Ethical Principles in Palliative Care Session 5

Question 1

Ethics

Answer 1

Moral judgement whether an action
towards a person is right or wrong

Question 2

Ethics and Palliative Care

Answer 2

Palliative care does not aim to hasten death but to enhance quality of life for both patients and their loved ones.

Question 3

Common ethical issues confronted by nurses in palliative care context:

Answer 3

Disclosure of disease to patient/family members

Treatment to alleviate symptoms

End-of-life care decisions

Withholding or withdrawing of artificial
hydration and nutrition.

Question 4

Nurses’ Responsibilities

Answer 4

1.Provide appropriate care

2. Be honest
3. Maintain confidentiality
4. Maintain good relationship with patient and family
5. Maintain trust by managing potential conflict of
   interest/values

Question 5

Ethical Principles

Answer 5

1. Autonomy
2. Beneficence
3. Nonmaleficence
4. Justice

Question 6

Autonomy

Answer 6

The ability of an adult of sound mind to make decision
concerning his/her own life.

Relevant issues:
* Respecting a person’s choice and dignity
* Informed consent
* Communication, honesty and truthfulness

Question 7

5 Statutory Principles of
Mental Capacity Act

Answer 7

1. Assume a person has capacity unless the opposite is proven.
2. Take all practicable steps to help a person make their own decision.
3. A person has the right to make an unwise decision.
4. Always act in the person’s best interest.
5. Choose the less restrictive option.

Question 8

Beneficence and Nonmaleficence

Answer 8

Beneficence and non-maleficence are normally considered together as two sides of one coin.

• Relevant issues:
• Moral engagement.
• Evaluation of benefit and harm.
• Treatment options.
• Provision of appropriate education.

Question 9

Justice

Answer 9

• Ranging from fairness in the treatment of individuals to
  equitable allocation of healthcare resources or budget.

Relevant issues:

• Distribution of resources
• Respect for people’s rights
• Respect for morally acceptable laws

Question 10

Artificial nutrition
and hydration Definition

Answer 10

Artificial nutrition and hydration is defined as the nutritional and
hydration support of an invasive nature requiring the placement of a tube into the alimentary tract or parenterally via intravenous or subcutaneous means.

Decisions on artificial nutrition and hydration must be made on an
individual basis. Communications with patient and family is an important component of this decision.

Question 11

Advantages of hydration

Answer 11

Some evidence suggests that artificial hydration for patients with intestinal
obstruction or delirium secondary to opioid toxicity may be useful

Question 12

Disadvantages of hydration

Answer 12

Artificial hydration can cause fluid overload, throat/respiratory secretions and
peripheral oedema. There is a need for IV/SC cannula to deliver hydration

Question 13

What if patients feel thirsty?

Answer 13

Most of the thirst sensation results from dry oral mucosa and lips. Patients with
good oral care are less likely to feel thirsty.

Studies have shown that artificial hydration does not affect thirst sensation in terminally ill patients

Question 14

Will patients die hungry?

Answer 14

Patient towards the end of life have decreased oral intake and poor appetite. This is part of the natural process of dying and patients do not feel hungry at this stage. In fact, force feeding them may result in vomiting

Question 15

Will patients starve to death?
“Patient will die hungry”

Answer 15

There is a lack of evidence to suggest this. Patients who are terminally ill will die from their underlying condition rather than from starvation.

Question 16

artificial nutrition and hydration management

Answer 16

Discuss ideas, concern and expectations of family and patient
regarding artificial nutrition and hydration. Most families have
unfounded fears about thirst and hydration which can be
addressed by the team.

Most terminally ill patient do not benefit from artificial nutrition
and hydration whether in survival or symptoms.

“Patient will die hungry”- Explain to family that decreased oral
intake and anorexia is a normal process of dying, patients rarely
feel hungry.

Monitor drug dosages and consider reducing doses as patient takes
less fluid progressively.

“Pleasure feeding” if patient is alert enough to consume orally.

Check regularly for bowel output, which may still be present
despite having no oral intake.

Use of time limited trial of hydration may be useful in some
cases. Have clear goals about intended outcomes and consider
stopping if these goals are not achieved after a stated period of
time or when burdens outweighed benefits (e.g. increased
respiratory secretions or peripheral oedema).

Oral care should be part of routine care.

Question 17

At-Own-Risk (AOR) Feeding

Answer 17

Refers to the decision for oral feeding despite compromised
swallowing safety.

Not keen for non-oral feeding.

Understand and accept risk of
aspiration and possible
complications.