A decision to accept hospice care often results only after much emotional turmoil in a family. But does this decision mean that difficult issues concerning end-of-life care cease? Patients, families, and providers may face many ethical issues throughout the provision of palliative care until death occurs. Sensitive management of ethical issues as they arise can ensure a good experience in end-of-life care and go a long way toward influencing the way that people handle future deaths. Social workers, as an integral part of the hospice team, can be valuable resources in the resolution of ethical dilemmas in end-of-life care.
Because end-of-life and palliative care often engender strong emotional responses, ethical dilemmas become central to decisions regarding care for the dying person. Ethical dilemmas occur when a choice must be made between two or more relevant but competing ethical directives or values or when, no matter the choice, it results in an undesirable outcome (Loewenberg, Dolgoff, & Harrington, 2000). Thus, it may be important to examine the ethical implications of each decision (Byock, 1994) and discuss inherent dilemmas perceived by the interdisciplinary team members. The hospice team's synergy is important to fulfilling hospice philosophy, which emphasizes care for the biological, psychological, social, and spiritual aspects of suffering and healing.
Social workers' participation on a hospice ethics committee can help them understand ethical issues and resolve ethical dilemmas. Ethics committees can provide guidance in discussion of specific cases and policies and education regarding ethical issues. However, hospice ethics committees are not widespread (Csikai, 2002; D'Olimpio, 1995; Fife, 1997). In the normal course of daily activities in hospice, decisions that may have ethical implications must be dealt with immediately, and an ethics committee may meet only monthly or quarterly. How then are ethical dilemmas in hospice care addressed?
This study explored common ethical issues, especially those that have a potential for producing dilemmas in hospice; methods of resolution; and hospice social workers' participation in "ethics committee-type" activities in their agencies. No earlier empirical studies have investigated this phenomenon.
SOCIAL WORK AND ETHICAL ISSUES IN HEALTH CARE SETTINGS
Social workers in health care have witnessed advances in medicine and the accompanying ethical issues and dilemmas since the profession was introduced in dispensaries and hospitals in the early 20th century. Since that time social workers have been at the heart of emotional discussions with patients and families faced with making end-of-life care decisions. Social workers develop relationships with patients and families and work with them to resolve problematic psychosocial situations in their lives. In health care, the goals may include discharge to home, placement in a nursing home, provision of home care services, or, as in hospice, promotion of a "good" death. During this process hospital social workers may encounter ethical dilemmas regarding quality-of-life, privacy and confidentiality, interpersonal conflicts, disclosure and truth telling, value conflicts, rationing of health care, and treatment options (Abramson & Black, 1985; Foster, Sharp, Scesny, McLellan, & Cotman, 1993; Reamer 1985). In discharge planning, social workers identify conflicts between fostering maximum patient self-determination and the pursuit of patients' best interest as occurring most frequently (Proctor, Morrow-Howell, & Lott, 1993). Hospital social workers have been asked to discuss euthanasia and assisted suicide (Csikai, 2000), which is particularly challenging because they are illegal in all states except Oregon and are the subject of much public and private ethical debate (Miller, 2000).
In home health care, issues of self-determination are prominent. A unique extension of self-determination is seen in the dilemma caused by attempting to balance both patients' and families' rights to self-determination. …