Dealing With Patient Death: Ethical & Legal Considerations (PDF)

Dealing with Patient Death: Ethical and legal considerations and compassionate A/Prof Carol Douglas communication A/Prof Bernadette Richards 1...

Dealing with Patient Death: Ethical and legal considerations and compassionate A/Prof Carol Douglas communication A/Prof Bernadette Richards 1 This Photo by Unknown Author is licensed under CC BY-NC-ND Acknowledgement of Country The University of Queensland (UQ) acknowledges the Traditional Owners and their custodianship of the lands on which we meet. We pay our respects to their Ancestors and their descendants, who continue cultural and spiritual connections to Country. We recognise their valuable contributions to Australian and global society. The Brisbane River pattern from A Guidance Through Time by Casey Coolwell and Kyra Mancktelow. 2 CRICOS code 00025B Commitment to Diversity and Inclusion Diverse perspectives, abilities, experiences and backgrounds inspire creativity, encourage innovation and enrich our communities. Members of our broad community are valued and respected for their individuality. UQ strives to create a culturally safe, welcoming and inclusive workplace, with strong community connections and partnerships. 3 KCP01.A2 Demonstrates kindness and compassion in clinical and professional encounters. KCP03.A2/SEC09.A2 Displays respect for patients’ spiritual, social and cultural values and the attitudes to life and death that can influence healthcare related decision. KCP06.B2 Develop awareness of the Acts, laws, rules and documents relevant to the practice of medicine across the life course. KCP06.L2/SEC09.B2 Demonstrates understanding of the concept of futile treatments, goals of end of life and palliative care and advance care planning. 4 Aim of the session: This session will provide you with the opportunity to reflect on the importance of empathy in end-of- life care along with the common challenges, fears and barriers encountered in discussing prognosis, treatment options and death. Effective communication strategies will be discussed along with specific end of life documentation and relevant law At the end of this session the following key concepts will have been discussed; Communication and end of life decision-making Empathy and end of life care Advance care planning and statement of choices Law at the end of life 5 Autonomy The patient's right to self-determination What does the patient want? Remember that patients have a right to determine how they wish to die. Does the patient have decision-making capacity to determine what they want? If they are competent, we must prioritise the patient’s autonomous decision. If they are not competent, is it possible to know how they felt or what they might have wanted in this situation, e.g., previously stated wishes or an ACD? Does the patient have all the information? Sometimes, family members and friends will not wish for a patient to die, but it is the patient’s autonomy that is the primary focus in healthcare. 6 This Photo by Unknown Author is licensed under CC BY Beneficence Acting in the patient's best interests A competent adult is the best judge of what is in their best interests (holistically – clinical, relational, cultural, economic, personal values etc). Medical best interests – to treat the disease or underlying condition or to end the pain Personal values – to die with dignity Relational – to not isolate family members and friends in the process Cultural – if the patient has particular cultural beliefs regarding death and dying Where a person’s wishes are not known how do we determine what is in their best interests? Who determines it? This Photo by Unknown Author is licensed under CC BY  Non-maleficence Would not following the patient’s wishes do more harm than good? Not following their wishes means: The patient continues to physically suffer Likely die in a way they do not wish which is psychologically harmful Cultural harm if the patient’s wishes are not respected. Following the patient’s wishes means they will die (Sanctity of Life argument) Remember that patients at the end of life can be vulnerable and may need further protection from harm. This Photo by Unknown Author is licensed under CC BY Justice Distributive - Fairness and equality Ensuring end-of-life options are not restricted by limits of resources Rights-based - Respecting patient rights including: The right to have one’s wishes respected The right to be treated with dignity and respect Legal – Being accountable under the law Palliative care; Withdrawal and withholding of life-sustaining treatment; or Voluntary assisted dying This Photo by Unknown Author is licensed under CC BY Guidelines: 10 Key Messages 1. There are different processes for deciding when life sustaining medical treatment should be provided and when it should be withdrawn 2. Always begin with the clinical question – what is good medical practice and in the patient’s best interests. Then consider the legal questions. 3. There are specific considerations in an emergency situation and consent is not required. However, if there is knowledge of a refusal of treatment then that must be considered. 4. Unilateral decisions to withhold or withdraw life sustaining treatment are not lawful (except in some emergency situations). The Guardianship and Administration Act 2000 provides that a collaborative approach is expected. 5. There is a legal requirement to document the decision-making pathway to every decision to withhold or withdraw life sustaining measures 6. Notes that all documents are not equal. Advance Health Directives (AHDs) is the ‘only document that act as the person’s decision-maker should they lose capacity. 7. Ethical considerations are guidelines 8. Resuscitation planning is a subset of advance care planning which should be discussed ‘early in the disease trajectory’ 9. Patients with capacity can refuse treatment even if this results in their death 10. There is no legal or ethical obligation to provide treatment that is considered futile. 10 Life Sustaining Measures: Guardianship and Administration Act 2000 : Health care intended to sustain or prolong life and that supplants or maintains the operation of vital bodily functions that are temporarily or permanently incapable of independent operation Specific inclusions: Cardiopulmonary resuscitation Assisted ventilation Artificial nutrition and hydration NB: A blood transfusion is not a life sustaining measure 11 Considerations Whether an urgent decision is required If the patient has capacity Whether the patient is terminally ill If the patient requests treatment or refuses treatment Whether the patient has set out their decisions in an AHD If the AHD is valid Whether the patient formally appoints a substitute decision-maker 12 Advance Care Planning: Advance Health Directive (AHD): A legally recognised expression of will and preferences Activated when the individual loses capacity Forms downloaded from the Department of Justice and Attorney General https://www.justice.qld.gov.au/public-advocate/our-advocacy/health/advance-care- planning To be recognised under the Guardianship laws, an AHD must be: 1. a written document 2. signed by the adult person (or by an ‘eligible signer’ on the adult’s behalf) 3. signed and dated by an ‘eligible witness’ and certified that the document was signed in their presence and the adult appeared to them to have capacity 4. signed and dated by a doctor (not the witness) and certified that the adult appeared to the doctor to have capacity to make the AHD 14 Other means of planning: Statement of Choices Developed in 2013/14 by Metro South Hospital and Health Service – provides indication of wishes at end of life but is really about guiding discussions and is not recognised under the legislation therefore can’t be relied upon in the same way as the AHD. Common Law Directives Not legally binding in Queensland – directive only Acute Resuscitation Plan An acute resuscitation plan is a medical order which prescribes what treatment will be provided where it can be reasonably expected that a patient might suffer an acute event in hospital in the foreseeable future necessitating the process of resuscitation planning 15 Hierarchy of Decision-Makers (Guardianship Act, s66) If they have made an AHD giving direction about the matter, may only be dealt with under the direction If the Tribunal has made an order appointing one or more guardians, then they must make the decision If there is a document appointing one or more attorneys, then they will have authority If none of the above apply, then the statutory health attorney (s66) AND A consent to the withholding or withdrawal of a life sustaining measure for the adult cannot operate unless the adult’s health provider reasonably considers the commencement or continuation of the measure for the adult would be inconsistent with good medical practice (s66A) 17