End of Life

Question 1

Difference between act and omission in end of life

Answer 1

Act is seen as interfering with natural course of events, may be seen as less morally acceptable
Active euthanasia is illegal in the UK under any circumstances. Open to misuse, without patients consent

Omission to treat (passive euthanasia) is legal under certain circumstances. May allow for a wrong diagnosis to be realised. Allows best interests to be implemented when pt is unconscious/lacks capacity. Free of coercion.

Question 2

What is the doctrine of double effect?

Answer 2

An action which has a good objective may be performed even though this can only be achieved at the expense of a corresponding harmful effect
(eg administration of high dose opioids for pain relief, which may inadvertently contribute to death)
2011: No circumstances in which the prescription of a lethal does of opioid is necessary to control suffering, and therefore there is no need to invoke the doctrine of double effect”

Question 3

If a competent adult wishes to die, what can be done?

Answer 3

Suicide is legal..
A refusal of initiation/continuation of life-sustaining medical treatment must be respected
But active euthanasia is illegal

Question 4

If a patient lacks capacity, when would it be legal to end their life?

Answer 4

Care is centred on person’s best interests
Strong presumption in favour of prolonging life, this is not absolute
Extremely poor QoL, pain, suffering, additional harm of treatment
Legal advice necessary if there is discordance between professionals and family
Where treatment is ‘futile, overly burdensome to the patient or where there is no prospect of recovery’

Question 5

What are the ethical arguments for sanctity of life?

Answer 5

Human life has intrinsic value, and therefore it is wrong to intentionally deprive a person of their life, even to avoid extreme suffering.
Religious: Life is God given, only God has the power to take life away
Secular: All humans are equal and therefore no one has the authority to determine that another’s life is not worth living

Question 6

What arguments would counter the sanctity of life principles?

Answer 6

Other values (beneficence, non-maleficence & justice should be considered
QoL versus sanctity of life
Human dignity should be considered

Question 7

Should nutrition always be offered to patients?

Answer 7

Offering food and water by mouth should always be offered.
Giving food by NG tube or drip (clinically assisted nutrition and hydration) can be refused by competent patients but cannot be demanded.
If pt lacks capacity, best interest must be considered. Presumption to prolong life. But if CANH just prolongs dying process then may not be in pt’s best interests.
No obligation to provide treatment that is futile

Question 8

What is futile treatment?

Answer 8

If it cannot cure or palliate the disease or illness from which the patient is suffering
Lady Hale 2013: if it provides benefit to the patient ‘even though it has no effect on the underlying disease or disability’
For the patient to decide, not the doctor?
But doctors must only give treatment if clinically indicated

Question 9

What does assisting suicide mean?

Answer 9

Usually it means providing the legal substance for the person to take
The final gesture (eg swallowing the pills) must be made freely by the person committing suicide
Punishable by up to 14yrs in prison
Taking a family member to Dignitas in Switzerland may count as assisting the sucide

Question 10

When are family members likely not to be prosecuted for assisting suicide if they go with the pt to Switzerland for assisted suicide?

Answer 10

If the patient has reached a voluntary, clear, settles and informed decision to commit suicide
Her family has sought to dissuade her
They are wholly motivated by compassion
Actions are of only minor assistance

Question 11

How should doctors avoid assisting/facilitating/encouraging a suicide attempt?

Answer 11

Doctors should not:

• Advise patients on what constitutes a fatal dose
• Advise patients on anti-emetics in relation to a planned overdose
• Suggest options instead of assisted suicide abroad
• Write medical reports specifically to facilitate assisted suicide abroad
• Facilitate any other aspects of planning a suicide

Question 12

Arguments against changing the law around assisted suicide?

Answer 12

• Good quality palliative care should ameliorate suffering
• It will undermine the trust between doctors and patients
• The value accorded to life would be diminished
• The vulnerable in society may feel pressured to ask for assistance to die

Question 13

What counts as terminally ill?

Answer 13

If he/she has been diagnosed with an inevitably progressive condition which cannot be reversed by treatment and the person is reasonably expected to die within 6 months

Question 14

What are the 2 forms of advance decision making under the MCA?

Answer 14

ADRT (advanced decisions refusing treatment)

LPA (lasting power of attorney)

Question 15

What is an ADRT?

Answer 15

An advanced decision refusing treatment
Made by an adult with capacity stating the treatments they would wish to refuse in the event of loss of capacity and the circumstances of refusal
This does not include basic care (oral food and water, warmth, hygiene)
If refusing life sustaining treatment then it must be written, witnessed and signed by the person making it, acknowledging that it is to apply to that treatment even if life is at risk

Question 16

What happens if a doctor refuses to follow an ADRT?

Answer 16

If the ADRT is valid and applicable, a failure to follow it would render the doctor liable to a claim of battery
ADRT and respect for prior expression of autonomy trumps best interests

Question 17

What is advance care planning?

Answer 17

A process if discussion between an individual, and often those close to them, and their care providers about what treatment and care they may want in the future
GMC says ‘doctors should encourage this for patients who have a condition that will affect the length/QoL or where loss of capacity may be anticipated
May lead to an ADRT or appointment of a health and welfare LPA

Question 18

Describe the ethical issues of treating someone after attempted suicide

Answer 18

Is suicide the ultimate exercise of autonomy?
But they may not be acting autonomously (mental disorder/severe personal distress)
Paternalistically intervention after attempted suicide would protect against harmful consequences of their own choices
Consequentialism: fail to intervene sends out a message of lack of societal concern for those that have expressed such deep distress
Is suicidal ideation evidence of a mental disorder?

Question 19

What is an issue with an ADRT in someone with mental illness?

Answer 19

There is a presumption of capacity at the time of making an advance decision
However if there is an ‘alerting background’ of previous mental illness, rather than relying on the presumption of capacity, the person making the ADRT should demonstrate they have capacity at the time of making it.
MCA states that if a person making an ADRT is clearly suicidal, this may raise questions about their capacity
Would still be taken into consideration for best interests decision even if not abided by

Question 20

What should a DNACPR decision involve?

Answer 20

Decision should be requested by the patient or made by the most senior member if the medical team or GP after discussion with the patient where appropriate and potentially also with their relatives
All decisions should be clearly documented

Question 21

What 4 things do the Resuscitation Council state there must be for a DNACPR order?

Answer 21

• Effective recording of decisions about CPR in a form that is recognised and accepted by all those involved in the care of the patient
• Effective communication with and explanation of decisions about CPR to the patient, or clear documentation of reasons why that was impossible or inappropriate
• Effective communication with and explanations of decisions about CPR to the patient’s family, friends or other carers or other representatives, or clear documentation of reasons why that was impossible or inappropriate
• Effective communication of decisions about CPR among all healthcare workers and organisations involved with the care of the patient

Question 22

Give some common examples of when a DNACPR is appropriate

Answer 22

• When CPR is unlikely to restart a patient’s heart
• When the patient is in the terminal stages of an illness
• Where it is believed that the patient’s QoL is such that the benefit of CPR would not improve their QoL

Question 23

How is brainstem death confirmed?

Answer 23

By establishing that the cerebral cortex is no longer active and that without ventilation the patient would not be able to breathe spontaneously
By 2 senior doctors:
-Absence of oculocephalic reflexes (doll’s eye movements)
-Absence of corneal reflexes
-Pupils fixated bilaterally and unresponsive to light
-Absent vestibulo-ocular reflexes (absence of nystagmus when ice-cold water inserted into ear canal)
-Absence of any motor response to painful stimuli
-Absence of gag and cough reflex
-Absence of spontaneous respiration (trial off ventilator)

Question 24

When do you report a death to a coroner?

Answer 24

• Infant death
• Traffic accidents
• Alcoholism
• Industrial disease
• Drugs and poisons
• Suicide
• Sudden death
• Murder
• Deaths in custody
• Domestic accidents
• Perioperative deaths
• Cause of death unknown
• If a patient has not been seen by a medical professional during the last 2 weeks of life

Question 25

Do all cases reported to a coroner end in a post mortem?

Answer 25

No, 60% do

Question 26

When must the coroner hold an inquest into the death?

Answer 26

When the post-mortem has not fully confirmed the cause of death
Or
Where the death was violent and unnatural

Question 27

Who needs to fill in cremation forms?

Answer 27

2 doctors who have viewed the body after death
Form B by a doctor who was involved in the patient’s care prior to their death
Form C by an independent doctor who is at least 5 years post full registration with the GMC who has spoken to a relative/carer of the deceased for any concerns over cause of death