Ethics End of Life Death & Dying

8/2/2019 Ethics End of Life Death & Dying

1/42

Ethical Decision-Makingin End-of-Life Care

Dr. Maria Fidelis C. Manalo, MScPalliative Care


2/42

Sanctity of LifeYou shall not kill.

You have heard that it was said to the men of old, "You shall not kill:and whoever kills shall be liable to judgment." But I say to you thatevery one who is angry with his brother shall be liable to judgment.

"Human life is sacredbecause from its beginning itinvolves the creative action of God and it remains for everin a special relationship with the Creator, who is its soleend.

God alone is the Lord of life from its beginning until its end:no one can under any circumstance claim for himself theright directly to destroy an innocent human being.

Catechism of the Catholic Church, 2258


3/42

Stewardship of Life

In this view, we are stewards, not owners,of our own bodies and are accountable toGod for the life that has been given to us.


4/42

Human life as a value

Life, however, is not an absolute value.

The Christian understanding of lifes

meaning and purpose is founded on a beliefin the resurrection of Christ and the hope ofan afterlife.

We have a duty to preserve our life and touse it for the glory of God, but the duty topreserve life is not absolute.


5/42

Care for the Sick

Those whose lives are diminished or weakeneddeserve special respect.

Sick or handicapped persons should be helped tolead lives as normal as possible.



6/42

EuthanasiaConsists of an act or omission which, of itself or by

intention, causes death in order to eliminate suffering

Constitutes a murder gravely contrary to the dignity of thehuman person and to the respect due to the living God,

his Creator.

The death caused by euthanasia is not part of thenatural process of dying of a terminally ill person.

Whatever its motives and means, direct euthanasiaconsists in putting an end to the lives of handicapped,sick, or dying persons. It is morally unacceptable.



7/42

Medicalized killing

Medicalized killing of a person without thepersons consent, whether nonvoluntary (wherethe person is unable to consent) or involuntary

(against the persons will), is not euthanasia:it is murder.

Hence, euthanasia can be voluntary only.Materstvedt et al, Palliative Medicine2003


8/42

Euthanasia & Physician Assisted Suicide

Euthanasiais killing on request and is defined as adoctor intentionally killing a person by the administrationof drugs, at that persons voluntary and competentrequest.

Physician-assisted suicideis defined as a doctorintentionally helping a person to commit suicide byproviding drugs for self-administration, at that persons

voluntary and competent request.Materstvedt et al, Palliative Medicine2003


9/42

Foregoing Extraordinary Means to Prolong

the Life of a Dying Patient

Foregoing extraordinary means to sustain life is differentfrom euthanasia on several main points:

Unlike euthanasia, foregoing extraordinary means isnot intended to cause death.

The death that follows from foregoing extraordinary

means was not induced or directly caused. Thedeath simply follows from the natural process ofdying that is no longer postponed by extraordinarymeans.


10/42

Foregoing Extraordinary Means to Prolongthe Life of a Dying Patient

Discontinuing medical procedures that are burdensome,dangerous, extraordinary, or disproportionate to theexpected outcome can be legitimate

It is the refusal of "over-zealous" treatment.

Here one does not will to cause death; one's inability toimpede it is merely accepted.

The decisions should be made by the patient if he iscompetent and able or, if not, by those legally entitled to actfor the patient, whose reasonable will and legitimate interestsmust always be respected.



11/42


Determining whether a treatment is ordinary orextraordinary depends upon the balance between

two sets of factors.

On one hand, we have to consider the physical,psychological, economic and other harm which a

given modality of treatment is expected to cause, firstof all, to a patient, but also to his or her relatives andfriends as well as to society.


12/42

Foregoing Extraordinary Means toProlong the Life of a Dying Patient

On the other hand, we have to take into account thedegree of probability, if any, first of all, that the patientwill be cured or will be able, for a significant period of

time, to live on under humanizing conditions.

If the good outweighs the harm, then it can bereasonably affirmed that the means is morally

ordinary (proportionate). If the harm outweighs thegood, then disproportion probably exists and meansis probably morally extraordinary.


13/42


Extraordinary means usually refer to highly specialized,physically difficult, psychologically draining or veryexpensive measures used in order to delay the imminent

death and prolong the life of the dying patient.

These extraordinary means no longer correspond to thereal situation of the patient, either because they are by nowdisproportionate to any expected results or because theyimpose an excessive burden on the patient and his family.


14/42

Care for the Terminally-ill

Even if death is thought imminent, the ordinary care owed toa sick person cannot be legitimately interrupted.

The use of painkillers to alleviate the sufferings of the dying,even at the risk of shortening their days, can be morally inconformity with human dignity if death is not willed as eitheran end or a means, but only foreseen and tolerated asinevitable

Palliative care is a special form of disinterested charity. Assuch it should be encouraged.



15/42

Palliative Sedation vs. Euthanasia

In terminal or palliative sedation of those imminently dying:

The intentionis to relieve intolerable suffering

The procedureis to use a sedating drug for symptom control

The successful outcomeis the alleviation of distress

In euthanasia:

The intentionis to kill the patient

The procedureis to administer a lethal drug

The successful outcomeis immediate death

Materstvedt et al, Palliative Medicine2003


16/42

Palliative Sedation

In palliative care, mild sedation may be used therapeuticallybut in this situation it does not adversely affect the patientsconscious level or ability to communicate.

The use of heavy sedation (which leads to the patientbecoming unconscious) may sometimes be necessary toachieve identified therapeutic goals.

However, the level of sedation must be reviewed on a

regular basis and in general used only temporarily.

It is important that the patient is regularly monitored.


17/42

It is licit to relieve pain by narcotics, even when the result isdecreased consciousness and a shortening of life, "if noother means exist, and if, in the given circumstances, this

does not prevent the carrying out of other religious andmoral duties."

In such a case, death is not willed or sought, even though

for reasonable motives one runs the risk of it: there issimply a desire to ease pain effectively by using theanalgesics which medicine provides. (Evangelium Vitae,65)

The Use of Painkillers That May Shortenthe Life of a Terminally-ill Patient


18/42

Advance Directivesand End-of-Life Decisions

Dr. Maria Fidelis C. Manalo, MScPalliative Care


19/42

Purpose

Discuss advance directives and end-of-life caredecisions

Learn the different types of advance directives

Recognize advantages and disadvantages ofadvance directives

Learn the ethical principles that guide end-of-lifecare and decisions, especially withholding and

withdrawing therapy


20/42

What rights do patients have regarding

their medical treatment?Patients are entitled to complete information about their

illness and how it may affect their lives, and they have the

right to share or withhold that information from others.

Patients should also be informed about any proceduresand treatments that are planned, the benefits and risks,

and any alternatives that may be available.


21/42


their medical treatment?Patients have the right to make decisions about their own

treatment. These decisions may change over time.

In the face of worsening disease, some patients may want totry every available drug or treatment in the hope thatsomething will be effective.

Other patients may choose to forgo aggressive medicaltreatment.


22/42


their medical treatment?Many patients turn to family members, friends, or caregivers

for advice.

But it is the patient's decision how much or how littletreatment to have.

Sometimes a patient is unable to make this decision, due tosevere illness or a change in mental condition.

That is why it is important for people with life-limiting

illnesses to make their wishes known in advance.


23/42

End-of-life care

A general term that refers to the medical andpsychosocial care given in the advanced or

terminal stages of illness.


24/42

Legal documents, such as the living will, durable power ofattorney and health care proxy, which allow people toconvey their decisions about end-of-life care ahead of

time.

Provide a way for patients to communicate their wishes tofamily, friends, and health care professionals and to avoid

confusion later on, should they become unable to do so.

What are Advance Directives?


25/42

Ideally, the process of discussing and writingadvance directives should be ongoing, rather thana single event.

Advance directives can be modified as a patient'ssituation changes.

Even after advance directives have been signed,patients can change their minds at any time.

Advance Directives


26/42

Why are advance directives important?

Complex choices about end-of-life care are difficulteven when people are well. If a person is seriously ill,these decisions can seem overwhelming.

But patients should keep in mind that avoiding thesedecisions when they are well will only place a heavierburden on them and their loved ones later on.

Communicating wishes about end-of-life care willensure that people with life-limiting illness face the endof their lives with dignity and with the same values by

which they have lived.


27/42

What is a Living Will?

A living will is a set of instructions documenting aperson's wishes about medical care intended to sustainlife.

It is used if a patient becomes terminally ill, incapacitated,or unable to communicate or make decisions.

Everyone has the right to accept or refuse medical care.

A living will protects the patient's rights and removes theburden for making decisions from family, friends, and

physicians.


28/42


There are many types of life-sustaining care that should

be taken into consideration when drafting a living will.These include:

the use of life-sustaining equipment (dialysis machines, ventilators,and respirators);

"do not resuscitate" orders; that is, instructions not to use CPR ifbreathing or heartbeat stops;

artificial hydration and nutrition (tube feeding);

withholding of food and fluids;

palliative/comfort care; and

organ and tissue donation.


29/42


It is also important to understand that a decisionnot to receive "aggressive medical treatment" isnot the same as withholding all medical care.

A patient can still receive antibiotics, nutrition,pain medication, radiation therapy, and otherinterventions when the goal of treatment

becomes comfort rather than cure. This is called palliative care, and its primary focus is

helping the patient remain as comfortable as possible.


30/42


Patients can change their minds and ask to

resume more aggressive treatment.

If the type of treatment a patient would like to

receive changes, however, it is important to beaware that such a decision may raise insuranceissues that will need to be explored with thepatient's health care plan.

Any changes in the type of treatment a patientwants to receive should be reflected in the

patient's living will.


31/42


Once a living will has been drawn up, patientsmay want to talk about their decisions with thepeople who matter most to them, explaining thevalues underlying their decisions.

In the US, most states require that the documentbe witnessed.


32/42


Then it is advisable to make copies of the

document, place the original in a safe, accessibleplace, and give copies to the patient's doctor,hospital, and next of kin.

Patients may also want to consider keeping a

card in their wallet declaring that they have aliving will and where it can be found.


33/42

History of the "living will"

The "living will" was originally invented in 1967by two groups, the Euthanasia Society ofAmerica and Euthanasia Education Council, and

was touted as a first step in gaining publicacceptance of euthanasia.

These groups had been struggling for years toget "mercy-killing" bills (which would allowdoctors to give disabled or dying patients lethaloverdoses) passed in various state legislatures.


34/42

Resisting the new "Death Ethics"

Even Catholic hospitals and nursing homes nowoffer some kind of "living will" and most peoplefalsely assume that such directives are

automatically compatible with Church teaching.

While it has always been true that futile orexcessively burdensome treatment or care can

morally be refused, the Catholic Church has longcondemned causing or hastening death, whetherby omission or commission.

POPE JOHN PAUL II :


35/42

POPE JOHN PAUL II :Clarify the substantive moral difference between

DISEASE DEATH

Discontinuing medicalprocedures that may beburdensome, dangerous,

or disproportionateto theexpected outcome

> "the refusal of 'over-zealous'treatment"

Taking away the

proportionate means ofpreserving life, such as

ordinary feeding, hydration,

and normal medical care


36/42

However, no "living will" is risk-free and even refusing

to sign a "living will" is no guarantee that the "right todie" will not be exercised for the patient despite his/herwishes.

The best defense now is to have a loving relative orfriend who is informed about ethical options and whocan legally speak for the patient if he/she cannotbecause of illness or injury.

It is also crucial that the patient chooses a doctorwithout a "right to die" bias, preferably one with a goodunderstanding of Catholic ethical principles andNatural Moral Law.

Living Will


37/42

What is a Medical Power ofAttorney?

A legal form that states who the patient wants to

make decisions about medical care

The person is authorized to speak for the patient

ONLY if the patient is unable to make his/herown medical decisions

May also be called:

"health care proxy or agent"health care surrogate"durable power of attorney for health care"


38/42

Withholding, WithdrawingLife-Sustaining Treatment

RICHARD J. ACKERMANN, M.D.RICHARD J. ACKERMANN, M.D.

AmAmFamFamPhysician.Physician. 20002000 OctOct 1;62(7):15551;62(7):1555--1560.1560.

Adapted from Education for Physicians on End-of-Life CareTrainer's Guide, Module 11, withholding, withdrawing therapy.In: Emanuel LL, von Gunten C J, Ferris FD. Education forphysicians on end-of-life care/Institute for Ethics at theAmerican Medical Association. Chicago, IL: EPEC Project,The Robert Wood Johnson Foundation, 1999.


39/42

Any life-sustaining treatment

Resuscitation (CPR)

Elective intubation,mechanicalventilation

Surgery

Dialysis,Hemofiltration

Blood transfusions,blood products

Diagnostic tests

Artificial nutrition,(parenteral or enteral)or hydration (IVF)

Antibiotics

Vasopressors

Future hospital, ICU

admissions

aimed at maintaining organ function that only

prolong death may be withdrawn or withheld


40/42

8-step protocol to discusstreatment preferences . . .

1. Be familiar with policies, statutes

2. Appropriate setting for the discussion

3. Ask the patient, family what they understand

4. Discuss general goals of care


41/42

. . . 8-step protocol to discusstreatment preferences

5. Establish context for the discussion

6. Discuss specific treatment preferences

7. Respond to emotions

8. Establish and implement the plan


42/42

Aspects of informed consent

Problem treatment would address

What is involved in the treatment /procedure

What is likely to happen if the patientdecides not to have the treatment

Treatment benefits

Treatment burdens

Documents

Ethics End of Life Death & Dying