VAD Flashcards
Discuss advance directives
In cases of life saving/prolonging/maintaining treatment the patient is often unable to make a clear decision as they are unconscious.
Family etc. have no decision-making rights; but they can help clarify the patients wishes.
Those with statutory guardianship (‘enduring power of attorney’) can make healthcare decisions, including refusal / cessation of LST.
However, they should be in a position to show this is what the patient would have wanted i.e. an advance directive.
If they cannot, they still have decision making power, but it is constrained by ‘patient wishes’, ‘least restrictive option’ and ‘best interest’ test in the same way the decision making of doctors is constrained if it falls to them.
Established in common law. Formal legislation exists everywhere except NSW and Tas.
An AD may be invalid under formal legislation but still valid as a matter of common law.
Providing treatment that has been refused in a valid and applicable AD amounts to treating a patient against their will i.e. a criminal act.
A request for treatment may be justifiably refused.
A valid AD may be made orally or written, it requires the person to have capacity, able to communicate, free from coercion.
For an AD to be applicable it should:
- not be ambiguous (‘heroic measures’ also application to circumstances)
- continue to reflect patient’s wishes (i.e. no evident change of belief)
- be correct in its underlying assumptions about treatment.
Discuss exceptions to AD law
IN QUEENSLAND
An Advance Directive refusing LST is only valid if the patient has a terminal illness or a condition that is incurable and be within a year of death.
Or they are in a PVS/ permanently unconscious.
Or have no reasonable prospect of recovery such that LST will no longer be needed.
And: No prospect of regaining capacity; ANH may only be foregone if it is consistent with good medical practice. Drs cannot be compelled to act against GMP, meaning it may be possible to treat patient despite an AD refusing treatment.
In SA: A patient who lacks capacity (dementia, say) may overrule an AD.
Discuss withholding and withdrawing life saving treatment
In some cases, withholding treatment—an inaction— seems to be ethically correct e.g. withholding CPR from those unlikely to benefit, surgery from those unlikely to survive, antibiotics (for pneumonia) from those who are (actively) dying (from cancer).
In others it does not e.g. failing to correct a duodenal atresia in a neonate with Down’s syndrome.
In other cases, withdrawing treatment seems ethically correct, e.g. removing life support from those in PVS, but the simple fact that it entails taking positive action gives some healthcare professionals reluctant.
Recall Dax Cowart, he was conscious and could express his wishes, something not shared by the following cases.
Recall some cases of withholding/withdrawing treatment
SOME CASES (USA):
Karen Ann Quinlan (1954-1985):
In April 1975, and whilst on a ‘crash diet’, Quinlan took valium and alcohol, after which she collapsed, became comatose and was subsequently diagnosed as being in a PVS (although not peaceful). In Sept. 1975 her parents petitioned court to end mechanical ventilation, which the court appointed guardian argued would amount to homicide. In 1976 ventilation was removed but, unexpectedly, Quinlan continued breathing unaided. Transferred to a nursing facility and given ANH, Quinlan remained alive until 1985.
Terri Schiavo (1963-2005):
In 1995 Schiavo suffer a cardiac arrest and although resuscitated suffered brain damage and was diagnosed as being in a PVS. In 1998 her husband petition for the removal of her feeding tube, something her parents objected to. Feeding tubes were removed and reinserted in 2001 and 2005. Legal and public court battles continued until 2005.
SOME CASES (UK & ITALY):
Tony Bland (1970-1993):
A victim of the 1989 Hillsborough disaster, Bland suffered brain damage and was diagnosed as being in a PVS. Having been told that he would be charged with murder Bland’s doctor, with the agreement of his parents, applied to the court to remove ANH. This was granted. The case is often used to exemplify the view that ordinary care (nutrition and hydration) can be considered extraordinary as a function of they way it is delivery (PEG/ ANH).
Eluana Englaro (1970-2009):
In 1992 Englaro was diagnosed as being in a PVS as a result of a car accident. Medical staff initiated feeding. On the basis of his daughters previously expressed views, her father argued it should be withdrawn. Early legal appeals to stop nutrition failed, and Englaro was kept alive for the next 17 years. Fresh appeals were successful in 2009.
A CONTINUING ISSUE
11 Years in a PVS (2008-19)
6 years of legal battles.
His father, Pierre Lambert, 90, described the court decision as “murder in disguise” and “madness.”
Vincent Lambert, a psychiatric nurse, suffered severe brain damage in a traffic accident in 2008 that left him a quadriplegic.
Discuss the concept of futility
When we say that treatment is futile we mean it will not work, it will not be effective.
However, there are different ways of understanding what this means, and different senses in which we might say treatment is futile.
Physiologic Futility: Treatment will not have the desired physiologic effect.
Quantitative Futility: Treatment will not benefit the patient given the low probability of success.
Qualitative Futility: Treatment will not benefit the patient given the low quality of the outcome.
Some distinguish between ‘hard’ and ‘soft’ futility.
Has some clinical utility, but argued that it may not be so useful.
Discuss issues with the concept of futility
Perhaps we can solve the issue of withdrawing/ withholding using the concept of futility? A treatment can be considered futile when its goals are unachievable. But who gets to define the goals of treatment and who decides if they have been achieved? Futility cannot be determined objectively: 1. Absolute or statistical physiological futility 2. Qualitative or evaluative futility. For some, another day (or month, or year) on life support or with advancing dementia is not a goal worth pursuing. For others it clearly is. Academics suggest abandoning the term, but it continues to have significance in clinical practice. Talk of futility should always engender reflection: to what degree is an objective assessment being made? To what degree is it evaluative? Would it be better to talk of interventions that are (in)appropriate?
What is the distinction between killing and letting die?
The traditional view is that there is a moral difference between killing and letting die. The former is always wrong, the latter is not.
This view is often associated with the ‘doctrine of double effect’ (Aquinas) according to which it is permissible to bring about a bad effect by a good act if the bad effect is unintended, even if it is foreseen.
James Rachels (1941-2003) challenged this view, arguing there is no moral difference between killing and letting die. He used the example of Smith and Jones who stand to inherit if their cousin dies. Smith drowns his cousin; Jones plans to but finds his cousin has already fallen into the bath and is drowning. He does nothing.
Rachels argument is that the only difference between Smith and Jones is the means by which they bring about their cousin’s death. But this is morally irrelevant. What matters is their intention.
Discuss euthanasia
The term euthanasia is derived from the Greek words eu (good) and thanatos (death) and refers to the practice of intentionally ending a life in order to relieve pain and suffering.
There are various forms of euthanasia:
- Voluntary euthanasia: where the person who is killed has requested to be killed.
- Non-voluntary euthanasia: where the person who is killed made no request and gave no consent.
- Involuntary euthanasia: where the person who is killed made an expressed wish to the contrary.
Euthanasia can be further divided into:
- Active euthanasia: where someone actively does something that causes the patient to die.
- Passive euthanasia: where someone does not do something necessary to keep the patient alive.
VAD, MAiD etc.
Voluntary Assisted Dying (VAD) and Medical Aid in Dying (MAiD) are terms used to describe the practice where a physician provides a patient with the means to end their own life, typically through the self-administration of a lethal dose of medication.
The practice is legal in a growing number of jurisdictions around the world, including some states in Australia, Canada, Belgium, the Netherlands, Luxembourg, and Switzerland.
The conditions under which VAD/MAiD is permitted vary, but typically include that the patient must be suffering from a terminal illness, be in significant pain or suffering, and have a clear and persistent request for assistance in dying.
The debate around VAD/MAiD often centers on issues of autonomy, dignity, the relief of suffering, the role of the physician, and the potential for abuse or slippery slopes.
Discuss action and inaction
We intuitively feel that there is a significant moral difference between acts & omissions (inaction). Ergo: between not starting treatment (inaction) and stopping treatment (action). But: We do not start treatment because we think it will not succeed. However, treatment is brought to an end when it becomes clear that it has not or will not succeed.
An inability to withdraw treatment risks withholding it from those who may benefit. It also means we will encounter difficulties when treatment is no longer warranted. Perhaps we should distinguish between doing & allowing. When we withdraw treatment we are doing something, we act; but do we kill or merely allow to die?
Discuss the equivalence thesis
If it would have been morally permissible to have withheld a therapy (that has in fact already been started), then it is now morally permissible to withdraw that therapy; and: If, in the future, it would be morally permissible to withdraw a therapy (that has in fact not yet been started), then it is now morally permissible to withhold that therapy. (Sulmasy & Sugarman 1994, 218)
PRIMA AND SECUNDA
A pair of baby twins arrive in the ER suffering from smoke inhalation. Their clinical situation is exactly the same. Only one life support machine is available. The clinical team assign it to Prima, meaning that Secunda will almost certainly die. The parents arrive and, prior to any clinical change in the twins, they indicate that they would prefer Secunda to receive treatment (for non-clinical / non-moral reasons). At this stage, the clinical team refuse to reassign the life support machine. However, if the parents had arrived at the same time as the twins, they would have been likely to accede to the request.
A challenge to the equivalence thesis.
DOES MORAL EQUIVALENCE MATTER?
Some (relatively contrived) cases of withdrawing and withholding appear to be morally equivalent. Thus, asking oneself ‘would I do this if it were a case of withholding rather than withdrawing’ can be useful, but should not be taken as definitive. One should also keep in mind that although withholding involves inaction and withdrawing involves action both are things we actively decide to do: both require reflection, reason, and justification. Thus: ≈ both are kinds of action for which you can be held responsible. Just as when we provide treatment, each instance of withdrawing or withholding should be given due consideration on its own merits.
Discuss palliative care and continuous sedation
Curative medicine seeks to return patients to their own lives, so that they might independently pursue their own priorities and do so in the manner of their choosing. Palliative care seeks to assist patients in leading their lives and to support them in the pursuits they wish to prioritize in the time that they have left.
Continuous Deep Sedation: A response to refractory or intractable pain and suffering in actively dying patients. Sedated to the point of unconsciousness, and until death. Some have suggested it is ‘slow euthanasia.’ Rarely implemented in clinical practice.
What are the conditions of VAD?
To be eligible a person must:
- be 18 years or older;
- be an Australian citizen or permanent resident who is ordinarily resident in Victoria;
- have decision-making capacity in relation to voluntary assisted dying;
- be diagnosed with a disease, illness or medical condition that is incurable, advanced, progressive and will cause death, and is expected to cause death within < 12 months;
- be experiencing suffering that cannot be relived in a manner that the person considers tolerable.
Excludes mental illness and disability. To access voluntary assisted dying the patient must make a clear and unambiguous request to a medical practitioner. No other individual, including one who has power of attorney, can make the request. It cannot be made in an Advanced Care Directive.
VOLUNTARY ASSISTED DYING IN VICTORIA
A coordinating medical practitioner checks eligibility and discusses:
- the diagnosis and prognosis;
- the available treatment options and their likely outcomes;
- the palliative care options and their likely outcomes;
- the potential risks of taking a poison or controlled substance under the Bill;
- that the expected outcome of taking the poison or controlled substance is death; and
- that the person may withdraw from the process at any time. Consulting medical practitioner confirms all criteria
