Medical Ethics in Caring for Patients at the End-of-Life PDF

Caring for Patients at the End of Life Goals of End-of-Life Care Patients must be afforded dignity and privacy: The usual rules of confidentiality apply.  Patients should maintain control over as many aspects of their care as possible, including by advance planning if they wish.  Health profess...

Caring for Patients at the End of Life Goals of End-of-Life Care Patients must be afforded dignity and privacy: The usual rules of confidentiality apply.  Patients should maintain control over as many aspects of their care as possible, including by advance planning if they wish.  Health professionals should be sensitive to patients' cultural and religious backgrounds.  Care provided to dying patients includes helping people close to them to come to terms with the situation. Goals of End of Life Care  It is important to recognise when death is approaching and to help people prepare for it.  Compassion and sensitivity are particularly important but honest communication is also essential, while recognising that people's desire for information can vary at different stages of their illness.  Effective communication within the health team is vital so that mixed messages are avoided. Withholding Treatment, Nutrition, Hydration  Difficult decisions to withhold or withdraw lifeprolonging treatment arise if treatment can no longer provide sustained benefit to the patient.  Reasons for not providing life-prolonging treatment must be clearly communicated to individuals who have capacity, or those close to people who lack capacity.  Efforts should be made to communicate with people who appear to lack capacity. Withholding Treatment, Nutrition, Hydration  Advance care planning may indicate whether treatment should be withheld or withdrawn.  Treatment cannot be provided if patients have made a valid refusal.  Decisions for incapacitated patients are made on the basis of their best interests or what would benefit them.  Oral nutrition and hydration should be maintained as long as the patient is willing and able to tolerate it; they cannot be forced on patients who resist or refuse. Supporting an End of Life Patient  Dying patients should have opportunities to discuss matters such as where they want to die.  Giving patients the opportunity to plan aspects of their care can have a positive psychological effect. [Many organisations, defined by their country of origin] provide a nationally accepted framework for care in the last hours or days of life. Supporting an End-of-Life Patient  Patients who have made an advance decision to refuse some forms of active treatment can override their advance decision if they retain the mental capacity to do so.  When patients with capacity approach the stage where the aim shifts from curative to supportive care, decisions about the benefits or otherwise of further active treatment need to be discussed with them. Prescribing and Administering Medication General Principles  The doctor who signs a prescription accepts clinical and legal responsibility for the decision.  Doctors should prescribe medication only when they have sufficient knowledge and experience to be satisfied that it is appropriate for the patient.  It is generally unwise for doctors who prescribe to form business connections with companies that produce, market or promote pharmaceutical products. General Principles  Unless the patient objects, if the prescribing doctor is not the patient's GP, he or she should communicate with the GP in order to avoid any conflict with existing treatment. Doctors must not ask for or accept any inducement, gift or hospitality from pharmaceutical companies or others that may affect, or be seen to affect, their judgement.  Doctors can prescribe unlicensed medicines and drugs to be used outside the terms of their license but take on greater responsibilities when doing so. This is particularly true when a course of treatment is innovative or there is little evidence to support its use. Responsibility for Shared Prescribing  Legal responsibility for prescribing rests with the doctor who signs the prescription.  Hospital consultants have full responsibility for prescribing for inpatients and for specific treatments administered in hospital outpatient clinics.  Responsibility for prescribing should rest with the consultant if the drugs are included in a hospital-based clinical trial and when it is more appropriate for the consultant to monitor the medication because of the need for specialised investigations, or where there are supply problems with the drugs.  Where doctors do not feel they have sufficient knowledge or experience to be satisfied that the treatment is appropriate they should not prescribe. Responsibility for Shared Prescribing  Where doctors do not feel they have sufficient knowledge or experience to be satisfied that the treatment is appropriate they should not prescribe.  Prescribing off-label where alternative licensed medication exists for economic reasons should only be done when recommended by authoritative guidance bodies.  When a GP takes responsibility for prescribing or dispensing drugs that are not normally dispensed in the community, place a liaison between the transferring hospital and the community pharmacist. Responsibility for Shared Prescribing  When a consultant considers that a patient's condition is stable, he or she may seek the agreement of the GP concerned to share the care.  The consultant may advise the GP which medicine to prescribe.  When a new or rarely prescribed medicine is being recommended, its dosage and administration must be specified and any potential adverse drug reactions to watch out for  When a treatment is not licensed for a particular indication, full justification for the use of the drug should be given by the consultant to the GP. Responsibility for Shared Prescribing  When an inpatient is discharged from hospital, sufficient drugs should be prescribed and dispensed by the hospital pharmacy for pharmacy for at least a 7-day period.  For outpatients, a minimum 14 days' supply should be prescribed and dispensed.  The GP to whose care the patient is transferred should receive notification in good time of the patient's diagnosis and drug therapy in order to maintain continuity.  If that information cannot be transferred to the GP within the timescale, drugs should be prescribed by the hospital for as long a period as is necessary. Responsibility for Shared Prescribing  When clinical, and therefore prescribing, responsibility for a patient is transferred from hospital to GP, the GP must feel fully confident to prescribe the necessary drugs.  Transfer involving drug therapies with which the GP would not normally be familiar should not take place without full agreement between the hospital consultant (or any transferring doctor) and the GP Pressure from Patients  When faced with patients' requests for particular medication, doctors are not obliged to comply and should do so only if they are satisfied that the treatment requested is the most appropriate option for the particular patient.  Doctors have an ethical duty to use the most economic and efficacious treatment available when the patient is receiving treatment within the NHS. Pressure from Patients  Doctors must resist pressure from patients to prescribe larger doses of medication than they consider clinically appropriate or for prescriptions to be issued repeatedly without clinical review.  Lifestyle drugs should be prescribed only when the doctor considers them clinically appropriate for the patient and where the actual, or perceived, benefits outweigh any risks. Prescribing from a Distance If Then the GMC advises that doctors must Doctors  Establish the patient's current medical conditions  have sole responsibility for and history and concurrent or recent use of other a patient medications including non-prescription medicines  are working on behalf of another doctor who does  Carry out an adequate assessment of the patient's condition  are working where a doctor has prior knowledge of a patient's condition and has the authority to access his or her medical record  Identify the likely cause of the patient's condition  Ensure that there is sufficient justification to prescribe the medicines or treatment proposed and discuss other treatment options with the patient where appropriate  Ensure that the treatment and/or medicines are not contraindicated for the patient  Make a clear, accurate and legible record of all medicines Prescribing from a Distance  Prescribing by email or over the telephone could seriously compromise the standard of care provided to patients.  Doctors should think carefully about whether prescribing in this way is in the best interests of their patients.  There are serious safety risks of prescribing in cases where the patient is unknown to the doctor, there is no opportunity for examination and the arrangements for monitoring and follow up are limited. Prescribing from a Distance  Doctors are not obliged to comply with requests from patients to prescribe drugs for relatives in another country.  Those who wish to assist must be aware of the possibility of liability arising and should seek information from the patient's own doctor whenever possible in order to verify the information provided. They also need to give consideration to the practicalities of the arrangement. End of Life Decisions Once it is recognized that the patient’s conditions is incurable, palliative care offers relief from pain and distressing symptoms. It also provides support for the patient's family.  Any decision to withhold or withdraw life-prolonging treatment and why should be documented in the patient's notes.  Patients with capacity should be involved in decision making about future treatment.  Prior to withdrawing or withholding treatment, nutrition and hydration, a senior clinician should talk to the patient.