before and is not being considered for publication elsewhere in its final form either in printed or electronic form.

Some questions and answers about duplicate publication Q.‘I am considering joining two of my fellow journal editors in writing a joint editorial about plagiarism and academic disputes. It would be published simultaneously in three journals.’ A. This is appropriate multiple publication. Multiple publication helps convey the strength of the (important) message. Each editorial should refer to the others, as references and in a direct statement.

Q.‘We publish abstracts from specialist societies, then often get the full paper a few months later.’ A. This is not duplicate publication. Abstracts do not present full results/analysis. Q.‘Our Chinese edition has translated papers from the main journal a few months after the original was published.’ A. This could be appropriate re-publication. Translated papers should make it clear (perhaps in their titles) that they are translated from a primary source, and they should refer directly to the primary source (in their abstract and their text, as a reference, and as a footnote).

Best Practice: Registering clinical trials Since 2005, some medical journals [notably those edited by members of the International Committee of Medical Journal Editors (ICMJE)] have made registration in a publicly accessible trial register a requirement for publishing clinical trials (). The World Health Organization (WHO), in May 2006, urged ‘research institutions and companies to register all medical studies that test treatments on human beings’ (). ICMJE allowed authors a grace period for registration of new or ongoing trials; this grace period ended September 2005. WHO states that ‘all clinical trials should be registered at inception’, i.e. Prospectively before patients/subjects are enrolled, using the complete 20 criteria described by its International Clinical Trials Registry Platform (). Blackwell Publishing recommends that editors of medical journals require that the clinical trials they consider for publication are registered in free, public clinical trial registries (for example,,, ) before publication. Editors may choose to allow authors submitting to their journals a grace period in which ongoing or completed trials can be registered.

Editors should develop policies about trial registration that suit their own particular publishing environment, and should make their policies about trial registration clear to prospective authors. Even if editors decide that prospective registration is not made compulsory for their journal, journals should encourage clear trial identification and should have a policy for including the clinical trial registration number and name of the trial register within the publication, and perhaps should adapt their electronic submission process to collect this information. Sample wording for statement in instructions for authors [Insert journal name] requires that the clinical trials submitted for its consideration are registered in a publicly accessible database.

Authors should include the name of the trial register and their clinical trial registration number at the end of their abstract. If you wish the editor[s] to consider an unregistered trial please explain briefly why the trial has not been registered. Best Practice: Protecting research subjects, patients and experimental animals Policing the standards of human or animal research is beyond the responsibilities of an editor. Even so, medical journals can encourage authors to follow the highest standards and may consider requiring, for example, statements from authors that trials conformed to Good Clinical Practice [for example, US Food and Drug Administration Good Clinical Practice in FDA-Regulated Clinical Trials (); UK Medicines Research Council Guidelines for Good Clinical Practice in Clinical Trials ()] and/or the World Medical Association Declaration of Helsinki (). Journals should ask authors to state that the study they are submitting was approved by the relevant research ethics committee or institutional review board. If human participants were involved, manuscripts must be accompanied by a statement that the experiments were undertaken with the understanding and appropriate informed consent of each. If experimental animals were used, the materials and methods (experimental procedures) section must clearly indicate that appropriate measures were taken to minimize pain or discomfort, and details of animal care should be provided.

Blackwell Publishing suggests that all these standards are defined by the lead investigator's national standards. Editors should reserve the right to reject papers if there is doubt whether appropriate procedures have been followed. If a paper has been submitted from a country where there is no ethics committee, institutional review board, or similar review and approval, editors should use their own experience to judge whether the paper should be published.

If the decision is made to publish a paper under these circumstances a short statement should be included to explain the situation. Where individual human subjects or case studies are discussed (for example, as in medicine, psychology, criminology), journals should protect confidentiality and should not permit publication of items that might upset or harm participants/subjects, or breach confidentiality of, for example, the doctor–patient relationship. Best Practice: Respecting confidentiality In the majority of cases, editors should only consider publishing information and images from individual participants/subjects or patients where the authors have obtained the individual's explicit consent. Exceptional cases may arise where gaining the individual's explicit consent is not possible but where publishing an individual's information or image can be demonstrated to have a genuine public health interest. In cases like this, before taking any action editors should seek and follow council from the journal owner, Blackwell Publishing and/or legal professionals. In the case of technical images (for example, radiographs, micrographs) editors should ensure that all information that could identify the subject has been removed from the image. Respecting cultures and heritage Editors should exercise sensitivity when publishing images of objects that might have cultural significance or cause offence (for example, Australian aboriginal remains held in museums, religious texts, historical events).

It may be acceptable to publish images of human remains (for example, Egyptian mummies, Roman remains) so long as these considerations are respected, despite the fact that for archeological specimens it is impossible to obtain consent from the individual or their descendants. Journals should have clearly set-out policies to explain the type of peer review they use (for example, blinded, non-blinded, multiple reviewers) and to explain whether peer review varies between types of article.

Systems differ between journals (one system, for example, would be to state that editorials and letters are not peer reviewed, and that research articles and review articles are always peer reviewed). Material that has not been peer reviewed should be clearly identified (for example, in a short description of different types of content in instructions for authors). Best Practice: Publishing work from a journal's own staff When making editorial decisions about peer reviewed articles where an editor is an author or is acknowledged as a contributor, journals should have mechanisms that ensure that the affected editors or staff members exclude themselves and are not involved in the publication decision. In these cases, a short statement explaining the process used to make the editorial decision should be included. When editors are presented with papers where their own interests may impair their ability to make an unbiased editorial decision, they should deputize decisions about the paper to a suitably qualified individual.

See ‘Conflicts of interest’, p. Best Practice: Timing of publication Editors should aim to ensure timely peer review and publication for papers they receive, especially where, to the extent that this can be predicted, findings may have important implications.

Authors should be aware that priority publication is most likely for papers that, as judged by the journal's editorial staff, may have important implications. The timing of publication may also be influenced by themed issues or if editors group submissions on a similar topic which, inevitably, prevents them from being published in the order that articles were accepted. Online publication prior to print publication (Blackwell Publishing OnlineEarly publication, or OnlineAccepted publication) can provide the fastest route to publication and, therefore, to placing research (and other) information in the public domain. Conflicts of interest Editors, authors, and peer reviewers have a responsibility to disclose interests that might appear to affect their ability to present or review data objectively. These include relevant financial (for example, patent ownership, stock ownership, consultancies, speaker's fees), personal, political, intellectual, or religious interests. ‘Financial conflicts may be the easiest to identify but they may not be the most influential.’ Horton R.

‘We want to try to have a policy that covers all conflicts of interest. Other sources of conflict are personal, political, academic, and religious, and we believe that these may be just as potent as financial conflicts.’ Smith R. Editors should seek disclosure statements from all authors and peer reviewers and should clearly explain the types of conflicts of interest that should be disclosed.

Authors’ conflicts of interest (or information describing the absence of conflicts of interest) should be published whenever these are directly or indirectly relevant to the content being published and whenever they are significant. For example, owning USD10 stock in a company that manufactures a product discussed in an article would not be significant, whereas consultancy fees of USD10,000 annually or the equivalent of 5% of an author's gross income from the previous year could be considered significant. Editors may consider not publishing details of authors’ interests when these interests have no relevance to the content being published. If there is doubt about whether conflicts are relevant or significant, it is prudent to disclose. The existence of a conflict of interest (for example, employment with a research funder) should not prevent someone from being listed as an author if they qualify for authorship. Business Plan Pro 11 Keygen Download Youtube on this page.

Editors may prefer not to commission subjective articles (for example, editorials or non-systematic reviews) from authors with conflicts of interest. However, arguments can be made that such authors are often well informed and have interesting opinions. Strict policies preventing people with conflicts of interest from publishing opinion pieces may encourage authors to conceal relevant interests, and may therefore be counter-productive. Best Practice: Conflicts of interest Editors should adopt a policy about conflicts of interest that best suits their particular publishing environment, and should describe this in their editorial policy.

Editors should adapt their submission processes to encourage submission by authors of the required information. For example, Blackwell Publishing can configure a journal's online submission system to identify submissions without required information, and can return these submissions to authors with an explanation that their submission cannot be processed without completed information. Editors should require statements about conflicts of interest from authors. Editors should explain that these statements should provide information about financial (for example, patent ownership, stock ownership, consultancies, speaker's fees), personal, political, intellectual, or religious interests relevant to the area of research or discussion. Research or publication funding is considered separately (see ‘Who funded the work?’, p.

Editors should describe the detail that they require from conflict of interest statements, including the period that these statements should cover (3 years is suggested, but relevant conflicts of interest that are older should not be neglected). When describing financial information, the purpose of the funding received should be described by funding organization (for example, travel grant and speaker's fees received from [name of organization]). Editors could consider using bands (for example, per year, bands for financial disclosures of USD10,000 or the equivalent of 5% of an author's gross income from the previous year) for authors to describe the level of relevant funding and from which organizations this has been received, or to describe the amount of relevant stocks and shares that they own (not including stocks and shares owned as part of a general, non-specific portfolio). Blackwell Publishing recommends that editors publish the minimum amount of information that will provide context and transparency for readers: the sources and types of funding received by the authors.

Editors should always publish a statement to describe authors’ conflicts of interest or, alternatively, a statement that confirms the absence of conflicts of interest. If there is doubt about whether conflicts are relevant, it is prudent to disclose. Authors should routinely provide a statement of conflicts of interest (or lack thereof), whether or not a journal requests this statement. Sample wording [Name of individual] has received fees for serving as a speaker, a consultant and an advisory board member for [names of organizations], and has received research funding from [names of organization]. [Name of individual] is an employee of [name of organization]. [Name of individual] owns stocks and shares in [name of organization]. [Name of individual] owns patent [patent identification and brief description].

It is good practice for journal editors, board members and staff (if involved with decisions about publication) to make and regularly update disclosures (either in the journal or via its website) about their relevant interests. Best Practice: Commercial issues Blackwell Publishing does not allow its sales teams to become involved with the editorial decision making process. The extent of the editorial information available to the sales team and the timing of its disclosure to them will be agreed for each journal with the relevant academic society partners and journal editors. Sales teams may only use this information after editorial decisions are finalized, to provide accurate and timely information to their potential customers. The positions available for advertising in a journal (for example, within or adjacent to an article, or collected in ‘wells’ within the journal) will be agreed for each journal with the relevant academic society partners and journal editors. Whether it is permissible to sell reprints of OnlineEarly papers (i.e. Papers published online prior to print publication) will be agreed for each journal with the relevant academic society partners and journal editors.

Best Practice: Supplements and other funded publications Journals may choose to publish supplements, special issues, sections, or similar materials that are funded by a third-party organization, for example, a company, society or charity (the supporter or sometimes sponsor). The content of funded items must align with the purpose of the journal. Journals should consider describing their policy for funded items, should always present readers with the name(s) of the organization(s) funding the publication, and should consider making statements at the beginning and at relevant points within the funded item, including: •.

Details of the journal's affiliations and Editorial Board. Blackwell Publishing recommends that journals appoint co-editors (including the individual who proposed the initial idea for the funded material and a second individual appointed by the journal) as standard procedure for all funded materials. This enables editorial decisions to be easily deputized as should be the case when one editor is an author or is acknowledged as a contributor to a particular article, or when one editor is presented with papers where their own interests may impair their ability to make an unbiased editorial decision. A short statement explaining the process used to make editorial decisions should be included. Journals should not permit funding organizations to make decisions beyond those about which publications they choose to fund and the extent of the funding. Decisions about the selection of authors and about the selection and editing of contents to be presented in funded publications should be made by the editor (or co-editors) of the funded publication.

Blackwell Publishing reserves the right not to publish any funded publication that does not comply with the requirements defined for the journal to which the manuscript or supplement has been submitted. Responsible publication practices Editors should pursue cases of suspected misconduct that become apparent during the peer-review and publication processes, to the extent and in the ways defined in this document in the ‘Promoting research integrity’ section (p. Editors should first work with the authors, the journal owners and/or the journal publishers (at Blackwell Publishing this is via the Journal Publishing Manager), referring to information from the Committee on Publication Ethics (COPE), the Council of Science Editors (CSE), or another appropriate body if further advice is needed. Many journals require authors to declare that the work reported is their own and that they are the copyright owner (or else have obtained the copyright owner's permission). This is enforced further by the Blackwell Publishing Exclusive License Form, the OnlineOpen Form, or the Copyright Assignment form, one of which must be submitted before publication in any Blackwell journal. This form requires signature from the corresponding author to warrant that the article is an original work, has not been published before and is not being considered for publication elsewhere in its final form either in printed or electronic form.

Different systems are available to protect intellectual property and journals must choose whichever best suits their purpose and ethos. Some Blackwell journals require authors to relinquish their copyright, other Blackwell journals license content from authors, whereas others adopt an open-access model under creative commons licenses. Blackwell Publishing recommends adoption of a system that licenses content from authors, rather than more traditional systems that require copyright assignment/transfer by authors. The Blackwell Publishing OnlineOpen Exclusive License Form (OOF). While allowing articles to be published and made freely available for all to access online, this form of copyright agreement (among other things and like the ELF) enables the owners of intellectual property (be they authors or named organizations) to retain copyright in their journal articles; the OOF adheres to Creative Commons 2.5 and Blackwell Publishing or the journal owner retains the commercial publishing and journal compilation rights.

End-of-life care decision making carries paramount importance due to the advancements in medical sciences. Since medical science has evolved over the time and now has a potentiality to reshape the circumstances during death and in turn prolong lives, various ethical issues surround end-of-life care. The purpose of this narrative review is to discuss issues such as autonomous decision making, importance of advance directives, rationing of care in futile treatments and costs involved in providing end-of-life care. Even though much progress has been made in this area continued advancement in medical science demands further research into this topic. Introduction All human-beings are mortals and hence death is an inevitable occurrence.

Advancements in medical technology are changing the norms of natural death. These technologically advanced treatments have a capability to intervene at the time of death and prolong the lives of people. Medical technologies are facilitating to reshape the circumstances around natural death, by sustaining human lives. Even though medical treatments have advanced technologically they hold no promises for recovery, they can sustain life with or without meaningful existence or with secondary support (like feeding tubes, ventilators, etc.). Hence, these medical advancements have empowered patients and their families (proxies) with an important task of choosing their treatment preference during end-of-life care []. “Decision-making” for end-of-life care has earned paramount importance as it has capability to prolong human life with the support of medical technologies or can let the natural death process continue by foregoing the treatment option [].

Hence, end-of-life care is facing various ethical dilemmas. The purpose of this narrative review is to discuss issues such as autonomous decision making, importance of advance directives, rationing of care in futile treatments and costs involved in providing end-of-life care. This is a US centered study and the text does not necessarily apply to countries and contexts outside the United States. Autonomous Decision Making “Decision making” is itself a very complex process of thoughts and sets-up various challenges for patients and their families to make up an end-of-life care decision []. Persons have a right to put forward their end-of-life treatment preferences.

The Federal Patient Self-Determination Act (PSDA) effective since 1991 has facilitated communication between the healthcare providers and patients or consumers []. The person’s right to autonomously voice their end-of-life treatment choices has to be respected ethically considering the use of advance treatments and their prognosis. This right of autonomy has some limitations, and hence faces an ethical dilemma. The healthcare professional should respect the patient’s autonomy while considering its limitation and carry out their duties to benefit the patient without doing harm []. Even though we are discussing about patients right to autonomy we are talking about its limitations. To elaborate further, autonomy gives patients’ a right to control their treatment according to their preferences, though many a times their autonomy is not respected. They receive end-of-life care which is in-consistent with their end-of-life care preferences [].

This gives importance to the ethical issue of autonomy surrounding end-of-life care preferences. Physician’s Role and Responsibilities to Resolve the Issue Healthcare professionals can play an important role by providing detailed information about an advanced medical treatment which can be used during end-of-life care. Physicians can perform their duties rightfully by providing patients detailed information about the benefits, limitations and drawbacks of that treatment. Physician can work according to “deontological theory” and perform their duties to gain greatest good for the patient and act for patients benefit []. Even though the patient has autonomy to choose a treatment, physician can explain its implications and try to emphasize on its consequences. Here, the patient has to perform a self-beneficence duty to take an autonomous decision as a competent individual to undergo the treatment and prolong life or forgo a futile treatment for the greatest good of society by saving cost and emotional stress. If the patient insists to prolong life with medically advanced treatment intervention, which according to physician evaluation might be futile, physician has the upmost responsibility to explain the information facts about withholding or withdrawing the medical treatment and see to it that there is no unnecessary utilization of resources for the futile treatment without causing harm to the patient.

Physicians should respect the beliefs and values of that patient before withholding or withdrawing a treatment or giving an order for DNR (do not resuscitate) or resuscitation. Physician, additionally has a duty to preserve patient’s life but this duty is not to be confused with unnecessary use of resources and inflicting more harm than good to the patient by continuing medically futile treatments []. Physicians have to reach a mutual agreement with the patient about withholding or withdrawing a futile treatment and explain the drawbacks of unrealistic expectations from the treatment. Communication between patient and families, discussing patient’s goal regarding treatment and care, can be helpful to bridge a gap between the patient, their families and the physician []. Advance Directives An “advance directive” enables competent individuals to design and document their health care decision plan in advance in case of future disability or terminal illness. This advance directive can be of two types, instructional and proxy, which allow competent individuals to make their healthcare choices in advance or specify their wishes to their providers or families in case of future disability in carrying out end-of-life decision [].

This can give the patient an “individual autonomy” so as to receive end-of-life care consistent with their preference. In case of a competent individual, he or she can convey or document their end-of-life treatment preferences autonomously to the authorities on admission or can take a consensus autonomous decision after getting end-of-life care information from the physician as discussed above.

On the other hand in case of incapacitated individuals, families play a central role as proxies or primary care givers. Families have a responsibility of putting forth the end-of-life care preference of the patient.

Family members play the role of proxy due to the virtue of their relationship with the patient and may not be very good in guessing the patients preference for end-of-life decision making, in the case where explicit declaration of patients preferences is not clear. These proxies try to judge the medical situation as the patient may have evaluated but it is seen that they are not very good at taking end-of-life decisions for the patients.

Families playing the crucial role of surrogate or proxy are emotionally attached to the incapacitated patient and hence their moral interest (emotional, financial pressure, etc.) may be diversified in opting for a treatment or declining them []. The unstable advance preferences may not be authentic in some eventful situations. Hence, the medical situation may need renewed evaluation and decision making. To address these ethical and legal issues arising from advance directives there is a need to educate the general population about the legal requirements and rights of the patient to accept or refuse a recommended treatment and advance directive. The information about proper implications and use of advance directives can facilitate in understanding and addressing legal issues arising from planning ahead by the patient or by the primary care givers []. Rationing of Care and Futile Treatment The technological advancements and innovations are reshaping the decisions and treatment preferences surrounding end-of-life care.

These technologically advanced treatments have a capability to prolong the life of a patient rather than allowing the natural dying process. The end-of-life decisions to sustain life are considered on the basis of patient centered care, quality of life after these advance treatments and have to be weighed along with shared decision-making process [].

These new medical treatments and technologies are increasing the number of people seeking long-term care. It is challenging to provide long-term advanced treatment and care to the population considering the increase in older population and assessing the projected increase in this population, especially when the baby boom (a cohort born between 1946–1964) reach old age by 2030 []. It is assumed that people will adapt to healthy lifestyles and thus, this will reduce disabilities, diseases and injuries. This advancement will lower death rate and increase people living longer and needing long term care in their later life []. People should understand that they are mortals and consider getting information and making plans for end-of-life care preferences []. The futile and expensive treatment at end-of-life situations are increasing the unaffordable cost of healthcare and promoting inequitable healthcare.

The ethical value of patient autonomy and surrogate autonomy should be respected but weighed against the use of expensive treatment in futile case circumstances with current increase in healthcare costs. Hence, in case of futile treatments, families and patients can ethically consider the option for comfort care. The advanced technologies hold no promises for recovery. These treatments can also lead to few humiliating and undignified situations for the patients which can be emotionally burdensome. Healthcare rationing of end-of-life care in futile situations can be considered as greatest good for society but has to be weighed against the patient autonomy [].

It is difficult for the general population seeking medical care to understand the concept of limited treatment in case of futile cases. The stewardship of limiting medical care is surrounded by ethical issues as the patients and their families do not understand the need to limit treatment in some cases where it is futile. Healthcare providers and physician are working towards this challenging task of making patients understand the need to refuse treatment as it may not benefit them and in some cases can cause harm. “Bioethics” points this limiting treatment or refusing futile treatment option as “rationing of care” in cases where unanimous decision about refusing advance treatment is not made collaboratively by patient and their healthcare providers. There are no strict criteria to differentiate futile treatment; hence it has to be relied on expert judgment and case prognosis. Considering the aspect of access of quality care to the people who need them most, the rationing of care in futile situation can be justified. Rationing of care is present in the current healthcare system and can be justified as equitable justice if carried out ethically and equitably [].

Medical resource allocation is often limited and hence has to be distributed equitably. There is a need for evaluating and assessing the medically advanced treatment so as to avoid any undue use of already limited resources. This can be achieved by good education, knowledge about advanced treatment implications and improved healthcare decision making from patients, their families and physicians []. Costs Involved in End-of-Life Care The expenditure on healthcare is too much in relation with total number of people and outcome. United States is spending a lot of money on health care and the average dollar amount per person is also much higher. Having said that, the health care expenditure is increasing, and at the same time people are spending more on getting the care they need.

The cost of producing health care services due to advancement and innovations in technology is increasing the expenditure involved in providing these healthcare advanced treatment services. These healthcare services should not only target lengthening the life of people but also improve the quality of life [], especially when end-of-life decisions and the costs involved in it are concerned.

Compassionate care is another option seeked by the patients while considering end-of-life care which can be at times less costly and a good preference when medicine is unable to restore patient’s health. The medical treatments are financially burdensome to some patients; hence easy accessibility to quality care at affordable cost can lessen the financial issue adherent to the end-of-life care considering the increase in the unaffordability of healthcare []. Ethical Theories Involved in End-of-Life Care Healthcare providers and physicians have to consider patient’s perspective and preferences. They have to work against the egoistic theory by working for the good of the patient [].

Patient’s family members when implied with the task of making appropriate treatment choices or end-of-life care choices for the incapacitated patient should put aside their self-interest and judge the situation and come to a decision in the patient’s best interest. This act of working towards achieving greatest good for the patient by family members and by the physician can be termed under “Virtue theory” of ethics. Physicians have to judge the situation and provide appropriate treatment prognosis so that patients’ can make an autonomous choice of treatment preferences or patients’ family can make these choices for them and work towards act of beneficence for the patient. While carrying out this act of beneficence, the physician has to provide information about the treatment, especially in case of futile treatment so as to avoid any undue harm to the patient. In case of futile treatments, healthcare providers also have to consider the allocation of limited resources available to manage the case scenario so as to avoid inequity.

Hence, healthcare providers also have to consider the aspect of equitable and distributive justice in cases where expensive treatment provided to the patient during end-of-life situation may be futile, and utilize lot of resources, leading to unequal distribution of limited medical and technological resources []. Additionally, they have to address the issues of unnecessary and unequal distribution of resources by withdrawing or withholding the futile treatment []. Policy Implications The task of healthcare executives to manage ethical issues surrounding end-of-life care is challenging. Healthcare executives can address these ethical dilemmas ensuring certain policies to be followed during managing this task. They can guide the patients and their surrogates to make informed treatment preferences by providing them trustful information, appropriate prognosis and available options regarding the case specific treatment choices. They can assist the patient and their families to make a well judged end-of-life care decision and document their preferences. In case there is a disagreement between the healthcare provider and the patient or surrogate end-of-life care choices, then they can take appropriate steps by appointing an ethics committee to address this ethical or legal issue and document its proceedings.

Healthcare executives can compile policies, so as to introduce, promote, and discuss the use of advanced directives as an admission procedure []. This can motivate the patients to make a living will (advanced directive) about their end-of-life care preferences which in due process can facilitate families to make appropriate decisions in case of incapacitated patients. Healthcare organizations can work towards developing and implementing guidelines & policies for end-of-life care decision making, especially policies for withholding or withdrawing the treatment options so as to avoid the ethical dilemmas. There should be a proper disclosure mentioning the limitations of certain specific treatment options if there are any, so that the patients and families are well informed about their treatment options and make well-judged decisions. Healthcare executives can develop resources supporting palliative treatment care choices. They can additionally provide detailed information and knowledge about these palliative care options so as to facilitate patients and their families to make a competent end-of-life care preference.

Healthcare organizations can provide effective support by appointing an interdisciplinary ethics committee and employee assistance facility available so as to address any ethical crisis []. A well-formed, consistent and integrated ethics committee can safeguard organization’s future by increasing patient satisfaction, increasing organizations productivity, avoiding unethical activities, restricting undue costs, and reducing the risk of lawsuits []. Conclusions and Future Implications Healthcare providers should take an initiative and discuss patient’s goal for end-of-life care or palliative care, as their preferences can change from person to person. Free Download Entrepreneurship By William D. Bygrave Andrew Zacharakis Pdf Programs. Some patients might target for cure or some for comfort care, hence this trustful communication can avoid the ethical crisis surrounding that topic. The stability of these health preference goals is another issue as it has a potentiality to change with illness. Hence, the health scenario in each specific case has to be renewably evaluated so as to opt for scenario-based preferences. Here, the role played by clinicians is important as they can promote communication, education and discussion related to end-of-life care preferences and their implications among the patient, and their families in order to facilitate improved decision making.

Effective advance planning or advanced directives can assist in putting forth patient’s autonomous choices but flexibility in these advanced directives can be appraised as it can accommodate any inadvertent scenario-based preference change and evaluation. Community standards can work well where the patient’s desire from the end-of-life treatment choices is not well demarcated []. It is crucial to have a public dialogue discussing the ethical issues and dilemmas surrounding end-of-life care. This open discussion can facilitate development and implementation of policies and guidelines safeguarding the interest of patients and healthcare organizations []. Much progress has been made to address the ethical issues surrounding end-of-life care situation, and with the continued advancement in medical science, and its leading role in our lives demands further research into this topic.

As age advances so thus the illness in many cases, hence there is a need to research and implement recommendations to relive the stress faced by people during that critical time and optimize quality care to improve and ease end-of-life journey [].