Ethical Consideration in Death/Dying Flashcards
1
Q
Decisional Capacity
A
- Provider makes determination based on clinical examination that a patient is able to make decisions for him/herself
- Differs from competency
- Patient can receive information, evaluation/analyze the information, and communicate a treatment preference
- Providers should look for understanding, logic, and consistency
2
Q
Informed Consent
A
- Purpose is to promote autonomy of the individual in medical decision making
- May be viewed as counter productive to physician ideals of patient’s well-being
- Process where provider discloses information to help a patient make healthcare choices
- Requires 3 conditions: patient is able to make a voluntary decision, informed, and has capacity to make medical decision
3
Q
Advanced Directives
A
- 2 types: Living will (list of what they want done if patient becomes incompetent), decision-maker/surrogate
- POLST Paradigm Program: starts in 1991, standardized advance care planning document to be completed by healthcare professional with patient or surrogate decision maker
- Active medical order transferred with patient through HC system
4
Q
Sudden Cardiac Arrest
A
- Several factors have been identified that increase likelihood of survival to hospital discharge: witnessed arrest, VT/VF as initial rhythm, pulse regained during first 10 minutes of CPR
- 24.2% of patients of any age
- CPR not intended for dying patients in an expected death from chronic illness
5
Q
DNR Orders
A
- No code or allow natural death
- Usually after failing multiple therapeutic interventions
- Main goal to avoid life-sustaining measures that would be futile or could cause harm in the patient’s final days or hours
- DOESN’T mean don’t treat
- May include DNI
6
Q
Problems with DNRs
A
- Discussions don’t occur enough for patient’s preferences regarding resuscitation
- Delayed too late for patients to participate in resuscitation
- Physician don’t provide adequate information to make decisions
- Physicians inappropriately extrapolate DNR orders to limit other treatments
7
Q
Surrogate Decision Maker
A
- AKA Healthcare proxy
- Named by patient when he/she had capacity and is a family member or close acquaintance designated by law or statute
- NM Uniform HC Decision Act identify surrogate in descending order: spouse, close/long term relationship, adult child, parent, adult brother/sister, grandparent
8
Q
Withdrawing Care
A
- Asssuming all treatment is stopped, including hydration/feeding death may occur in minutes, hours to days, or stable cardiopulmonary fxn could lead to different care plans including hospital discharge
- Family should be informed about steps involved and counseled on oxygen and medications for symptom support
9
Q
Medical Futility
A
- Serving no useful purpose, ineffective
- Interventions have no pathophysiological rationale, cardiac arrest despite max treatment, failed intervention
- No goals can be achieved, success likelihood is very small, QoL is unacceptable
10
Q
Futility Domains
A
- Phsiological/Quantitative Futility: proposed intervention CANNOT achieve desired effect
- Imminent-demise futility: likelihood that patient will die in very near future
- Lethal-condition futility: patient has terminal illness that will result in death in near future, intervention doesn’t affect illness
- Qualitative futility: quality of benefit an intervention will provide is exceedingly poor
11
Q
Determining Futility
A
- Doesn’t apply to treatments globally, particular interventions at particular times for specific patients
- Futile treatments can be continued temporarily to help patient or family come to terms with situation
- Allow for closures/goodbyes
- Shouldn’t be used to benefit family member if causing substantial suffering or at odds to patient
12
Q
Problems with Invoking Futility
A
- Judgements are often mistaken or problematic
- Futility applies to few patients
- Unilateral decisions polarize parties
- Value judgements may be masked as scientific expertise
- Physicians don’t understand they are not obligated to offer/recommend all interventions
13
Q
Chemotherapy at EOL
A
- Palliative vs curative intent
- Elderly significantly underrepresented in trials but growing population
- Lack of adequate/ongoing conversation between patient and physician
- Can decrease quality of remaining life or even shorten survival time
- Violates nonmaleficence
14
Q
Ethical Issues Unique to Long Term Care
A
Control/Choice
- Loss of fxnal impairment and increasing dependency
- Loss of decision making capacity
- Limited access to services and specialists
Psychosocial
- Social and spiritual isolation
- Limited availability of family
- Depression
- Loss of privacy
EoL
- Higher rates of untreated pain/other symptoms
- Quality standards/reimbursement incentives support restorative/tech intense care over labor-intensive palliative care
15
Q
Euthanaisa
A
- “Good death”
- Legal in Netherlands, Belgium, Luxembourg, Columbia, and Canada
- ~50% of physicians in these countries received such a request while <20% received it in US
- EXIT laws in Switzerland ruled all people of sound judgement (even in mental illness cases) have right to decide manner of death
- No laws against suicide since 1937, can assist suicide in physically sick if altruistic reasons
16
Q
Physician Aid-In-Dying
A
- Legal in 10 US states
- Overruled in Supreme Court as a right in NM
- Elizabeth Whitefield EoL Options Act: Terminally ill patient determined to have capacity and ability to self-administer oral medication
17
Q
Lethal Medication
A
- Rx shouldn’t be filled until 48 hours after it was written
- Indicate time/date Rx written and first allowable time/date for its fill
- Secobarbital is commonly used, phenobarbital and morphine can also be used
- 9 capsules in secobarbital in juice on empty stomach with antiemetics 1 hour prior to ingestion
18
Q
Morphine and Hastened Death
A
- Many inaccurate believe morphine has a high risk of causing death in elderly and EoL
- Double effect principle: safe to use when used with appropriate titrations and monitoring
- Drowsiness => confusion => loss of consciousness => respiratory depression
19
Q
Pharmacist Role
A
- ASHP Statement on Pharmacist Participation in Medical Aid in Dying
- Inclusion on care team
- Medication dispensing and counseling
20
Q
Palliative/Terminal Sedation
A
- Estimated to be used in 15-30% of dying
- Provided to both cancer and non-cancer patients
- Incidence varies based on setting, patient population, culture/ethics - LOTS of variance in definitions
- Lowers awareness into unconsciousness for patients with severe/refractory symptoms
21
Q
Refractory Symptoms
A
- Aggressive palliative treatments have failed or have produced intolerable side effects
- Additional treatments are unlikely to provide adequate relief without intolerable side effects
- Patient is likely to die before conventional treatment could work
- Commonly used for pain, dyspnea, delirium, N/V, agitation/restlessness, seizure, myoclonus
- >50% of patients receiving PS have >1 qualifying symptom
22
Q
Why are we still uneasy about PS
A
- Moral experiences: evolving terminology doesn’t remove all ethical concerns, causes family distress and believed to hasten death
- Practice Variation: intent (symptom relief), advanced knowledge of symptom management and palliative care, variance by provider and country
- Difficulty with prognostication
- Need for improved communication, education, guidelines
- Loss of holistic approach to human suffering
23
Q
Existential Suffering
A
- No concise definition
- Lack of meaning or purpose, loss of connectedness, thoughts about dying, loss of autonomy and temporality
- Concerns about separating physical symptoms from spiritual/psychological distress
24
Q
Use of Medical Cannabis
A
- Lack of efficacy from RCTs regarding efficacy/safety
- Lack of data/unstandardized dosing (no FDA approval)
- Most commonly smoked, palliation of many symptoms experienced in terminal illness
- Variation in THC contents
25
Q
Psychedelics
A
- Higher levels of existential/spiritual well being with improved QoL and decreased depression/hopelessness
- Considered integral component of care
- Psilocybin not shown to be addictive and may have anti-addictive effects (used for alcoholism and cancer distress in 50-70s)
