Decision making at the end of life: a model using an ethical grid and principles of group process

Those who provide care for the dying seek to address issues of pain and suffering in the context of the psychological, spiritual, mental, and physical complexities of the individual experiencing a terminal illness. People who are dying are still living. They have the right to be in control of their lives. The staff (caregivers) also have an integrity which must be preserved. They too must be connected to the decision-making process. The reality of palliative care brings up unresolved psychological issues, often turbulent personal issues, for all involved in the process. This can cause extra unnecessary pain and suffering for all concerned. It is essential that a real (unflinching) and an ethical relationship between the patient and the staff be maintained and valued as these issues are confronted and resolved. This relationship will be subject to group process influences, which must be recognized and embraced. Avoidance of these issues can lead to unfairness, misunderstanding, shame, and lasting resentment among the caregivers, as well as to tragic consequences for the patient and the family. The purpose of this article is to describe a decision-making process in palliative care that includes the use of ethical principles as well as features of group process. The ethical grid was adapted and developed from the work of Jonsen, Siegler, and Winslade. The features of group process are based on theories of group work as defined by Trotzer; Johnson and Johnson; Gladding; Bion; Yalom; and Amundson, Borgen, Westwood and Pallard.