End of Life - Hubert Yeargan Center for Global Health

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Transcript End of Life - Hubert Yeargan Center for Global Health

End of Life
Divya Bappanad
May 6, 2010
Issues to Address
• Advance Directives
Do Not Resuscitate/Do Not Attempt
• Cessation of Feeding and Advanced Life
• Palliation
Guiding Principles in Medical Ethics
• Autonomy
– The right of individuals to self-determination
• Beneficence
– Physicians should act in the best interest of their
• Non-maleficence
– Physicians should not cause harm to their patients
• Justice
– Fairness and equality
Advance Care Planning
• Start at any time, with illness progression, or at
key points in life:
– Life changing event, e.g. the death of spouse or close
friend or relative
– Following a new diagnosis of life limiting condition eg
cancer or motor neurone disease
– Significant shift in treatment focus e.g. chronic renal
failure where options for treatment require review
– Assessment of the individual’s needs
– Multiple hospital admissions
• 54 year old woman with cancer of the colon with liver metastases. She
develops jaundice which cannot be treated and is feeling increasingly
weak and tired. This lady is now recognising she has a progressive disease
and may wish to discuss her future care.
• 76 year old man with heart failure with increasing breathlessness on
walking who finds it difficult to leave his home, has had two hospital
admissions in the last year and is worried about the prospect of any more
emergencies and coping with the future.
• 81 year old lady with COPD, heart failure, osteoarthritis and increasing
forgetfulness, who lives alone. She fractured her hip after a fall, eats a
poor diet and finds mobility difficult. She wishes to stay at home but is
increasingly unable to cope alone and appears to be ‘skating on thin ice’.
Setting the stage
• Full knowledge of patient’s medical condition,
treatment options and social situation
• Time and setting should be appropriate for a private
• Patient centered dialogue, focus on the views of the
individual, although they may wish to invite their carer
or another close family member or friend to participate
• Maintain confidentiality
Advance Care Planning
• the individual’s concerns and wishes
• their important values or personal goals for care
• their understanding about their illness and
• their preferences and wishes for types of care or
treatment that may be beneficial in the future
and the availability of these.
Advance Directives
• Statement of wishes and preferences
– Not legally binding
• Advance Decision
– Can be made by someone over the age of 18 who has mental capacity
– Refusal of specific treatment and may be in specific circumstances
– If an advance decision includes refusal of life sustaining treatment, it must be
in writing,signed and witnessed and include the statement ‘even if life is at
– Written or verbal
– Legally binding
– In effect when patient lost capacity
– Circumstances in which can be questioned
Advance Directive
• Lasting Power of Attorney
– Statutory form of power of attorney created by the Mental
Capacity Act 2005
– Anyone who has the capacity to do so may choose a person (an
‘attorney’) to take decisions on their behalf if they subsequently
lose capacity.
– Must specify whether the appointed holder of the LPA has the
authority to make decisions on life sustaining treatment.
– Any decisions taken by the appointed person must be made in
the individual’s best interests
Incapacitated Adults
• Medical best interest + person’s known values
• Any statement made when the person had
capacity and discussion with those close to the patient.
• Proxy decision maker
– Only asked once patient lacks capacity
• Advocate
– IMCA, but cannot give consent
Patient’s Best Interest
Not make any judgement using the professional’s view of the individual’s quality
of life
Consider all relevant circumstances and options without discrimination
Not be motivated by a desire to bring about an individual’s death
Consult with family partner or representative as to whether the individual
previously had expressed any opinions or wishes about their future care e.g. ACP
Consult with the clinical team caring for the individual
Consider any beliefs or values likely to influence the individual if they had capacity
Consider any other factors the individual would consider if they were able to do so
Consider the individual’s feelings
Patients rights
• Can refuse treatments/procedures
• Cannot insist on clinically inappropriate
• Can insist on artificial nutrition and hydration
• If the clinical team believes that CPR will not re-start the
heart and maintain breathing, it should not be offered or
• Responsibility rests with the most senior clinician currently
in charge of the patient’s care.
• May delegate the task to another person who is competent
to carry it out.
• Wherever possible, a decision should be agreed with the
whole healthcare team.
• Where no explicit decision has been made in advance there
should be an initial presumption in favor of CPR.
• A Do Not Attempt Resuscitation (DNAR) decision does not
override clinical judgement in the unlikely event of a
reversible cause of the patient’s respiratory or cardiac
arrest that does not match the circumstances envisaged.
– choking, induction of anesthesia, anaphylaxis or blocked
tracheostomy tube
– procedures
• DNAR decisions apply only to CPR and not to any other
aspects of treatment.
Informing patients
• Clinicians discussing or communicating such
decisions should:
– offer patients as much information as they want
– provide information in a manner and format
which patients can understand( i.e. interpreter)
– answer questions as honestly as possible
– explain the aims of treatment.
Withdrawal of care
• Medical treatment can legally and ethically be
withdrawn when it is unable to benefit the
• It should be withdrawn when it is not in the
patient's best interest or if the patient has
refused it
Assisted Suicide
• BMA policy opposes euthanasia and does not
believe that doctors should participate in actions
deliberately intended to hasten death.
• Rejects all forms of assisted dying
• Emphasise the importance of improving palliative
care services.
• www.bma.org.uk/ethics
• http://www.mcpcil.org.uk
• www.endoflifecareforadults.nhs.uk