Ethics and End of Life

Question 1

Define autonomy, beneficence, non maleficence and medical futility.

Answer 1

• Autonomy;
  Respect for autonomy refers to a physician’s obligation to respect a patient’s preferences and to make decisions that accord with a patient’s values and beliefs; free and informed consent
• Beneficence: benefit the patient
• Non maleficence: do no harm
• Medical futility, the WMA defines it as treatment that “offers no reasonable hope for recovery”

Question 2

When is resus futile?

Answer 2

When the chances of good quality survival are minimal.

Question 3

What is an advanced directive?

Answer 3

Decisions about treatments provided prospectively: 2 different forms: living wills or LPAs

Question 4

What is a living will?

Answer 4

written documents that express a person’s preferences regarding the provision or the withholding of specified treatments in the event that they become unable to make decisions in the future

Question 5

What is an LPA for healthcare?

Answer 5

Lasting Power of Attorney for healthcare: allows individuals to appoint a proxy (e.g., a trusted relative or friend) who can make health care decisions on their behalf in case they lose decision-making capacity

Question 6

What criteria must these legal documents meet?

Answer 6

Three criteria:

• existence
• validity
• applicability

Question 7

What were the two clinical decision rules from the AHA Get with the Guidelines Programme?

Answer 7

• Flow chart re: likelihood to survival with good neuro outcome

Question 8

How long do we continue CPR?

Answer 8

• As long as VF persists?

- Asystole form more than 20 mins during ALS without a reversible cause - abandon.

Question 9

What is the Go Far score?

Answer 9

Outcome predictor scoring system: using 13 pre-arrest variables.
Low - good outcome, high - poor outcome.

Question 10

For how long is it difficult to predict final neurological outcome?

Answer 10

• 3 days after CA.

- 2-3 days after hypothermia terminated.

Question 11

What is ROLE? And when can you ROLE?

Answer 11

Recognition of Life Extinct.
(massive cranial and cerebral destruction, decapitation, decomposition or putrefaction, inciner- ation, dependent lividity (hypostasis) with rigor mortis, and foetal maceration.)

Question 12

When can you consider withholding/withdrawing CPR?

Answer 12

• Safety of the provider can no longer be sufficiently assured
• obvious mortal injury or irreversible death [ROLE]
• valid/relevant advance directive becomes available
• strong evidence that further CPR would be against
  patient’s values and preferences or is considered ‘futile’;
• asystole for more than 20 min despite ongoing ALS, in the absence
  of a reversible cause.

Question 13

When would you consider transporting with ongoing CPR?

Answer 13

• EMS witnessed arrest
• ROSC at any moment
• VT/VF presenting rhythym
• Presumed reversible cause

NB: consider early

Question 14

Define dysthanasia

Answer 14

Merciless prolongation of life

Question 15

What is slow code?

Answer 15

Symbolic resuscitation measures - unhurriedly/something.

Deceptive and paternalisitic.

Question 16

Tailored code

Answer 16

High quality resus but clear limits provided

Question 17

What should you do in suicidal patients?

Answer 17

CPR and address issues later

Question 18

How does organ donation link to resuscitation?

Answer 18

Aim change from saving life to preserving organs for donation. No different in outcome from receiving CPR

Question 19

How does family presence during CPR work?

Answer 19

Allow if possible and wanted.

Question 20

Principles of the Mental Capacity Act?

Answer 20

1. Presume capacity.
2. All practical steps taken to support decision-making.
3. A person should not be treated as lacking capacity merely if making, what appears to be an unwise decision.
4. An action taken on behalf of a person must be in their best interests.
5. An act or decision on someone’s behalf must be the least restrictive of a person’s rights and freedoms.

Question 21

Differences between LPA for health and welfare, and property/financial.

Answer 21

LPA health - only allowed to use when lose capacity.
A LPA must be registered with the Office of the Public Guardian (takes 8-10wks, £110). A doctor must have proof of LPA before taking any requests into account.
A LPA can be ended using a ‘Deed of Revocation’: if they still have capacity, statement to the Office of the Public Guardian. Or automatically, if the attorney dies, loses capacity or are divorced (if the spouse). If an advanced decision is written a LPA cannot override this.

Question 22

When to consider a DNACPR?

Answer 22

• a dying patient is at risk of cardiac and respiratory arrest and CPR would not clinically appropriate
• the risks and uncertain outcome of CPR could outweigh any potential benefits (medical futility)
• a patient with capacity has clearly stated they do not wish to have CPR