End of life - Ethics

Advance Care Directives

• Advance care directives are independent of a patient's decision-making capacity at the time of application
• Advance Care Directives are different from living wills or healthcare proxy appointments

Surrogate Decision Makers

• A surrogate decision-maker is appointed to make medical or legal decisions on behalf of an incapacitated individual.
• The surrogate decision-maker is typically a close family member, such as a spouse, adult child, or parent.
• Their role is to ensure medical treatments and decisions align with the incapacitated individual's wishes and best interests

Physician Duties

• Physicians must provide all information about their patients’ conditions.
• Physicians should provide detailed information to patients and their decision-makers about advanced medical treatments that can be used during end-of-life care

Code Status

• Full code: make all efforts to resuscitate
• DNR: do-not-resuscitate order
• DNI: do-not-intubate order
• A patient's code status should be documented and confirmed with the patient or surrogate at each hospital admission.
• A patient's code status may be unknown at the time vital interventions are necessary

Withholding vs Withdrawing Treatment

• Withholding treatment is deciding not to initiate or start a particular treatment.
• Withdrawing treatment is ceasing or discontinuing a treatment that is currently being provided.

Pronouncing Death

• The physician typically pronounces death and records the time of death.
• In certain states, some registered nurses can pronounce death.
• Emergency response teams may pronounce a person "Dead on Arrival" (DOA) if criteria are met (e.g., obvious postmortem changes or injuries incompatible with life).

Pain Management

• Pain control at end-of-life care is essential.
• It is acceptable to give high doses of pain medication that may inadvertently facilitate end of life.
• Never withhold adequate pain management.

Refusal of Treatment

• Patients with decision-making capacity (or their surrogate) have the right to refuse any form of treatment at any time.
• Physicians should understand the reasons behind a patient's decision to refuse treatment.
• Patients who opt to withdraw from treatment and have limited life expectancy may be approved for hospice care/palliative care.

Persistent Vegetative State (PVS)

• The decision to maintain a patient in PVS depends on their advance directive or surrogate decision-maker.

Medical Aid in Dying

• Physician-assisted dying involves the physician providing medication, intervention, or information to a patient to enable or accelerate death.
• Physician-assisted dying is illegal in most states.
• The U.S. Supreme Court has ruled that the laws of physician-assisted death are to be decided on a state-by-state basis.

Withholding and Withdrawal of Artificial Nutrition

• The level of evidence required to withhold or withdraw artificial nutrition has been compared to evidentiary standards in criminal cases.
• Similar to criminal cases, the system errs on the side of caution. It would be preferable to withhold nutrition in a questionable case rather than potentially allowing someone to die who may have wished otherwise.
• It is generally accepted that decisions about providing or withholding artificial nutrition and hydration (ANH) for patients lacking capacity should be made based on the same standards as any other medical treatment.
• Some states have stricter standards for withholding or withdrawing ANH compared to other medical treatments.

Physician-Assisted Suicide

• Physician-assisted suicide is considered ethically unacceptable even when it is legal.
• The physician provides the means for the patient to end their own life.
• The physician does not administer the substance that ends the patient's life.

Withholding and Withdrawal of Medical Treatment

• Every competent adult has the right to decide which medical treatments they receive.
• There is no ethical or legal distinction between withholding and withdrawing medical treatment.
• A patient's right to refuse treatment applies whether it is a new treatment or a treatment they have already received.

Advance Directives

• Living wills are a form of advance directive that can overrule family wishes.
• Living wills are difficult to make comprehensive because it is hard to predict which medical treatments may be required in the future.
• A health-care proxy can provide more flexibility in decision-making.
• If a patient has written out specific conditions and treatments, a living will can be useful.

Decision-Making for Patients Without Capacity

• An adult with capacity can make their own decisions about treatment.
• An adult without capacity can have their decisions made by a health-care proxy or living will if it is clear and specific.
• Most patients, even elderly or terminally ill patients, lack a formal advance directive.
• This often makes decision-making difficult.

This quiz covers essential concepts surrounding advance care directives, surrogate decision-makers, physician duties regarding patient information, and code status classifications. It is designed to enhance understanding of crucial end-of-life decisions and the responsibilities of healthcare professionals in these scenarios.