Ethics Consult Service: A Case Study Walter Limehouse, MD, MA MUSC Ethics Committee

Ethics Consult Ethics Consult Service: A Case Service: A Case

StudyStudyWalter Limehouse, MD, MAWalter Limehouse, MD, MA

MUSC Ethics CommitteeMUSC Ethics Committee

ObjectivesObjectives

Using a case studyUsing a case studyexplore ethical principlesexplore ethical principlesdiscover how the ECS may discover how the ECS may

help resolve ethical concerns help resolve ethical concerns in patient management.in patient management.

Case Study:Case Study: 79 year old woman has aged 79 year old woman has aged

gracefullygracefully Very independent, lives alone. Very independent, lives alone. Ten days ago while out shopping Ten days ago while out shopping

experienced a massive stroke experienced a massive stroke required endotracheal intubation by required endotracheal intubation by

EMS. EMS. She remains in ICU on a She remains in ICU on a

ventilator.ventilator.

Case Study: Case Study: 79 year old woman has aged 79 year old woman has aged

gracefullygracefully

No advance directive. No advance directive. Widow with three Widow with three

children children


gracefullygracefully local daughterlocal daughter

“ “don’t keep mom on ventilator” don’t keep mom on ventilator” admits no related talks with admits no related talks with mothermother

daughter from NYC – newly daughter from NYC – newly arrivedarrived

“ “do everything”do everything” son from CA - travels frequentlyson from CA - travels frequently

not yet notifiednot yet notified


gracefullygracefully MD wantsMD wants

withdraw ventilator withdraw ventilator tracheostomy and feeding tubetracheostomy and feeding tube

QuestionsQuestions

What is the difference between What is the difference between ethics committees and ethics ethics committees and ethics consult services?consult services?

How may ECS help resolve How may ECS help resolve ethical concerns in patient care?ethical concerns in patient care?

ETHICS COMMITTEEETHICS COMMITTEE MUHA CommitteeMUHA Committee within Center for within Center for

Clinical Effectiveness and Patient SafetyClinical Effectiveness and Patient Safety CharterCharter

Facilitate shared clinical decision-Facilitate shared clinical decision-makingmaking within ethical framework by within ethical framework by patients, family members or surrogate patients, family members or surrogate decision makers, and staff. decision makers, and staff.

Subcommittee structureSubcommittee structure on education, on education, policy development and review, and clinical policy development and review, and clinical ethics consultationethics consultation

Ethics Consultation Ethics Consultation ServiceService

Service branch of the Ethics CommitteeService branch of the Ethics Committee Multiprofessional groupMultiprofessional group

Nurses, physicians, chaplains, community Nurses, physicians, chaplains, community representatives, an attorney, other clinicians representatives, an attorney, other clinicians

PROVIDING HELP FOR DIFFICULT AND PROVIDING HELP FOR DIFFICULT AND COMPLEX PATIENT CARE DECISIONS COMPLEX PATIENT CARE DECISIONS

Providing help with professional conflicts Providing help with professional conflicts


PROVIDING HELP FOR DIFFICULT PROVIDING HELP FOR DIFFICULT AND COMPLEX PATIENT CARE AND COMPLEX PATIENT CARE DECISIONSDECISIONS Identify the ethical issuesIdentify the ethical issues Identify the ethically appropriate Identify the ethically appropriate

treatment optionstreatment options Provide problem-solving and Provide problem-solving and

informational expertiseinformational expertise Promote efforts to work out the conflict Promote efforts to work out the conflict

among the participants, if necessary among the participants, if necessary


Difficult & Complex Patient Care Difficult & Complex Patient Care Decisions Decisions differences in opinion among caregivers differences in opinion among caregivers

and/or family members about treatment and/or family members about treatment end of life decision-making end of life decision-making surrogate decision-makers and/or patient surrogate decision-makers and/or patient

advance directives advance directives questions about policies, such as questions about policies, such as

resuscitation or withholding/withdrawing resuscitation or withholding/withdrawing life-sustaining treatment life-sustaining treatment

QuestionsQuestions How do Advance Directives differ How do Advance Directives differ

from Health Care Powers of from Health Care Powers of Attorney?Attorney?

Who are health care surrogates and Who are health care surrogates and under what standard do surrogates under what standard do surrogates act?act?

Who may be patient surrogates Who may be patient surrogates under SC Law?under SC Law?

Advance DirectivesAdvance Directives Statements by competent Statements by competent

decision-makersdecision-makers Interventions to accept or refuse if they Interventions to accept or refuse if they

lose decision-making capacitylose decision-making capacity Who may act as surrogateWho may act as surrogate

Advance DirectivesAdvance Directives Oral StatementsOral Statements

To family members or friendsTo family members or friends Informed? Specific treatment/ situations? Informed? Specific treatment/ situations?

Repeated?Repeated? To physiciansTo physicians

Written documentsWritten documents Living willLiving will Health care proxy / power of attorneyHealth care proxy / power of attorney

Advance DirectivesAdvance Directives Oral StatementsOral Statements

Limited by court requirements for Limited by court requirements for evidenceevidence ““Beyond reasonable doubt”Beyond reasonable doubt” ““Clear and convincing”Clear and convincing”

May require mention of specific May require mention of specific intervention and clinical situationintervention and clinical situation

““Preponderance of evidence”Preponderance of evidence”

Advance DirectivesAdvance Directives Written documentsWritten documents

Living willLiving will Directs physicians to withdraw or Directs physicians to withdraw or

withhold specific life-saving withhold specific life-saving treatments if patient has terminal treatments if patient has terminal condition or persistent vegetative condition or persistent vegetative statestate

What is “terminal condition”What is “terminal condition” Which treatments “merely prolong dying Which treatments “merely prolong dying

process”process”

Advance DirectivesAdvance Directives Written documentsWritten documents

Health care proxy / power of Health care proxy / power of attorneyattorney Decision-making priority over other Decision-making priority over other

potential surrogatespotential surrogates Applies to all medical situations where Applies to all medical situations where

decision-making capacity is lostdecision-making capacity is lost Substituted judgmentSubstituted judgment

Patient’s previously expressed choices or Patient’s previously expressed choices or best interestsbest interests

Healthcare SurrogateHealthcare Surrogate Has authority to make healthcare Has authority to make healthcare

decisions for patient who has lost decisions for patient who has lost decision-making capacity decision-making capacity

StandardsStandards Substituted judgment (if patient’s wishes Substituted judgment (if patient’s wishes

known)known) Best interestBest interest

ADULT HEALTH CARE CONSENT ACT ADULT HEALTH CARE CONSENT ACT SC Code of Laws, Title 44 Chapter 66SC Code of Laws, Title 44 Chapter 66

ADULT HEALTH CARE ADULT HEALTH CARE CONSENT ACTCONSENT ACT

Priority of SurrogatesPriority of Surrogates Legal guardian, attorney-in-fact Legal guardian, attorney-in-fact

appointed by the patient in a durable appointed by the patient in a durable power of attorney, statutory power of attorney, statutory surrogate given prioritysurrogate given priority

Spouse, unless legally separated Spouse, unless legally separated Parent or adult child of the patient Parent or adult child of the patient adult sibling, grandparent, or adult adult sibling, grandparent, or adult

grandchild of the patient grandchild of the patient

ADULT HEALTH CARE ADULT HEALTH CARE CONSENT ACTCONSENT ACT

Priority of Surrogates (2)Priority of Surrogates (2) any other relative by blood or any other relative by blood or

marriage who reasonably is believed marriage who reasonably is believed by the health care professional to by the health care professional to have a close personal relationship have a close personal relationship with the patient;with the patient;

person given authority to make person given authority to make health care decisions for the patient health care decisions for the patient by another statutory provision.by another statutory provision.


gracefullygracefully No consensus obtained on withdrawal of No consensus obtained on withdrawal of

care. Tracheostomy done and care. Tracheostomy done and PEG-tube inserted. PEG-tube inserted.

Three months pass. NY sister has Three months pass. NY sister has accused the local sister and physicians accused the local sister and physicians of "wanting to murder mother." NY of "wanting to murder mother." NY sister camps out in patient's room; local sister camps out in patient's room; local sister visits infrequently; brother has sister visits infrequently; brother has appeared, but has difficulty mediating appeared, but has difficulty mediating between sisters.between sisters.


gracefullygracefully Patient successfully weaned from Patient successfully weaned from

ventilator, but no change in mental ventilator, but no change in mental status. Has spontaneous eye opening, status. Has spontaneous eye opening, but does not otherwise respond.but does not otherwise respond.

She develops pneumonia and incipient She develops pneumonia and incipient respiratory insufficiency. Nurses respiratory insufficiency. Nurses express discomfort about continuing express discomfort about continuing "futile" care."futile" care.

QuestionsQuestions What is persistent vegetative state What is persistent vegetative state

(PVS)?(PVS)? How do Quinlan, Cruzan, Schiavo How do Quinlan, Cruzan, Schiavo

cases affect care of persons in PVS?cases affect care of persons in PVS?

Quinlan, Cruzan, SchiavoQuinlan, Cruzan, Schiavo

www..trinity.edu www..trinity.edu

Vegetative StateVegetative State

No cortical functionNo cortical function No purposeful activity No purposeful activity Can not obey verbal commandsCan not obey verbal commands Can not experience painCan not experience pain

Preserved brainstem functionPreserved brainstem function Breathing and circulation intactBreathing and circulation intact Not comatose (has sleep-wake Not comatose (has sleep-wake

cycles)cycles)

Vegetative StateVegetative State

Preserved brainstem function Preserved brainstem function (2)(2) Roving eye movements, may trackRoving eye movements, may track Reflexes intact (not replicable)Reflexes intact (not replicable)

Suck, chew, swallowSuck, chew, swallow Pupillary, oculocephalic, deep tendon Pupillary, oculocephalic, deep tendon

reflexesreflexes Withdrawal, posturing, startle to noiseWithdrawal, posturing, startle to noise

Persistant Vegetative Persistant Vegetative StateState

Vegetative state lasting over Vegetative state lasting over one monthone month Nontraumatic injury waking rareNontraumatic injury waking rare

after 3 monthsafter 3 months Traumatic injury waking rare after Traumatic injury waking rare after

1 year1 year Mean survival 2-5 years, some over Mean survival 2-5 years, some over

15 years15 years


Tube feeding requiredTube feeding required Unable to swallow or protect airwayUnable to swallow or protect airway

Incontinent, requiring total Incontinent, requiring total nursing carenursing care

Common complicationsCommon complications Decubitus ulcersDecubitus ulcers Aspiration pneumoniaAspiration pneumonia UrosepsisUrosepsis


Other neurologic catastrophesOther neurologic catastrophes Brain deathBrain death – no cortical or brainstem – no cortical or brainstem

functionfunction Locked-in syndromeLocked-in syndrome – conscious, – conscious,

minimal motorminimal motor Severe dementiaSevere dementia – conscious, poorly – conscious, poorly

responsive; some motorresponsive; some motor

Quinlan, Cruzan, Quinlan, Cruzan, SchiavoSchiavo

Karen Ann Quinlan caseKaren Ann Quinlan case 21 year-old woman in PVS on 21 year-old woman in PVS on

ventilator (1975)ventilator (1975) had ingested alcohol and sedatives had ingested alcohol and sedatives

during partyduring party Physician beliefsPhysician beliefs

would never regain consciousnesswould never regain consciousness would die off ventilatorwould die off ventilator


Karen Ann Quinlan case (2)Karen Ann Quinlan case (2) FatherFather

supported by chaplain, Catholic priest supported by chaplain, Catholic priest and Diocese of New Jerseyand Diocese of New Jersey

wanted ventilator stoppedwanted ventilator stopped requested court appointment as requested court appointment as

guardian with authority to stop guardian with authority to stop ventilator when physicians refusedventilator when physicians refused


Karen Ann Quinlan case (3)Karen Ann Quinlan case (3) New Jersey Supreme Court ruling New Jersey Supreme Court ruling

(1976)(1976) SUBSTITUTED JUDGEMENTSUBSTITUTED JUDGEMENT Right to privacy included right to decline Right to privacy included right to decline

medical treatment – guardian could exercise this medical treatment – guardian could exercise this right – permitted to render best judgment right – permitted to render best judgment whether whether patient would choose to whether whether patient would choose to decline treatmentdecline treatment

Withdraw ventilator if guardian, family, Withdraw ventilator if guardian, family, physicians, and ethics committee agree no physicians, and ethics committee agree no possible recovery of cognitive statepossible recovery of cognitive state


Karen Ann Quinlan case (4)Karen Ann Quinlan case (4) First “right to die” caseFirst “right to die” case exploring exploring

dilemma that life-sustaining interventions dilemma that life-sustaining interventions inappropriate in some circumstancesinappropriate in some circumstances

Decision-making by patients, family, Decision-making by patients, family, and physiciansand physicians without routine recourse without routine recourse to courtsto courts

Hospital ethics committees Hospital ethics committees development development supportedsupported

Survived 10 years PVS post ventilator removalSurvived 10 years PVS post ventilator removal


Nancy Cruzan caseNancy Cruzan case 26 year-old woman in PVS post-MVA 26 year-old woman in PVS post-MVA

(1983)(1983) ParentsParents asked feeding gastrostomy be asked feeding gastrostomy be

removed (1986)removed (1986) State hospitalState hospital requested court order requested court order Cruzan statementCruzan statement prior to MVA made to prior to MVA made to

housemate “not want to live as vegetable” housemate “not want to live as vegetable”

– – family supported statementfamily supported statement


Nancy Cruzan case (2)Nancy Cruzan case (2) Missouri Supreme Court (1986)Missouri Supreme Court (1986) Restricted decision-making for Restricted decision-making for

incompetent patientsincompetent patients withhold life-sustaining treatment only if withhold life-sustaining treatment only if

living will or clear statement that specific living will or clear statement that specific intervention not wanted in specific situationintervention not wanted in specific situation

Unqualified state’s interest in Unqualified state’s interest in preserving lifepreserving life


Nancy Cruzan case (3)Nancy Cruzan case (3) U.S. Supreme Court (1990)U.S. Supreme Court (1990)

Competent patientsCompetent patients have have “constitutionally protected liberty “constitutionally protected liberty interest in refusing unwanted medical interest in refusing unwanted medical treatment”treatment”

Constitution may rely on familyConstitution may rely on family decision-making, but not requireddecision-making, but not required


Nancy Cruzan case (4)Nancy Cruzan case (4) U.S. Supreme Court (1990)U.S. Supreme Court (1990)

StatesStates may establish “procedural may establish “procedural

safeguards” for medical decisions safeguards” for medical decisions for incompetent patientsfor incompetent patients

may require life-sustaining may require life-sustaining interventions absent clear evidence interventions absent clear evidence incompetent patient would refuseincompetent patient would refuse


Nancy Cruzan case (5)Nancy Cruzan case (5) U.S. Supreme Court dissentsU.S. Supreme Court dissents

Brennan, Marshall, BlackmunBrennan, Marshall, Blackmun Freedom from unwanted treatments is Freedom from unwanted treatments is

fundamental right of competent and fundamental right of competent and incompetent patientsincompetent patients

Decisions for incompetent patients by Decisions for incompetent patients by families or patient-designated surrogates families or patient-designated surrogates


Nancy Cruzan case (6)Nancy Cruzan case (6) U.S. Supreme Court dissentsU.S. Supreme Court dissents

StevensStevens Constitution requires that patients’ best Constitution requires that patients’ best

interest interest

be followedbe followed


Nancy Cruzan case outcomes Nancy Cruzan case outcomes (6)(6) Established “right to die”Established “right to die” - tube - tube

removedremoved additional witnesses validated Cruzan additional witnesses validated Cruzan

wishes, physician decided to support wishes, physician decided to support feeding stop, Missouri withdrew court feeding stop, Missouri withdrew court proceedingproceeding


Nancy Cruzan case outcomes Nancy Cruzan case outcomes (7)(7) Support for legislation on advance Support for legislation on advance

directivesdirectives state laws on health proxiesstate laws on health proxies federal Patient Self Determination federal Patient Self Determination

Act (1991)Act (1991) written advice upon admission written advice upon admission

about right to advance directiveabout right to advance directive


Theresa Shiavo caseTheresa Shiavo case 27 year-old woman in PVS27 year-old woman in PVS post post

cardiac arrest due to potassium cardiac arrest due to potassium abnormalities (1990)abnormalities (1990)

1998 1998 – husband requests court to – husband requests court to discontinue feedings; parents oppose discontinue feedings; parents oppose feeding tube removalfeeding tube removal

Trial court ruledTrial court ruled clear evidence patient clear evidence patient would want tube removed, decision would want tube removed, decision appealedappealed


Theresa Shiavo case (2)Theresa Shiavo case (2) 20022002 – overwhelming evidence patient in – overwhelming evidence patient in

PVS with no potential treatment benefit PVS with no potential treatment benefit Florida appellate courtFlorida appellate court denies appeals; denies appeals;

Florida Supreme Court declines caseFlorida Supreme Court declines case 2003 Florida legislature2003 Florida legislature passes “Terri’s passes “Terri’s

law”law” Governor authorized to stay removal of feeding Governor authorized to stay removal of feeding

tube challenged by family membertube challenged by family member


Theresa Shiavo case (3)Theresa Shiavo case (3) 20042004 Florida courtFlorida court declares “Terri’s declares “Terri’s

law” unconstitutional – Florida law” unconstitutional – Florida Supreme Court affirms decisionSupreme Court affirms decision

2005 Congress2005 Congress passes legislation to passes legislation to move case to federal court – US move case to federal court – US Supreme Court refuses caseSupreme Court refuses case


Theresa Shiavo case Theresa Shiavo case outcomes(4)outcomes(4) Feeding tube removedFeeding tube removed Written advance directiveWritten advance directive

importance illustratedimportance illustrated Family disagreementsFamily disagreements requiring court requiring court

intervention highlightedintervention highlighted


Theresa Shiavo case Theresa Shiavo case outcomes(4)outcomes(4) Third party interferenceThird party interference in end-of-life in end-of-life

decision-making occurreddecision-making occurred SC actSC act to provide nutrition and to provide nutrition and

hydration to incompetent patient hydration to incompetent patient without advanced directive proposedwithout advanced directive proposed

QuestionsQuestions

Does withholding/withdrawing Does withholding/withdrawing care differ?care differ?

What is “futile care” (medically What is “futile care” (medically ineffective treatment)?ineffective treatment)?

Withholding/withdrawing Withholding/withdrawing

Life-sustaining Life-sustaining TreatmentsTreatments

No ethical differenceNo ethical difference Courts consistently rule no Courts consistently rule no

differencedifference Passive vs active actionPassive vs active action

– – patient wishes more patient wishes more importantimportant

Withholding/withdrawingWithholding/withdrawing Life-sustaining Life-sustaining

TreatmentsTreatments Autonomy of competent Autonomy of competent

patient/surrogatepatient/surrogate Informed consent justifies treatmentInformed consent justifies treatment Informed refusal justifies foregoing or Informed refusal justifies foregoing or

discontinuing treatmentsdiscontinuing treatments Decide by weighing benefits and Decide by weighing benefits and

burdensburdens Minimize disability and painMinimize disability and pain Relieve sufferingRelieve suffering Avoid harmAvoid harm

Futile treatmentFutile treatment Ordinary vs extraordinary Ordinary vs extraordinary

treatmenttreatment – – no differenceno difference Given patient preferences,Given patient preferences,

examine benefit and burden of examine benefit and burden of treatmentstreatments

****Medically Ineffective Treatment********Medically Ineffective Treatment**** provides little/ no benefit with undue burdenprovides little/ no benefit with undue burden

****futile********futile****

QuestionsQuestions

How does “Allow Natural Death” How does “Allow Natural Death” differ from “Do Not differ from “Do Not Resuscitate”?Resuscitate”?

How does “distributive justice” How does “distributive justice” affect treatment?affect treatment?

AND versus DNRAND versus DNR

Do Not ResuscitateDo Not Resuscitate relays patient/family wish … no relays patient/family wish … no

resuscitation attempts (CPR) start resuscitation attempts (CPR) start if patient diesif patient dies

does not stop treatment…changes does not stop treatment…changes goal to comfort care goal to comfort care


Do Do NotNot Resuscitate Resuscitate (2) (2) Negative statement generates Negative statement generates

confusionconfusion ? abandon care and stop all treatment? abandon care and stop all treatment ? permission to terminate patient’s ? permission to terminate patient’s

life. life. ? family guilt about not sufficiently ? family guilt about not sufficiently

helping patienthelping patient ? unrealistic expectation? unrealistic expectation


Allow Natural DeathAllow Natural Death acknowledges patient is dying acknowledges patient is dying comfort measures becomes comfort measures becomes

positive goalpositive goal reflects language used in SC reflects language used in SC

Declaration of Desire for Natural Declaration of Desire for Natural Death Death


Allow Natural Death (2)Allow Natural Death (2) withholds or withdraws painful withholds or withdraws painful

and burdensome treatments and burdensome treatments (including ventilator, artificial (including ventilator, artificial nutrition/hydration, feeding tube) nutrition/hydration, feeding tube)

AND versus DNRAND versus DNR Using AND…Using AND…

FULL SUPPORTFULL SUPPORT INTERMEDIATE SUPPORTINTERMEDIATE SUPPORT - ALLOW - ALLOW

NATURALNATURAL DEATHDEATH……medical procedures medical procedures discontinued (vent, IV's, artificial nutrition/ discontinued (vent, IV's, artificial nutrition/ hydration) but if patient arrests no code hydration) but if patient arrests no code startedstarted

COMFORT SUPPORTCOMFORT SUPPORT - ALLOW - ALLOW NATURALNATURAL DEATHDEATH……all care aimed at all care aimed at comfort. comfort.

Distributive JusticeDistributive Justice Allocation of health care Allocation of health care

resourcesresources FairnessFairness – get what deserved – get what deserved People equal ethically, treated equally;People equal ethically, treated equally;

different ethically, treated differentlydifferent ethically, treated differently Ration time and resourcesRation time and resources according to according to

need, probability and degree of benefitneed, probability and degree of benefit

AMA Code of Ethics 2.03 Allocation of Limited Medical AMA Code of Ethics 2.03 Allocation of Limited Medical ResourcesResources

Distributive JusticeDistributive Justice Adequate health care accessAdequate health care access

Democratic decisionDemocratic decision after public input after public input during development and approval stagesduring development and approval stages

Monitor variationsMonitor variations in care not medically in care not medically explained to avoid ethnic/ racial disparityexplained to avoid ethnic/ racial disparity

Adjust level of careAdjust level of care over time assuring over time assuring public acceptancepublic acceptance

Equal access to basic care; equal Equal access to basic care; equal consideration for discretionary careconsideration for discretionary care

AMA Code of Ethics 2.097 Provision of Adequate AMA Code of Ethics 2.097 Provision of Adequate Health CareHealth Care

Distributive JusticeDistributive Justice Barring disaster or prior societal Barring disaster or prior societal

decisions rationing healthcare decisions rationing healthcare resources…resources…

physician shall remain focused physician shall remain focused upon effective treatment of upon effective treatment of individual patientindividual patient

AMA Principles of Medical AMA Principles of Medical Ethics VIIIEthics VIII

QuestionsQuestions

May physicians withdraw or May physicians withdraw or withhold care without consent of withhold care without consent of the surrogate? the surrogate?

What must the physician do for What must the physician do for the patient or surrogate if the patient or surrogate if medical staff members ethically medical staff members ethically feel they can not continue “futile feel they can not continue “futile treatment”?treatment”?

Withdraw or Withhold Withdraw or Withhold Care without Consent of Care without Consent of

SurrogateSurrogate No ethical obligation No ethical obligation

to render medically ineffective to render medically ineffective treatmenttreatment

Denial must be justified Denial must be justified

by ethical principles and by ethical principles and acceptable standards of careacceptable standards of care

AMA Code of Ethics 2.035 Futile AMA Code of Ethics 2.035 Futile CareCare

Stopping medically Stopping medically ineffective treatment ineffective treatment

without surrogate consentwithout surrogate consent ObligationsObligations

to shift care toward comfort/ to shift care toward comfort/ closureclosure

to not prolong dying without benefit to not prolong dying without benefit to patient or legitimate interestto patient or legitimate interest

All health institutions need policy All health institutions need policy with due processwith due process


without surrogate consentwithout surrogate consentMedically ineffective treatment Medically ineffective treatment

policy (1)policy (1) NegotiateNegotiate what constitutes what constitutes medically ineffective treatment medically ineffective treatment for patient, and limitsfor patient, and limits for for physician, surrogate, and institutionphysician, surrogate, and institution

Maximize joint decision-makingMaximize joint decision-making between patient or proxy and between patient or proxy and physicianphysician


without surrogate consentwithout surrogate consent

Medically ineffective treatment Medically ineffective treatment policy (2)policy (2) Negotiate disagreementsNegotiate disagreements for for

resolution, involving appropriate resolution, involving appropriate consultantsconsultants

Involve ethics committee/ECS, Involve ethics committee/ECS, if if unable to resolve differencesunable to resolve differences


without surrogate consentwithout surrogate consent Medically ineffective treatment policy Medically ineffective treatment policy

(3)(3) If institutional review supports patientIf institutional review supports patient and and

physician unpersuadedphysician unpersuaded, arrange transfer of , arrange transfer of care within institutioncare within institution

If institutional review supports physicianIf institutional review supports physician and patient/ proxy unpersuadedand patient/ proxy unpersuaded, seek transfer , seek transfer to another institution while medically to another institution while medically supporting patientsupporting patient

If transfer not possible, need not offer If transfer not possible, need not offer treatmenttreatment

AMA Code of Ethics 2.035 Medical Futility in End-of- LifeAMA Code of Ethics 2.035 Medical Futility in End-of- Life


gracefullygracefully Pneumonia successfully treated with Pneumonia successfully treated with

brief use of ventilator and brief use of ventilator and antibiotics; however patient antibiotics; however patient develops progressive renal develops progressive renal insufficiency. insufficiency.

A month goes by. Despite skin care A month goes by. Despite skin care patient develops large sacral patient develops large sacral decubitus. She develops increasing decubitus. She develops increasing creatinine, edema, and dyspnea.creatinine, edema, and dyspnea.


gracefullygracefully Granddaughter appears "from off"; Granddaughter appears "from off";

she remembers grandmother saying she remembers grandmother saying she wanted to "go quickly when her she wanted to "go quickly when her time came, but God would decide." time came, but God would decide."

QuestionsQuestions

Does euthanasia differ from Does euthanasia differ from terminal sedation?terminal sedation?

What is the rule of “double What is the rule of “double effect”?effect”?

Euthanasia and Palliative Euthanasia and Palliative SedationSedation

Active euthanasiaActive euthanasia Physician provides means and causes Physician provides means and causes

patient’s deathpatient’s death Voluntary – patient requests;Voluntary – patient requests;

involuntary – patient opposes; involuntary – patient opposes;

nonvoluntary – patient lacks decision-nonvoluntary – patient lacks decision-makingmaking


Passive euthanasia or ANDPassive euthanasia or AND Withholding or withdrawing treatmentWithholding or withdrawing treatment Comparable to informed refusal of life-Comparable to informed refusal of life-

sustaining treatment by patient or sustaining treatment by patient or surrogate; surrogate;

respects patient autonomyrespects patient autonomy underlying illness causes deathunderlying illness causes death


Palliative sedationPalliative sedation High dose opiate or sedative with object High dose opiate or sedative with object

to relieve suffering or dyspneato relieve suffering or dyspnea May hasten death, but death not May hasten death, but death not

intendedintended Ensure excellent palliative care; Ensure excellent palliative care;

decision to use informed and decision to use informed and voluntary;voluntary;

no depressionno depression

Rule of Double EffectRule of Double Effect

Distinguishes between intended effect Distinguishes between intended effect and effects foreseen but unintendedand effects foreseen but unintended

Applicable to passive euthanasia and Applicable to passive euthanasia and palliative sedation palliative sedation

Bad effect Bad effect (respiratory depression/ (respiratory depression/ death from opiatesdeath from opiates) not means of ) not means of good effect good effect (relief of suffering); (relief of suffering); unintended but foreseen bad effect unintended but foreseen bad effect proportional to intended good effectproportional to intended good effect

QuestionsQuestions

Are dialysis or medical hydration Are dialysis or medical hydration and nutrition indicated in PVS?and nutrition indicated in PVS?

What is the physiologic response What is the physiologic response to withdrawal of hydration?to withdrawal of hydration?

Medical Hydration and Medical Hydration and NutritionNutrition

or Dialysis in PVS? or Dialysis in PVS? Value judgment…Value judgment…

What is a human being?What is a human being? Decisions personal, Decisions personal,

often involve religious beliefs of often involve religious beliefs of patientpatient

Ethically…may withdraw or withhold Ethically…may withdraw or withhold any intervention in accord with any intervention in accord with advance directive or surrogate advance directive or surrogate decisiondecision

Medical Hydration & Medical Hydration & NutritionNutrition

and Religionand Religion ““Pope declares feeding tube removal Pope declares feeding tube removal

immoral.”immoral.” AP News March 20. AP News March 20.

20042004

““There should be presumption in favor of There should be presumption in favor of providing nutrition and hydration to all providing nutrition and hydration to all patients, including patients who require patients, including patients who require medically assisted nutrition and hydration, medically assisted nutrition and hydration, as long as this is sufficient benefit to as long as this is sufficient benefit to outweigh the burdens involved to the outweigh the burdens involved to the patient.”patient.”

Ethical and Religious Directives for Catholic Health Care Services, 4Ethical and Religious Directives for Catholic Health Care Services, 4thth ed, ed, 20012001


and The Lawand The Law Nancy Cruzan case (1990)Nancy Cruzan case (1990)

Medical hydration & nutrition: Medical hydration & nutrition: treatment subject to refusaltreatment subject to refusal

State has right to “clear and State has right to “clear and convincing evidence” from patient convincing evidence” from patient about stopping medical hydration about stopping medical hydration & nutrition& nutrition


and The Lawand The Law Helga Wanglie case (1991)Helga Wanglie case (1991)

Upheld right of husband to Upheld right of husband to continue feeds in PVS though seen continue feeds in PVS though seen as nonbeneficial by health care as nonbeneficial by health care teamteam


and SC Lawand SC Law

SC Health Care Power of SC Health Care Power of AttorneyAttorney If no decision re tube feeding, agent If no decision re tube feeding, agent

has no legal authority to withhold / has no legal authority to withhold / withdraw medical hydration and withdraw medical hydration and nutrition “necessary for comfort care”nutrition “necessary for comfort care”

SC CODE SC CODE SECTION 62-5-SECTION 62-5-504.504. Health care power of Health care power of attorneyattorney

Medical Hydration and Medical Hydration and NutritionNutrition

Hunger rare at end of lifeHunger rare at end of life Artificial hydration and nutrition can Artificial hydration and nutrition can

be harmful, increase suffering and be harmful, increase suffering and prolong dyingprolong dying

If fluid/ food stopped, death from If fluid/ food stopped, death from dehydrationdehydration

– – not starvationnot starvation

Physiology of Terminal Physiology of Terminal DehydrationDehydration

Increased endogenous endorphin Increased endogenous endorphin releaserelease

Azotemia and uremic encephalopahyAzotemia and uremic encephalopahy Decreased body fluidsDecreased body fluids

Urine outputUrine output Pulmonary secretions/ edemaPulmonary secretions/ edema Gastric fluids, so decreased vomitingGastric fluids, so decreased vomiting

QuestionsQuestions

How do cultural and religious How do cultural and religious differences affect the concept of differences affect the concept of “good death”?“good death”?

How may hospital chaplains How may hospital chaplains contribute to ethics consultation?contribute to ethics consultation?

““Good Death”Good Death”

Some cultural differencesSome cultural differences Telling person she is dying may not be Telling person she is dying may not be

acceptedaccepted Surrounded by family Surrounded by family Freedom from pain or indignityFreedom from pain or indignity Life preserved at any cost may have Life preserved at any cost may have

valuevalue

““Good Death”Good Death”

Some religious differencesSome religious differences Rituals required differ as death Rituals required differ as death

approachesapproaches Faiths weigh ethical principles Faiths weigh ethical principles

differentlydifferently Accepting suffering may have valueAccepting suffering may have value

““Good Death”Good Death” How does your cultural tradition How does your cultural tradition

define a “good death”?define a “good death”? What is your personal definition of a What is your personal definition of a

“good death”?“good death”?

ChaplainsChaplains

Provide insight to clinicians about Provide insight to clinicians about cultural and religious expectationscultural and religious expectations

Help patient, families, and Help patient, families, and surrogates clarify how their religious surrogates clarify how their religious beliefs, needs, and desires affect beliefs, needs, and desires affect treatment decisionstreatment decisions

Offer pastoral and emotional support Offer pastoral and emotional support regardless of faith traditionsregardless of faith traditions


gracefullygracefully Ethics consult service has met several times Ethics consult service has met several times

with the family and medical staff during the with the family and medical staff during the patient's hospital stay. ECS each time has patient's hospital stay. ECS each time has offered treatment options. offered treatment options.

After the last ECC visit, the family agreed After the last ECC visit, the family agreed with the recommendation for no dialysis, with the recommendation for no dialysis, stopping tube feedings & hydration, and stopping tube feedings & hydration, and offering opiate sedation based upon offering opiate sedation based upon apparent need for comfort.apparent need for comfort.

The patient died peacefully days later. The patient died peacefully days later.

QuestionQuestion

Have you completed a personal Have you completed a personal Health Care Power of Attorney?Health Care Power of Attorney?

Documents

Ethics Consult Service: A Case Study Walter Limehouse, MD, MA MUSC Ethics Committee