Death as “Harm” When It Is an Anticipated Outcome in Palliative Care—Or Anywhere

Dear Editor:

Despite its recognized importance in other areas of health care, ¹ palliative care has until recently shown little interest in the question of patient safety.^2–4 Although there appears to be no reason to believe that the imperative to ‘do no harm’ applies any less in palliative care, it has been suggested that the philosophical underpinnings of palliative care in some way preclude the direct translation to palliative care of the parameters defining patient safety in curative medicine. ⁴ Of the harms available during medical care, death, at least untimely death, remains the most significant harm. However, in a palliative care environment, as an adjudicator of patient safety, death poses particular difficulties when it can be an anticipated, legitimate, and, arguably under some circumstances, desirable outcome. This raises the question of whether or not in a palliative care setting death can constitute a breach of patient safety.

AB was a 72- year-old woman with advanced chronic airways disease and a renal cell carcinoma diagnosed some months previously. Over a period of two days she had experienced a rapid decline in her general condition and at her family's request was admitted to a palliative care unit. With the patient too unwell to take part in the discussion of treatment options, AB's family asked that no investigations be undertaken and that no life supporting or disease modifying treatment be administered. The palliative care team agreed and AB died peacefully four days later. The family was pleased that AB's final illness had been short and her passing peaceful. The palliative care team was pleased that they had achieved their therapeutic goal of good symptom control. Had AB's safety been compromised?

While AB had debilitating and potentially life shortening pathology, prior to her brief final illness it was not obvious that death was imminent although anticipated at some unknown future time. Her demise, in that regard, was an unanticipated and possibly preventable event.

AB was a demanding individual and not greatly loved by her family; palliative care's philosophical view regarding the normality of death resulted in a failure to adequately assess and respond to her needs.

The author asserts that harm, in the form of untimely death, came to AB as a consequence of a flawed decision making process where conflicting needs of family and health care professionals took precedence over the needs of the patient; conflict, which was identified by neither party. With the death of the main protagonist, the patient, the game changes. Review of the process will only take place if the surviving players, health care professionals, and family perceive that the process was in some way flawed and that harm was indeed visited on the patient by way of an untimely death. There is, in addition, no avenue for reparation.

Undoubtedly not everybody will agree with this assessment. However, AB should remind us that untimely death does occur in palliative care and that it can constitute a breach of patient safety. Decision making processes must ensure that decisions made are in the patient's best interests as free as possible from conflict with family interests and professional ideology. ⁵