Please read part 4 of the textbook and review the lecture for this week. Please also view the video linked on the last page
ETHICS AND END OF LIFE CARE ETHICS AND END OF LIFE CARE Ethics & the Health Care Manager “It is as much the business of a physician to alleviate pain as to smooth the avenues of death...as to cure disease.” by John Gregory INTRODUCTION: THE DYING PATIENT Providing good care for dying patients requires that health care providers and leaders be knowledgeable of ethical issues pertinent to end-of-life care. Effective advance care planning can assure patient autonomy at the end of life even when the patient has lost decision-making capacity. Medical futility is difficult to identify in the clinical setting but may be described as an intervention that will not allow the intended goal of therapy to be achieved. Medical interventions, including artificial nutrition and hydration, can be withheld or withdrawn if this measure is consistent with the dying patient’s wishes. Health care providers and leaders caring for terminally ill patients receive requests for physician-assisted suicide. The physician should establish the basis for the request and work with the healthcare team to provide support and comfort for the patient. Physician-assisted suicide could negate the traditional patient-physician relationship and place vulnerable populations at risk. Physicians need to incorporate spiritual issues into the management of patients at the end of life. The integrity of the physician as a moral agent in the clinical setting needs to be recognized and honored. The physician has a moral imperative to assure good care for dying patients. INTRODUCTION:THE DYING PATIENT Physicians and other healthcare professionals providing care for dying patients will confront many ethical dilemmas and challenges. Providing good care to dying patients requires physicians to be knowledgeable of potential ethical dilemmas and be aware of strategies and interventions aimed at avoiding conflict. It is important for the physician to be proactive with regard to decision making and have good communication skills. Keeping the patient central in all decision making, that is, respecting patient autonomy, is essential to ethical care for dying patients. The role of advance care planning is important in caring for patients at the end of life. INTRODUCTION: THE DYING PATIENT The physician needs to have a good understanding of ethical principles and issues such as: medical futility withdrawing and withholding of medical interventions the legal ramifications of these ethical issues. With the growing attention on physician-assisted suicide and euthanasia, physicians need not only to be knowledgeable of the ethical, legal, and professional ramifications of these issues, but also to have a clear understanding of their own beliefs on this and other ethical issues at the end of life. INTRODUCTION: THE DYING PATIENT Ethical Principles and End-of-Life Care The ethical principles include: autonomy, beneficence, nonmaleficence, justice, and fidelity Autonomy One of the ethical principles central to ethical decision making, Calls for the patient to be the decision maker, that is, having the right to self-determination. Calls for physicians to preserve a patient’s right to self-determination even when the patient has lost decision-making capacity. Requires the appropriate use of advance directives. Ethical Principles and End-of-Life Care Because of the difficulty physicians and patients have in discussing end-of-life issues, physicians frequently resort to caregivers to make decisions in lieu of the patient. This action may be a violation of the principle of autonomy if the patient still has decisional capacity and has not authorized a surrogate decision-maker, or the patient no longer has decisional capacity and the decision maker was not designated by the patient or is unaware of the patient’s wishes. Ethical Principles and End-of-Life Care The ethical principle of beneficence calls for the physician to advocate for what is good or beneficial for the patient. Frequently, patients’ choices regarding end-of-life decisions have not been expressed through advance care planning and caregivers who are knowledgeable of the patient’s wishes may be absent. In this case, the physician’s role for the dying patient must always be to advocate for approaches that promote good care for the patient at the end of life. Ethical Principles and End-of-Life Care The physician needs to be careful that patient autonomy must not be violated in an attempt to do what the physician views is in the patient’s best interest. The patient’s desire to choose an option should be respected even if the physician views the option as not in the patient’s best interest. Patient autonomy should prevail over paternalism Ethical Principles and End-of-Life Care The principle of nonmaleficence calls for the physician not to inflict harm intentionally. The ethical principle of justice demands fairness in the delivery of healthcare In either case, physicians have an ethical obligation to advocate for fair and appropriate treatment of patients at the end of life. The last ethical principle, fidelity, requires the physician to be faithful and truthful to the dying patient. The physician should provide ongoing information about the patient’s condition when appropriate. The physician needs to be truthful in issues such as diagnosis and prognosis and be faithful in defending the choices and decisions of the patient even when the patient can no longer speak for himself or herself. This defense, of course assumes that the patient’s request not violate the physician’s own moral code or values Ethical Principles and End-of-Life Care Effective advance care planning is important in providing good care at the end of life because it enhances a discussion of end-of-life issues between the patient, physician, and caregivers. It provides the mechanism to honor the patient’s wishes even at a time when the patient may lack decision-making capacity. Effective advance care planning can promote patient autonomy Advance Care Planning The Patient Self Determination Act passed by the US Congress in 1990 has had a significant impact in bringing attention to advance care planning through the use of advance directives. As part of the Omnibus Budget Reconciliation Act, this act requires institutions receiving Medicare and Medicaid reimbursement to inform patients about the use of advance directives. Many believe that advance care planning can be most effective when not linked to an institutional setting but when it is part of the important dialogue between patients and their primary care physicians in the community setting Advance Care Planning Discussions regarding the patient’s wishes for care at the end of life are critical for advance care planning. Advance care planning can prevent confusion and conflict when end-of-life decisions need to be made. Without effective advance care planning, the physician is at risk of providing interventions that the patient may not have wanted Advance Care Planning Advance care planning can be achieved through appropriate use of advance directives. Advance directives may be presented in the form of oral statements by the patient, through a living will, or by the identification of a surrogate proxy decision maker. Oral statements regarding end-of-life care consist of an expression of the patient’s wishes for care at the end-of-life. It is important that oral statements be carefully documented in the patient’s medical record. Advance Care Planning The living will, or instruction directive, is a written document that identifies the patient’s wishes for end-of-life care. Both oral statements and the living will may include and address issues such as: pain management, location for end-of-life care, acceptance or rejection of life-sustaining interventions, or even issues related to organ transplantation. Advance Care Planning One of the pitfalls to written communication of end-of-life care is the challenge of appropriate interpretation of the patient’s wishes. The identification of a surrogate or proxy decision maker calls for the patient to identify someone who can make decisions when the patient has lost decision-making capacity. This is referred to as the proxy directive. It is important for the proxy decision maker to be aware of the patient’s wishes regarding end-of-life care. Therefore, effective communication on end-of-life issues between patients and their proxy decision makers must be encouraged Advance Care Planning Variations exist among states regarding laws related to the requirements for advance directives. Physicians must be aware of local legislation to assure the legal status of an advance directive. Physicians and their patients should review advance directives regularly, particularly as the end of life approaches. The discussion should also include proxy decision makers. It is generally recommended that advance care planning include all three forms of advance directives Advance Care Planning Common pitfalls related to advance care planning frequently result from: the patient’s preferences being unclear; the proxy decision maker not being informed or educated regarding the patient’s preferences; and the failure of the advance care planning discussions to include a broad array of issues frequently confronted at the end of life Conflicts may arise between the physician, other healthcare professionals, the proxy decision maker, and the family regarding the patient’s care at the end of life. Advance Care Planning Ethics committees are often helpful in resolving disagreements. Effective advance care planning will often help to avoid conflicts In addition to the role of advance care planning in clarifying healthcare issues at the end-of-life, advance care planning may also include issues such as: financial and legal affairs, final gifts, spirituality, autopsy, burial and memorial services, and guardianship. Advance Care Planning Withdrawing and Withholding Interventions The withdrawing and withholding of life-sustaining treatment in the management of patients at the end of life may be appropriate both medically and ethically. Certain interventions may simply be medically futile, in which case there are no ethical, legal, or medical requirements to administer care that offers no benefit. It is appropriate to withdraw and withhold treatment that is not wanted by the patient or the patient’s proxy decision maker. Physicians often have difficulty withdrawing interventions that have already been initiated. However, if an intervention can no longer achieve its intended goal or the patient no longer wants this specific intervention, the intervention should be withdrawn. From an ethical perspective, withholding and withdrawing treatment are moral equivalents Although end-of-life care involves a team approach, the physician is the only member of the healthcare team who is authorized to write orders identifying interventions that are to be withheld or withdrawn. It is important that physicians and health care manager are knowledgeable about the principles of withdrawing and withholding interventions in caring for patients near the end-of-life. Withdrawing and Withholding Interventions The decision to withdraw or withhold cardiopulmonary resuscitation, elective intubation and mechanical ventilation, and artificial nutrition and hydration are issues frequently encountered in the management of patients near the end of life. Other interventions that may be withdrawn or withheld could include surgery, dialysis, antibiotics, diagnostic tests, medications, or admissions to acute care facilities Withdrawing and Withholding Interventions A decision to withhold or withdraw a specific medical intervention is based on whether that intervention is able to achieve a goal established by the physician, the patient, and the proxy decision maker. From a medical perspective, the