End Life Issues Slides PDF

WE MAKE DOCTORS Medical Ethics Issues related to death/dying/palliative care Montserrat Ezquerra, MD Palliative care & Pain Medicine  Objectives Identify the foundational ethical principles relevant to end-of-life care Recognize specific ethical dilemmas that commonly arise in end-of-life ca...

WE MAKE DOCTORS Medical Ethics Issues related to death/dying/palliative care Montserrat Ezquerra, MD Palliative care & Pain Medicine  Objectives Identify the foundational ethical principles relevant to end-of-life care Recognize specific ethical dilemmas that commonly arise in end-of-life care situations Critically assess the impact of ethical decisions on end-of-life care outcomes. Introduction The goal of end-of-life care for dying patients is to prevent or relieve suffering as much as possible while respecting the patients’ desires. Important to protect the rights, dignity, and vigor of all parties involved  Ethical principles Autonomy is considered a patient’s right to self- determination. At the end of life, the priority of making decisions belongs to the patient.(capacity) ADs help ensure that → patient’s advance directives (Ads) patients receive the care → The proxy health care is second in decision-making on they want Guide the patients’ behalf of the patient. family To limit the use of If no AD or proxy, the decision-making is up to the family expensive, invasive, and members. If family members avoid making decisions, the useless care healthcare team must make a decision. Researches show that ADs improve the quality of end- of-life care and reduce the burden of care https://www.hhs.texas.gov/formas/advance-directives The advance directive form can be completed and signed either by the patient or, if the patient lacks capacity, a surrogate. The form is completed after a series of conversations between the patient and health care providers about the patient's medical condition, prognosis, and values and personal goals for end-of-life care. In contrast to a living will or healthcare proxy, which act only if the patient loses decision-making capacity, advance care directive forms apply independent of the decision-making capacity of the patient at the time of application. Next of kin surrogate decision maker A person appointed to make medical or legal decisions on behalf of someone who is unable to do so themselves due to illness, injury, or incapacity. This person is typically a close family member, such as a spouse, adult child, or parent, who is legally recognized to make decisions in the best interest of the incapacitated individual. Their role involves ensuring that medical treatments and other decisions align with the person's wishes and best interests.  Physicians, MUST provide all the information about their patients’ condition when appropriate. They have a duty to provide detailed information to patients and, if necessary, to the patients’ decision-makers about advanced medical treatments that can be used during end-of- life care Orders and legal considerations in end-of- life care Code status: Full code: make all efforts to resuscitate DNR: do-not-resuscitate order DNI: do-not-intubate order DNR orders may be accompanied by do not intubate (DNI) orders.  A patient's code status should be confirmed verbally with the patient or their appropriate surrogate at each hospital admission, regardless of the previous status, and documented. A patient's code status may nonetheless be unknown at the time vital interventions are necessary Question Video Discussion  Withholding vs Withdrawing Withholding Withdrawing Decision not to initiate or start a particular Cessation or discontinuation of a medical medical intervention or therapy for a patient, intervention or therapy that is currently being often because it is deemed medically provided to a patient. inappropriate, futile, or not in alignment with This decision is made after careful consideration the patient's wishes or best interests. of the patient's condition, prognosis, quality of life, and treatment goals. This decision is typically made when the May occur when the intervention is no longer potential risks, burdens, or ineffectiveness of effective, when it is causing undue suffering, or the treatment outweigh the expected benefits. when the patient or their surrogate decision- maker requests it in accordance with their wishes or advance directives. It is important to note that withdrawing treatment is distinct from euthanasia or physician-assisted suicide, as it involves the cessation of a specific treatment rather than actively causing the patient's death.  Withdrawal of care Patients with decision-making capacity (or their surrogate) have the right to refuse any form of treatment at any time, even if doing so would result in the patient's death. There is no ethical distinction between withholding care and withdrawing care at a later time. The physician should make an effort to understand the reasons behind the patient's decision for refusing treatment. Patients who opt to withdraw from treatment and have limited life expectancy may be approved for hospice care/palliative care Provide extra help and information for families that are interested, e.g., psychosocial counseling Persistent vegetative state (PVS) The decision to maintain a patient in PVS depends on their advance directive or surrogate decision-maker and should be made with the patient's best interests in mind Medical aid in dying Physician-assisted dying Physician provision of medication, intervention, or information to a patient to enable or accelerate their death Illegal in most states The U.S. Supreme Court has ruled three times that the laws of physician-assisted death are to be decided on a state-by-state basis. Medical aid in dying Euthanasia Active and intentional termination of a patient's life, usually by sedative or paralytic, performed by the physician at the explicit request of the patient Requires the full process of informed consent before initiation Currently illegal in the U.S. Medical aid in dying Terminal sedation The administration of sedative medication to a terminally ill patient to relieve intractable end-of-life pain Legal and distinct from euthanasia The intent must be to relieve pain rather than bring about death, even though doing so may hasten the dying process. An act may be justified when the positive effects outweigh the negative ones (e.g., administering large amounts of opioids to relieve pain despite causing respiratory depression). The Supreme Court also said it's okay for patients to receive terminal sedation, where they're made unconscious and life-support treatments like food and water are stopped, as long as the patient agrees and the double effect principle is followed. Double effect principle “The principle of double effect provides justification in which the process is based on the intended outcome of pain and symptom relief and the proportionality of benefit and harm. The intent of palliative sedation is to relieve suffering in dying patients but not to deliberately hasten death.” It's okay for doctors to give medications that help patients feel better, like painkillers, even if they might also speed up the patient's death.  Administering Palliative Care Administering Medications for Symptom Relief During the Dying Process Supreme Court made a clear distinction between assisted dying and palliative care. They accepted a principle called the "double effect" to explain this difference. But there are rules: Main goal must be the patient's relief, not causing their death. The doctor should know that the medicine might make the patient die sooner, but they shouldn't want that to happen. The good effects of the medicine should outweigh the bad ones. In other words, it's okay to take a small risk of death to help a terminally ill patient feel better, but only if there's no safer way to do it. Pronouncing death If a patient dies while under care, it is generally the physician's responsibility to examine the body to pronounce the death and record the time. Clinicians may also be called to the bedside for declaration of death. In some states, registered nurses (especially in hospice settings) are authorized to pronounce death Emergency response teams may pronounce a person “Dead on Arrival” (DOA) if certain criteria are met (e.g., obvious postmortem changes or injuries that are incompatible with life such as decapitation or evisceration of thoracic contents). Question  Patients who are in severe pain can appear as though they have major depression even when they do not. Pain control is one of the most important facets of ethics for USMLE. Always fully treat pain, even if the patient has history of drug abuse. It is acceptable to give high doses of pain medication that may inadvertently facilitate end of life. For USMLE, the general rule is: never withhold adequate pain management no matter what. It is never okay to allow patients to suffer from pain. Resources Akdeniz, M., Yardımcı, B., & Kavukc, E. (2021). Ethical considerations at the end-of-life care. SAGE Open Med, 9, 20503121211000918. doi:10.1177/20503121211000918 AMBOSS Medical Ethics for the Boards, Third Edition 3rd Edición