Ethics in End of Life Care - Elliott

Question 1

What is Narrative as it pertains to the end of life?

Answer 1

• The journey of life
• ​The last chapter in the story:
  
  • Assisting patients’ acceptance of mortality
  • The end of life is part of life, whatever age
  • Families need an acceptable narrative

Question 2

What are some of the issues in End of Life care ethics?

Answer 2

• Organ Donation (1° brain death, 2° cardiac death)
• Goals of care
• Advance care planning
• Decision points
  
  • Chemotherapy, radiation, dialysis, surgery
  • Re-hospitalization, discharge planning
  • Brain death/expected cardiac death

Question 3

Who decides a person’s Quality of Life? What is it defined by?

Answer 3

• Assessed by individual
  
  • unique to patient
• Defined by:
  
  • personal values
  • beliefs
  • priorities

Question 4

What is the difference between Foregoing vs. Withdrawing?

Answer 4

• Withdrawing
  
  • take something away
  • stop life-continuing interventions
  • e.g. extubate
• Foregoing
  
  • do not start life-continuing interventions
  • avoid CPR, feeding tube, ventilation, dialysis

Question 5

What does “Shared Decision Making” mean?

Answer 5

• Conversation about end of life cares/life-sustaining cares
  
  • discussion and decisions require patient-physician-family trust
  • facilitated by ongoing relationship
• Patient stays in charge of world and life

Question 6

When is CPR indicated?

Answer 6

• Expected vs. unexpected arrest
• Observed vs. unobserved arrest
• Comorbid conditions, prognosis
• Rarely: unobserved NH resident’s arrest
• DEPENDS

Question 7

What is POLST?

Answer 7

Physician-Ordered Life Sustaining Treatment

Question 8

What is the difference between Advanced Directives vs. POLST?

Answer 8

• Advanced Directives = wishes
• POLST = orders

Question 9

What is the difference between Temporary vs. Permanent Limitation of Nutrition/Hydration?

Answer 9

• Temporary
  
  • recovering from surgery, trauma, stroke
  • voluntary cessation of intake = natural process
• Permanent
  
  • Advancing Alzheimer’s, cachexia
  • Body shutting down (food causes more harm than good)

Question 10

What is the difference between hospice care and palliative care?

Answer 10

• Hospice
  
  • for people who are living the end of their life (expected to die within 6 months)
  • symptom management
  • not curative therapy
• Palliative
  
  • supportive care for long-term/terminal illness
  • symptom management with curative care
  • improve quality of life

Question 11

How is hospice care reimbursed?

Answer 11

• Medicare benefit for pt:
  
  • patient prognosis of 6 months or less
  • all medical care for pt paid for by them
  • housing not covered
• Capitated cost of care for provider:
  
  • provider of care reimbursed per diem
  • set amount per patient
  • doesn’t necessarily cover cost of care

Question 12

What bioethics principles (autonomy, beneficence, non-maleficence, justice) are important in end of life care?

Answer 12

aligning Autonomy and Beneficence while considering Non-maleficence and Justice

Question 13

What are three important questions to ask patients in Shared Decision Making?

Answer 13

• What are your goals if conditions worsen?
• What are your fears?
• What trade-offs are you willing to make and not willing to make?