Med-105 End of Life Ethics Handouts May 2023 PDF

End of Life Ethics MD-6, Year 1 May 2023 Dr Andreas A. Prokopiou Assistant Professor in Medical Ethics and Law Dr Andreas Prokopiou 1 Learning Objectives Discuss key ethical and legal issues which may arise in the End of Life Care. Explain different types of euthanasia and summarise two different co...

End of Life Ethics MD-6, Year 1 May 2023 Dr Andreas A. Prokopiou Assistant Professor in Medical Ethics and Law Dr Andreas Prokopiou 1 Learning Objectives Discuss key ethical and legal issues which may arise in the End of Life Care. Explain different types of euthanasia and summarise two different country approaches on euthanasia. Outline the ethical arguments for and against euthanasia and Physician Assisted Suicide. Explain how the “Doctrine of Double Effect” is utilised in medical practice. Dr Andreas Prokopiou 2 Overview Introduction to Palliative Care Ethics Euthanasia – law and ethics Suicide and Assisted Suicide – law and ethics Doctrine of Double Effect Dr Andreas Prokopiou 3 Can you recognise that person? Dr Andreas Prokopiou 4 What is palliative care? Dr Andreas Prokopiou 5 What is palliative care? Latin root: “to cloak” “Medical care that concentrates on reducing the severity of symptoms rather than trying to provide a cure or halt the progression of the disease” (HMS) “An approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering” (WHO). Dr Andreas Prokopiou 6 What is the relationship between palliative care and end of life care? Is palliative care the same as end of life care? No. Although it can include end of life care, palliative care is much broader and can last for longer. Having palliative care doesn't necessarily mean that you're likely to die soon – some people have palliative care for years. Dr Andreas Prokopiou 7 Some of the challenging ethical questions in clinical medicine surround care and decision making at the end of life. Dr Andreas Prokopiou 8 Case Study 1 Mrs Smith, a 75 year old female, was admitted to the hospital with terrible chest pain, dyspnoea, cough, fever and headache. Mrs Smith has a history of lung cancer, which she is in a terminal stage. Over the next few days Mrs Smith’s condition worsened. The on-call resident who was unfamiliar with the case transferred her to the Intensive Care Unit. During the night Mrs Smith suffered an acute nose bleed and aspirated blood in her lungs, therefore she was intubated. Mrs Smith is now laying in the ICU depending on a ventilator. Mrs Smith’s son and daughter-in-law remained hopeful that “she was a fighter” and would turn around. She has another son who lives abroad. Family was uncertain of what to do because they have never discussed it before. Dr Andreas Prokopiou 9 To Relieve or to Treat? What do you think is the most appropriate approach What kind of concerns are presented in Mrs Smith case? Dr Andreas Prokopiou 10 The case of Mrs Smith presents several concerns: 1. Mrs Smith fails to receive adequate pain and symptoms management. 2. Inadequate communication between the patient, family and clinical team. 3. Goals of care were not discussed while Mrs Smith was still able to communicate. 4. The family never realised the severity of Mrs Smith’s condition. 5. Junior doctors unfamiliar with issues on terminal patients. 6. Is being on a ventilator a better option? Dr Andreas Prokopiou 11 Why to relieve from pain? Dr Andreas Prokopiou 12 Case Study 2 The case of Dr Liam Dr Liam a GP, is giving to his wife every day small doses of Arsenic (a poison which can kill her). The wife is not suffering from any disease, is healthy and happy with her life. Arsenic is one of the most toxic metals derived from the natural environment. Can you legally justify his actions and how? Dr Andreas Prokopiou 13 Case Study 2 The Case of Dr Liam Your comments on the case. Dr Andreas Prokopiou 14 Case Study 3 The case of Dr Cox Lillian Boyes was a 70 year old woman with very severe rheumatoid arthritis, the pain of which seemed to be beyond the reach of analgesics. She was expected to die within a matter of days or weeks. She asked her doctor, Dr Cox, to terminate her life. Out of compassion for his patient, and because this is what she wanted him to do, Dr Cox injected a lethal dose of potassium chloride. (R v Cox ) Dr Andreas Prokopiou 15 Case Study 4 The case of Brother Fox During routine operation, Brother Fox (83y) suffered cardiac arrest and it caused substantial brain damage. He lost the ability to breath on his own and the hospital put him on respirator. F. Eichner the local director of the society asked the hospital to remove the respirator. The hospital replied that they would remove it only to a court order. F. Eichner applied to the courts for authority to direct that the respirator be removed. (R v stores [NY 1981]) Dr Andreas Prokopiou 16 Case Study 5 The case of Dr Kevorkian Two patients with a terminal illness went to Dr Kevorkian and asked him for help committing suicide. He provided them with drugs and information and they were successful. Dr Andreas Prokopiou 17 A Linguistic & Conceptual Maze Suicide Assisted Suicide Euthanasia Passive Euthanasia Active Euthanasia Dr Andreas Prokopiou 18 Euthanasia Easy or good death What the law says Dr Andreas Prokopiou 19 Active Euthanasia (AE) The physician takes an active and deliberate step to end the patient’s life, for example by injecting potassium chloride into the patient. Dr Andreas Prokopiou 20 Passive Euthanasia (PE) Dr Andreas Prokopiou 21 Passive Euthanasia Intentionally letting a patient die by withholding artificial life support such as a ventilator or feeding tube. Some ethicists distinguish between withholding life support and withdrawing life support (the patient is on life support but then removed from it). Dr Andreas Prokopiou 22 Give another example of Passive Euthanasia Not giving medication or not performing a surgery that would save the patient's life are instances of passive euthanasia. Dr Andreas Prokopiou 23 Active & Passive Suicide?! Most definitions of suicide assume that suicide must be active, but that may not necessarily be the case. Sometimes patients refuse life-saving treatment, but it is unclear whether this amounts to suicide. In any case, the Mental Capacity Act (2005) states that patients with capacity can refuse life-saving treatment. Also the Human Rights Act (1998) protects the right to freedom from inhuman and degrading treatment and the right to private and family life. The Suicide Act (1961) also states, as we have seen, that suicide is not unlawful. Dr Andreas Prokopiou 24 Suicide Suicide may be defined as the act of intentionally ending one’s own life. The act of suicide requires the victim to take his or her own life. Dr Andreas Prokopiou 25 Assisted Suicide (AS) Assisted suicide is suicide undertaken with the aid of another person. The term usually refers to physician-assisted suicide (PAS), which is suicide that is assisted by a physician or another healthcare provider. Dr Andreas Prokopiou 26 Voluntary Euthanasia Behaviour which caused the patient’s death at the patient’s request. Dr Andreas Prokopiou 27 Non-Voluntary Euthanasia Non-voluntary euthanasia occurs when the person is unconscious or otherwise unable (for example, a very young baby or a person of extremely low intelligence) to make a meaningful choice between living and dying, and an appropriate person takes the decision on their behalf. Dr Andreas Prokopiou 28 Non-Voluntary Euthanasia Behaviour which causes euthanasia without the consent or objection of the patient (i.e. Where the patient is unable to consent or object). Dr Andreas Prokopiou 29 Non-Voluntary Euthanasia Behaviour which euthanasia causes without the consent or objection of the patient (i.e. Where the patient is unable to consent or object). Dr Andreas Prokopiou 30 Arguments for Euthanasia Consistency Suicide is accepted From passive to active euthanasia From painkillers to lethal injections Appeal to principles Autonomy Beneficence Dr Andreas Prokopiou 31 Arguments against Euthanasia Sanctity of Life Palliative Care Slippery Slope Argument Killing is Wrong Non-Maleficence Physician Integrity Protection of the Vulnerable Dr Andreas Prokopiou 32 The Law in England Whether suicide is ethical or not is debatable, but it is not unlawful in England: “The rule of law whereby it is a crime for a person to commit suicide is hereby abrogated.” Whether assisted suicide is ethical or not is also debatable, but assisted suicide (including PAS) is unlawful in England:“A person who aids, abets, counsels or procures the suicide of another, or an attempt by another to commit suicide, shall be liable on conviction” Whether euthanasia is ethical or not is up for debate too, but euthanasia is illegal in England: “It is a form of homicide (i.e. manslaughter or murder)” Dr Andreas Prokopiou 33 Many cases… Dr Andreas Prokopiou 34 Euthanasia in different countries Euthanasia is legal in the Netherlands (2001), Belgium (2002), Colombia, Western Australia, Spain, Canada and Luxembourg (2009). Assisted suicide is lawful in the Netherlands (2001), Belgium (2002), Switzerland, Germany, Victoria (Australia) and parts of the USA (Washington, Oregon, Vermont, Colorado, Hawaii, New Jersey, California and Montana), Canada (2016) Uruguay ????? http://www.assistedsuicide.org/suicide_laws.ht ml Dr Andreas Prokopiou 35 Case Study 6 Anna is a 67 year old with advanced bowel carcinoma. She is admitted and is likely to die within days. She is in a great deal of pain which is not relieved by analgesics. Dr Smith wonders whether terminal sedation should be initiated. This will probably relieve Anna’s pain, but it may hasten the patient’s death. Anna just wants to stop suffering the pain. Dr Andreas Prokopiou 36 Case Study 6 If Dr Smith uses terminal sedation can he be said to have committed (active) euthanasia? Would he be responsible for Anna’s death? What would be the cause of death? Dr Andreas Prokopiou 37 Terminal Sedation Dr Andreas Prokopiou 38 Terminal Sedation In medicine, specifically in end of life care, palliative sedation (also known as terminal sedation, continuous deep sedation, or sedation for intractable distress of a dying patient) is the palliative practice of relieving distress in a terminally ill person in the last hours or days of a dying person's life, usually by means of a continuous intravenous or subcutaneous infusion of a sedative drug, or by means of a specialized catheter designed to provide comfortable and discreet administration of ongoing medications via the rectal route. Dr Andreas Prokopiou 39 The intension of an action if Dr Smith prescribes the high dose diamorphine with the intention of relieving Anna’s pain (even though he foresees that this may shorten Anna’s life) this is not a form of euthanasia. if Dr Smith prescribes the diamorphine with the intention of killing Anna (even though he may have done this to relieve Anna’s pain) this is a form of euthanasia. Dr Andreas Prokopiou 40 The doctrine of double effect ✓Thus, as long as Dr Smith intended to reduce Anna’s suffering and did not intend her death, he is very unlikely to be found guilty of murder. Dr Andreas Prokopiou 41 The doctrine of double effect ✓the nature of the act is not bad ✓at least one of the act’s consequences is good ✓at least one of the act’s consequences is bad ✓there is a sufficiently serious reason for allowing the bad consequence to occur ✓the bad consequence is not a means to the good consequence ✓the agent foresees the bad consequence but intends the good consequence Dr Andreas Prokopiou 42 The legality of doctrine of double effect (DDE) The law allows the doctrine of double effect to apply in some cases: ✓“a doctor may…lawfully administer painkilling drugs despite the fact that he knows than an incidental effect of that application will be to abbreviate the patients life” ✓Lord Goff in Airedale NHS Trust v. Bland 1 All ER 821 HL. Dr Andreas Prokopiou 43 “Death Tourism” Recent years have seen a number of high profile cases in which people have accompanied their relatives or friends to Dignitas (in Switzerland) where a cocktail of drugs that can cause death can be offered: Daniel James (23 year old paralysed playing rugby) Sir Edward & Lady Joan Downes (multiple conditions; cancer) Dr Anne Turner (supranuclear palsy) Dr Andreas Prokopiou 44 Case study 7 Ms Purdy sought reassurance that husband would not be prosecuted if he went with her to Dignitas The essence of her case turned on the ambiguity of prosecution guidance and the variable response of the CPS to previous cases House of Lords allowed the appeal and required the DPP to issue guidance setting out the circumstances under which he would prosecute someone who accompanied a relative Dr Andreas Prokopiou 45 DPP : The Director of Public Prosecution Factors that will weigh in favour of prosecution: Under 18 Questions about capacity No clear, settled and informed wish to die Equivocal about dying Process not initiated by person who dies No terminal illness, severe and incurable physical disability or severe degenerative disease Not motivated by compassion (or motivated by gain) Evidence of persuasion, coercion, undue influence or pressure Dr Andreas Prokopiou 46 DPP : The Director of Public Prosecution Factors that will weigh against prosecution:✓A clear, settled and informed wish to die ✓Unequivocal and consistent about dying ✓Process was initiated by person who died ✓Person had terminal illness, severe and incurable physical disability or severe degenerative disease with no possibility of recovery ✓Evidence that suspect was motivated solely by compassion ✓Person offering assistance is spouse, partner, close relative or friend within context of long-standing and supportive relationship ✓Assistance provided was minor Dr Andreas Prokopiou 47 Withholding and Withdrawing LifeSustaining Treatment (1/2) GMC End of Life Care - Guidelines (112) Clinically assisted nutrition includes intravenous feeding, and feeding by nasogastric tube and by percutaneous endoscopic gastrostomy. (113) Providing nutrition and hydration by tube or drip may provide symptom relief or prolong or improve the quality of the patient’s life. (114) Nutrition and hydration provided by tube or drip are regarded in law as medical treatment, and should be treated in the same way as other medical interventions. Dr Andreas Prokopiou 48 Withholding and Withdrawing LifeSustaining Treatment (2/2) Question Withholding or withdrawing artificial nutrition or hydration can be considered as euthanasia? Discuss such a case between you. Dr Andreas Prokopiou 49 More Questions… What are key disputes in the controversy over euthanasia? Killing vs. letting die: There is dispute over whether killing a patient is really any worse than letting the patient die if both result in the same outcome. Ordinary vs. extraordinary treatment: Ordinary medical treatment includes stopping bleeding, administering pain killers and antibiotics, and setting fractures. Death intended vs. anticipated: Some ethicists believe that if a suffering, terminally-ill patient dies because of intentionally receiving pain-relieving medications, it makes a difference whether the death itself was intended or merely anticipated. Dr Andreas Prokopiou 50 What ethical issue does the following extract from the Hippocratic Oath allude to? “I will neither give a deadly drug to anyone if asked for it nor will I make a suggestion to this effect.” Dr Andreas Prokopiou 51 Further Resources ‘A Short Stay in Switzerland’ (BBC drama based on the experiences of Dr Anne Turner and her family) ‘Real Lives: Right to Die’ (Sky documentary following Professor Craig Ewart’s decision to end his life) www.carenotkilling.org.uk www.dignityindying.org.uk www.healthcareprofessionalsforchange.org.uk ‘Easeful Death: Is There A Case for Assisted Dying?’ by Mary Warnock A Time to Live by George Pitcher ‘Euthanasia, Ethics and the Law: From Conflict to Compromise’ by Richard Huxtable Against Physician Assisted Suicide: A Palliative Care Perspective by David Jeffrey Papanikitas A.(2015) Crash Course Medical Ethics and Sociology (ebook) Dr Andreas Prokopiou 52 Conclusion ✓End of life issues is one of the more distressing aspects of medicine. ✓The law and ethics of end of life care is complex. ✓The distinction between killing someone and allowing someone to die. ✓Arguments about the rightness or wrongness of different types of euthanasia. ✓Remember that everyone’s approach to their own mortality is different. Respect their individuality and autonomy (within the confines of the law and professional/ethical guidance) Dr Andreas Prokopiou 53 Thank you Dr Andreas Prokopiou 54 Untreated pain could result in: a. Medical complications. b. Decrease of physical independence. c. Threatens patient autonomy. d. Increase fear, anxiety, depression. e. Longer hospital stays. Dr Andreas Prokopiou 55