End of life ethics

Question 1

Define end of life

Answer 1

• Defined by the GMC as those likely to die wihtin 12 months, includes those whose death is imminent and a few hours away, and those with advanced, progressive and incurable conditions, general frailty and co-existing conditions that mean they are expected to die within 12 months, existing conditions and could possible die from an acute crisis or a catastrophic event

Question 2

What is the WHO definition of palliative care

Answer 2

• Approach that improves the quality of life of patients and their families facing the problem associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual

Question 3

What are the aims of palliative care

Answer 3

• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends to neither hasten or postpone death
• Integrates psychological spiritual aspects of patient care
• Offers a support system to help patients live as actively as possible until death
• Cope during the patients illness and in their own bereavement
• Address the needs of patient and family
• Enhance quality of life

Question 4

Name the three stages of palliative care

Answer 4

1. Palliative care - encompasses all three
2. end of life care
3. terminal care

Question 5

Describe each of the three stages of palliative care

Answer 5

1. Palliative care - encompasses all three
   - introduction to palliative care services
   - symptom management
   - quality of life
   - months to years prognosis
   - anyone living with or at risk of developing a life-liming illness
2. end of life care
   - new baseline shows declining function
   - underlying condition is irreversible
   - weeks to months prognosis
3. terminal care
   - actively dying
   - comfort care
   - last hours to days of life

Question 6

What is advanced care planning (advance directives)

Answer 6

• Process that enables individuals to make plans about their future healthcare

Question 7

What are the advantages of advanced care planning

Answer 7

• Provides clarity to families and friends
• Provides direction to healthcare professionals when that person is not able to communicate their needs and choices anymore
• Can provide comfort to the person and their loved ones that this has been though about and planned for

Question 8

define death

Answer 8

either circulatory death or brain death

Question 9

define PVS

Answer 9

persistent vegetative state – chronic coma with some brain activity
- Suicide – deliberate self-killing

Question 10

define suicide

Answer 10

deliberate self-killing

Question 11

Define assisted suicide

Answer 11

providing the patient with poison to be administered by themselves to themselves upon their request

Question 12

define euthanasia

Answer 12

– killing that is supposedly in the best interests of the person or animal

Question 13

Define voluntary euthanasia

Answer 13

euthanasia following the patients request and consent

Question 14

Define involuntary euthanasia

Answer 14

euthanasia performed against the patients wish but according to their best interest or some necessity

Question 15

Define non voluntary euthanasia

Answer 15

– euthanasia performed on patients who cannot give consent

Question 16

define active euthanasia

Answer 16

performed with some active method such as injection or poison (only term used of euthanasia)

Question 17

define passive

Answer 17

– performed through withholding or withdrawing life sustaining treatment and or nutrition

Question 18

define an advance directive

Answer 18

an order given by competent persons authorising others what is or is not to be done to them under specified future conditions when they are no longer able to communicate their choices

Question 19

Define an DNAR order

Answer 19

a clinical decision to not attempt resuscitation – a form of passive euthanasia

Question 20

define terminal sedation

Answer 20

means killing the patient - Also note that while terminal sedation is done under the doctrine of double effect, the presumption that it relieves suffering, just like the presumption that death relieves suffering, has no basis: suffering can only be relieved if one feels better, and not if one feels nothing

Question 21

define medical futility

Answer 21

a concept denoting the unavailability of medical measures that can significantly improve the patients conditions, futility argument is used to justify withholding or withdrawing treatment

Question 22

define terminal state

Answer 22

a concept denoting a state where death is imminent and unavoidable, there is no consensus as to what makes a state terminal, it is sometimes construed as a sufficiency indication to deny treatment and hasten death

Question 23

What is the doctrine of double effect

Answer 23

• Some actions are expected to have two opposite effects at the same time
• The doctrine (or principle) of double effect is often invoked to explain the permissibility of an action that causes a serious harm, such as the death of a human being, as a side effect of promoting some good end

Question 24

What does the doctrine of double effect define good actions as if…

Answer 24

These actions are good if

• The good effect outweighs the bad one
• If you only intend to produce the good effect

Question 25

define unworthy life

Answer 25

– life rendered worthless and thus dispensable

Question 26

define intolerable prognosis

Answer 26

– chronic dependence on life support, inability to derive any benefit or pleasure from life or inability to engage in any social interaction

Question 27

define palliative care

Answer 27

– treatment that aims to relieve pain and suffering, and has no significant positive effect on the natural course of the illness

Question 28

define selective non treatment

Answer 28

- Selective non treatment – withdrawal of all treatment except palliative treatment

Question 29

List the legal status of end of life actions in England and Wales

Answer 29

1, Suicide and attempted suicide are not illegal [Suicide Act 1961]. However, it is not clear whether this implies a legal right to commit suicide, which would entail the duty of others to not interfere. This duty does not exist. Aiding and abetting suicide is strictly illegal [S.A. 1961, s 2(1)]. 2, Competent patients have an absolute right to refuse any treatment, including a life-saving one. The right does not depend on the prognosis or clinical status of the patient, and is considered to be different from suicide. Thus, withdrawing life-saving treatment in the context of a patient’s refusal is not regarded as PAS. 3, Euthanasia (active) - whether voluntary, involuntary or non-voluntary – is illegal and might carry a prolonged prison sentence. 4, Terminal sedation is lawful. 5, Causing death of a patient who suffers from intractable pain is not an offence, if done under the ‘Rule of Double Effect’. 6, DNAR orders, selective non-treatment, and withholding and withdrawing of life-saving treatment are not illegal but have no clear legal status. They must be subject to one of the following categories (BMA, RCN): –Brain death, PVS, dementia, some strokes, terminal incompetence –Severely disabled newborns –Futility in terminal conditions including CPR that is unlikely to be successful, or likely to result in poor QOL DNAR decisions should be based on consensus (professionals + relatives) 7. Advance directives are legally binding on doctors.

Question 30

Aiding and abetting sudicide is...

Answer 30

illegal

Question 31

sucidie and attempted sudicie is...

Answer 31

Not illegal, however it is not clear whether this implies a legal right to commit suicide which would entail the duty of others to not interfere

Question 32

a competent patient has....

Answer 32

Competent patients have an absolute right to refuse any treatment, including a life-saving one. - The right does not depend on the prognosis or clinical status of the patient, and is considered to be different from suicide. - Thus, withdrawing life-saving treatment in the context of a patient’s refusal is not regarded as PAS.

Question 33

Euthanasia is ..

Answer 33

Euthanasia (active) - whether voluntary, involuntary or non-voluntary – is illegal and might carry a prolonged prison sentence.

Question 34

terminal sedation is

Answer 34

Terminal sedation is lawful. (a concept denoting a state where death is imminent and unavoidable, there is no consensus as to what makes a state terminal, it is sometimes construed as a sufficiency indication to deny treatment and hasten death)

Question 35

causing death of a patient who suffers from intractable pain is...

Answer 35

Causing death of a patient who suffers from intractable pain is not an offence, if done under the ‘Rule of Double Effect’.

Question 36

what categories are DNAR subject to

Answer 36

–Brain death, PVS, dementia, some strokes, terminal incompetence –Severely disabled newborns –Futility in terminal conditions including CPR that is unlikely to be successful, or likely to result in poor QOL

Question 37

are DNAR legal

Answer 37

DNAR orders, selective non-treatment, and withholding and withdrawing of life-saving treatment are not illegal but have no clear legal status. They must be subject to one of the following categories (BMA, RCN): –Brain death, PVS, dementia, some strokes, terminal incompetence –Severely disabled newborns –Futility in terminal conditions including CPR that is unlikely to be successful, or likely to result in poor QOL

Question 38

advance directives are..

Answer 38

Advance directives are legally binding on doctors

Question 39

what is the right to die with dignity defined by

Answer 39

1, reaction against the tyranny of technology 2, reaction against the emergence of severe chronic and debilitating conditions that defy medical intervention 3, reaction against medical paternalism

Question 40

Arguments for and against euthanasia/ hastening death

Answer 40

For - stops people being in pain - cost - respecting patient autonomy - good death/ death with dignity against - slipper slope from right to die to duty to die - impact on doctor patient relationship - accuracy in estimating prognosis - accuracy in how much time people should have to be allowed to think this through - complications with assisted suicide - how to stop it going wrong - protection of vulnerable people

Question 41

What is the role of relatives in relation to withdrawal of treatment in incompetent adults

Answer 41

- make enquiries as to whether someone else holds legal authority to decide which option would provide overall benefit for the patient - check for an advance directive - take responsibility for deciding which treatment will provide overall benefit to the patient, when no legal proxy exists, and you are the doctor with responsibility for the patient’s care - You must consult those close to the patient and members of the healthcare team to help you make your decisions. If a legal proxy or other person involved in the decision making asks for a treatment to be provided which the doctor considers would not be clinically appropriate and of overall benefit to the patient, the doctor should explain the basis for this view and explore the reasons for the request. If after discussion the doctor still considers that the treatment would not be clinically appropriate and of overall benefit, they are not obliged to provide it. However, as well as explaining the reasons for their decision, the doctor should explain to the person asking for the treatment the options available to them. These include the option of seeking a second opinion, applying to the appropriate statutory body for a review (Scotland), and applying to the appropriate court for an independent ruling