Ethics of End of Life Care

HCR 210 Ethics for the Healthcare Professional End of Life Care Learning Objectives: • Explain the ethical issues related to an aging population and be demonstrate the ethical principles that apply to ethical decision making • Understand the application of ethical principles underlying the question of the complex issues of end-of-life care • Understand the process of personal and professional ethical decision making in relation to issues of aging and end of life care Where do you draw the line? Case Study You are a hospital administrator who has been asked to provide guidance on a recent patient’s case which requires an ethical evaluation. The patient is a 21 year old female who initially presented to the hospital in a comatose state after ingesting alcohol and benzodiazepines. This patient remains in a persistent vegetative state and requires ventilation and artificial nutrition to live. She has little to no chance of meaningful recovery. The patient’s adoptive parents want to remove her from life support and allow her to pass peacefully. However, the physician on the case does not feel comfortable removing life-support, as he believes this would be an act of murder. This case eventually goes to the court, and prosecutors are threatening to legal actions against any healthcare provider that removes this patient from life-support. However, the family is distraught as they do not believe their daughter would want to live like this. Case Study You are a hospital administrator who has been asked to provide guidance on a recent patient’s case which requires an ethical evaluation. The patient is a 21 year old female who initially presented to the hospital in a comatose state after ingesting alcohol and benzodiazepines. This patient remains in a persistent vegetative state and requires ventilation and artificial nutrition to live. She has little to no chance of meaningful recovery. The patient’s adoptive parents want to remove her from life support and allow her to pass peacefully. However, the physician on the case does not feel comfortable remove life-support, as he believes this would be an act of murder. This case eventually goes to the court, and prosecutors are threatening to legal actions against any healthcare provider that removes this patient from life-support. However, the family is distraught as they do not believe their daughter would want to live like this. What should you do? Case Study Support your argument with: Principles of bioethics • Beneficence • Nonmaleficence • Autonomy • Justice Ethical theories: Ethical egoism, virtue ethics, authority-based ethics, natural law, deontology, consequentialism Case Study What do you think? A. I would argue that the patient should be removed from life-support B. I would argue that the patient should NOT be removed from life-support Karen Ann Quinlan • Real-life case in 1975 • Karen’s parents would lose to their case in the Superior Court; however won in the New Jersey Supreme Court (right of privacy – same right invoked in Roe v. Wade) • Karen was removed from the ventilator in 1976, however she was continued on artificial nutrition • She was able to breath on her own and lived until 1986 in a persistent vegetative state, when she eventually passed after developing pneumonia Karen Quinlan’s Legacy • Karen Ann Quinlan was one of the first major cases of right-to-live versus right-to-die argument in the United States – this argument would continue for decades • In response to Karen Quinlan’s case, hospitals started developing ethics committees to address difficult questions • Many other states would also develop policies to protect healthcare providers who withdrew care in response to patient and patient family members’ requests - however this did not exist at a national level Right to Die (Refusal of Treatment) What may be the values of someone who believes in right-to-die? • Personal autonomy • Privacy of healthcare decisions What may be the values of someone who believes in right-to-live? • Sanctity of life • Security of life Right-to-Die (Refusal of Treatment) Other major historical cases include: • Nancy Cruzan o Persistent vegetative state after motor vehicle accident in 1983; parents wanted to discontinue tube feeding however was blocked by the state government o Cases went back and forth (from Missouri Lower Courts to Missouri Supreme court to the federal Supreme Court) o Led to states passing laws regarding who can make healthcare decisions for the incapacitated (surrogate decision makers) Right-to-Die (Refusal of Treatment) Other major historical cases include: • Terri Schiavo o Persistent vegetative state after cardiac arrest in 1990 (26 year old) o Husband sought to remove the feeding tube while parents wanted to continue o Husband would eventually win the case with the precedent set by Quinlan and Cruzan o Terri would eventually pass in 2005 o Introduces complications that may occur between family members Key Terms Withdrawal of Care: Removal of life-sustaining intervention (ventilator, artificial nutrition, etc) Withholding of Care: To not implement life-sustaining intervention • In current clinical medicine, withholding and withdrawing care are considered ethically similar. • Patients (or their medical power of attorney if they are incapacitated) have the right to request withdrawal and withholding of care. From the Code of Medical Ethics by the American Medical Association Key Terms Palliative care (sometimes called “comfort care”): Specialized medical care for serious illnesses that is focused on providing relief from symptoms to improve quality of life for patients. Can be offered at any stage of disease progression and at any age. Hospice: Specialized medical care for advanced diseases when treatment is no longer curative. Also focused on providing relief from symptoms and improving quality of life. Patient generally begin hospice care once they have a life expectancy of 6 months or less. Future Ethical Dilemmas While withdrawal and withholding of care, hospice, and palliative care are generally accepted as ethical actions when in support of a patient’s autonomy, future ethical dilemmas include: • Physician assisted suicide (also known as physician aid-in-dying) • Brain death Physician Aid In Dying • The physician writes a prescription for the patient that will enable the patient to end their life • Patient administers the medication on their own – the patient is the one who ultimately makes the decision, not the physician • States have their own physician-assisted suicide laws o Legal in Oregon, Washington, Vermont, and California o Patients must have a terminal illness Brain Death • Brain death is considered the time of cessation of all brain function • To diagnose brain death, rigorous clinical examination and testing must first occur and there can be no questionable or uncertain results • The diagnosis of brain death is widely accepted by the medical community • In many (but not all) states, a declaration of brain death by a physician is considered the time of legal death of the patient • Patient’s family members may have a difficult time understanding and accepting brain death • This has led to many high-profile cases within the last 15-25 years Culture and End of Life Issues Culture and End of Life Issues • Cultural views regarding end of life issues, healthcare providers, and or their spirituality may affect the rates at which patients create advance directives, chose DNR/DNI status, and accept hospice or palliative care services • Some cultures may choose to not discuss end of life issues due to: o Belief that discussing end of life issues can hasten one’s death o Belief that “everything” should be done to prevent death o Feeling uncomfortable discussing death • Some cultures may not want to discuss terminal diagnoses with the patient themselves (speak with family members instead) Culture and End of Life Issues • Cultural views regarding end of life issues, healthcare providers, and or their spirituality may affect the rates at which patients create advance directives, chose DNR/DNI status, and accept hospice or palliative care services • Some cultures may choose to not discuss end of life issues due to: o belief that discussing end of life issues can hasten one’s death o belief that “everything” should be done to prevent death o feeling uncomfortable discussing death • Some cultures may not want to discuss terminal diagnoses with the patient themselves (speak with family members instead) Try to avoid generalizing people based on their culture – always ask the patient first. Culture and End of Life Issues From “The Importance Of Cultural Competence in Pain and Palliative Care”: Culture and End of Life Issues From “The Importance Of Cultural Competence in Pain and Palliative Care”: Culture and End of Life Issues • African Americans tend to complete advance directives and enroll in hospice less compared to Caucasians • This has been attributed to multiple factors: o Misunderstanding of advanced care planning, palliative care, and hospice o Concerns of conflict with faith in God, or conflict with friends’ and/or family members’ spiritual beliefs o Mistrust in the medical system and healthcare providers Ø “I’ve seen it over and over again, where some African American patients feel that because of their knowledge of things that have happened in history that they may be getting less than adequate care, and that’s why they’re referred to hospice.” -African American hospice provider Case Study A 13-year-old African American girl presents to the hospital for a routine tonsillectomy. However, she unfortunately sustains complications from the surgery eventually leading to cardiac arrest and anoxic brain injury. The patient is declared to be brain dead, which is considered legal death in that state. However, the patient’s parents argue that their daughter cannot be dead given that her heart is still beating. The family wishes to continue all supportive measures. You are a member of the hospital ethics committee and must decide on the correct course of action for the hospital to take. Case Study Support your argument with: Principles of bioethics • Beneficence • Nonmaleficence • Autonomy • Justice Ethical theories: Ethical egoism, virtue ethics, authority-based ethics, natural law, deontology, consequentialism Case Study What do you think? A. I would argue that the patient should be removed from the ventilator B. I would argue that the patient should NOT be removed from the ventilator Jahi McMath • Real-life case in California in 2013 • Jahi’s family contested the diagnosis of brain death in the court • This led to many court cases between Jahi’s family and the hospital on whether or not “life-support” could be removed • Case was eventually settled – Jahi was declared legally dead but family would be allowed to continue caring for their child if they could find an accepting facility • Jahi eventually sustained cardiovascular death in 2018 Assignments • Self-reflection essay on Canvas • Ethics paper (rough draft)