End of Life Ethics Flashcards
How is the way we are dying changing?
- Less common to die quickly
- Rise in co-morbidities and frailty
How does the concept of a ‘good death’ change?
- Faith cultures (rites/rituals)
- Individualist society and promotion of personal autonomy
- Multicultural society, multiple beliefs
- Informed choice, anticipatory care planning
What makes a good death and what makes a bad death?
Studies have revealed the preferred place of death is where?
Home, then a hospice
Where do most people die?
Hospital
What is quality of life enhanced by as we age?
- Caring attitude of staff
- Family visits
- Physical environment
- Maintaining control
- Feeling safe/not alone
- Art sessions
- Smoking
What is quality of life diminished by as we age?
- Lost independence
- Lost activities
- Pain/fear of pain
- Feeling a burden
What are the ethics to consider when a patient requests their prognosis?
- Many patients do want to know there prognosis, others will not
- Non-malfeasance
- Beneficence
- Often families will want to know more than patients
- Respect autonomy
- Confidentiality
- Give the ‘gist’ rather than statistics
Example, an 84 year old has pancreatic cancer and her daughter requests that you do not tell her as nothing can be done, what ethics must be considered?
- Capacity
- Benefit/best interest
- Autonomy
- What if the daughter has power of attorney
What is collusion?
Refers to a secret agreement made between clinicians and family members to hide the diagnosis from the patient:
- Possible reasons for collusion needs to be established
- Establish patients level of awareness by asking relevant and direct questions
- Process helps break barriers between the patient and relatives
What are some reasons families may wish to collude?
- Disclosure causes the patient to lose hope
- Disclosure leads to depression
- Disclosure hastens the progression of the illness and death
- Disclosure increases the risk of patient suicide
- Disclosure may cause psychological pain for the patient
- Family members themselves may not be aware of the nature and severity of the illness
- Family members may be in denial
- Family members may be in conflict
Why does collusion go against the best clinical practice?
- Patient factors
- At odds with patient autonomy
- Revealing diagnosis to relatives before patient breaches confidentiality
- Patients cannot give informed consent if not aware of underlying illness
- Patient not able to complete unfinished business before death
- Family factor
- Family members have to bear burden of being untruthful
- Barrier in communication at time when patient needs it most
- Families have no guidance on making treatment decisions
- Clinician factors
- Breakdown of clinician-patient relationship and loss of trust
- May face treatment non-compliance from patients
What is a DNACPR form?
Not a legal document, but a record of decision, need document rationale in notes if not discussed with patient
Provide guidance for clinicians who do not know the patient
What is the guidance for using a DNACPR form?
- Patients must be aware of DNACPR form
- If the patient lacks capacity must inform those close to the patient without delay
- When there is clinical certainty DNACPR will remain in place, does not need to be reviewed
What types of cardiac arrests are shockable?
Only VF and VT
What is an example of withdrawal of treatment?
Stopping non-invasive ventilation
Can patients refuse treatment?
It is the patients legal and ethical right to decide to refuse treatment:
- If they have capacity the decision must be respected. Even if this may lead to death
- Continuing unwanted treatment is battery and is a criminal offence
What is continuing unwanted treatment on a patient considered to be?
Battery and is a criminal offence
What are important things to consider when withdrawing treatment?
- Communication is key
- Planning and preparation
- When a treatment is started patients should understand it can be withdrawn if they no longer want it
- Symptoms should be anticipated and managed effectively
What ethics must be considered when withdrawing treatment?
- Capacity
- Best interests
- Justice
What are the ethics of withdrawing treatment for a patient with no capacity?
- Duty to treat in patients best interests
- No obligation to prolong patients life irrespective of the quality of life or patients own views unless it is in the patients best interest
- In some cases comes a point when continuing treatment ceases to be in patients best interest and not able to provide a quality of life the patient would find acceptable
- In such a case the presumption in favour of prolonging life will be rebutted
When is letting a patient die (not admitting them to hospital) acceptable?
- Medical technology is useless
- Patient validly refuse a medical technology
- Ideally consensus patient, their family and other clinical staff
What may happen if you let a patient die (do not admit them to hospital) when the criteria to do so is not satisfied?
May be considered medical negligence
What is euthanasia?
Act of deliberately ending a person’s life to relieve suffering
What is assisted suicide?
Act of deliberately assisting or encouraging another person to kill themselves
What does physician assisted suicide involve?
Prescribing lethal drugs intended explicitly to end a life
What are some arguement for euthanasia?
- Suicide is legal. Those who are so disabled they cannot take their own life are disadvantaged.
- Withdrawing and withholding life-prolonging treatment is widely accepted and practised.
- The suffering associated with some diseases outweighs the benefits of continuing to live.
- Respect for patient autonomy.
What are some arguements against euthanasia?
- Good palliative care obviates the need for PAS.
- Discourages palliative care research.
- Vulnerable patients are at risk – coercion, feeling like a burden, free up medical resources.
- Slippery slope - may lead to involuntary euthanasia for people deemed ‘undesirable’.
- Affects other people’s rights, not just the patient.
- Contrary to the aims of medicine – promotion of health and life. Patients may lose trust.
