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Ethical Challenges at the End of Life PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "ETHICAL CHALLENGES AT THE END OF LIFE" by EYAD NASHAWATI, MD.

This medical PowerPoint presentation discusses how end-of-life care presents many ethical challenges that healthcare providers must navigate carefully. It is essential to communicate with patients and their families, respect their cultural and religious beliefs, and provide appropriate palliative care to ensure that patients receive compassionate and effective care at the end of their lives.

Tags : end-of-life care, critical care medicine, critical care medicine PowerPoint presentation

Published on : Mar 28, 2023 | Views : 1560 | Downloads : 2

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Slide 1-

ETHICAL CHALLENGES AT THE END OF LIFE EYAD NASHAWATI, MD
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ETHICAL CHALLENGES AT THE END OF LIFE Assessing decision making capacity Withholding vs. withdrawing treatment Doctrine of double effect Artificial nutrition and hydration Futility Physician assisted suicide and euthanasia
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Competent vs. decisional The case of the demented patient Who does it? “Testing” decision making capacity Ability to communicate Ability to understand treatment options Ability to grasp consequences of accepting or declining therapy Ability to reason ASSESSING DECISION MAKING CAPACITY
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The case of the depressed patient Usually decisional but preferences can be clouded by severe depression Psychiatrist should be involved Surrogate may need to be involved Ethics Consultation Careful with decisions to limit or withdraw or withhold care Ethnic and cultural variations ASSESSING DECISION MAKING CAPACITY
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Morally and legally equivalent Moral factors are the same including Respect of patient autonomy Intention of the physician Consequences and cause of death Withdrawing care is much more emotionally difficult Withdrawing care should be less controversial if it does not produce the desired effect after a specified time WITHHOLDING VS. WITHDRAWING TREATMENT
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The doctrine applies to interventions that have both a good and a bad effect The intervention may be used with the intent to achieve the good effect, but with the foreseen consequence of causing the bad effect. This is permissible as long as the intent is clear for the good effect DOCTRINE OF DOUBLE EFFECT
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Are you killing my father with too much Morphine? Giving a medication such as Morphine with the intention of making the patient comfortable at the end of life, but with the foreseen consequence (perhaps even likelihood) of hastening the patient’s death by respiratory depression is permissible since The intention here is not to kill the patient. The clinical priority here is to relieve suffering at the end of life DOCTRINE OF DOUBLE EFFECT
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ARTIFICIAL NUTRITION AND HYDRATION Medical debate Evidence supports the view that dehydration in terminally ill patients helps symptoms Less cough and chest congestion and pleural effusion Decreased urine output and need for catheterization Decreased GI fluid and bloating and diarrhea and ascites Decreased leg edema and pain No thirst ( Poor correlation with hydration status in the terminally ill) Most patients dying in acute care hospital receive hydration until death Most patients who die in Hospice hospitals or at home receive no fluids
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ARTIFICIAL NUTRITION AND HYDRATION DISCUSS WITH PATIENT AND FAMILY SOMETIMES APPROACH NEEDS TO BE INDIVIDUALIZED
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88 year old male with history of pancreatic cancer, with metastases to liver and abdominal wall. Patient has end stage renal disease on regular hemodialysis, recurrent respiratory failure. He has now been hospitalized for close to 6 months, mostly in the ICU on mechanical ventilation and sedation and artificial nutrition. Exam shows evidence of tumor invasion of abdominal wall with ulceration. Patient unresponsive and unable to decide for himself. MEDICAL FUTILITY
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Family dysfunctional and divided and manipulative, insisting that all be done and expecting a miracle and healing through faith. Daughters and son are all professionals in administrative jobs, one daughter is a judge her self. They all sate that life is precious and that he is fighting to live. Should stay full code. Lengthy daily discussions of every detail about patient’s care and procedures. Patient’s next of kin is a second younger wife who is intimidated and threatened by the powerful children. She is younger than some of the children, and is unable or unwilling to go against their wishes. MEDICAL FUTILITY
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Numerous physicians involved in the case. At times, confusing and contradicting messages are given to the family. Palliative care service involved on different occasions during hospitalization without progress to EOL care. Nurses distressed about taking care of this debilitated and dying patient with visible terminal cancer, and who appears to be uncomfortable and at times in pain. They are in tears frequently as the family members’ demands are often overwhelming and unreasonable. Ethics consultation requested. ‘ MEDICAL FUTILITY
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Futile treatment is any course of treatment that provides no beneficial outcome or is medically ineffective or even harmful to the patient. It is usually contrary to generally accepted standards of care A treatment may have an effect on the patient but may not benefit the patient Treating the disease and not treating the patient Treating the numbers and not treating the patient MEDICAL FUTILITY
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Quantitative futility The likelihood that an intervention will benefit the patient is exceedingly low (less than 1/100) Qualitative futility The quality of benefit an intervention will produce is exceedingly poor (Goals/Definition of recovery) MEDICAL FUTILITY
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PHYSICIAN AUTONOMY INTEGRITY OF MEDICAL PROFESSION VS PATIENT/SURROGATE AUTONOMY TYPICALLY A CONFLICT SITUATION MEDICAL FUTILITY
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Physicians have no obligation to offer treatments that do not benefit their patients Although respect for patient autonomy entitles them to choose a medically acceptable treatment option, it does not not entitle the patients to receive whatever treatments they ask for Futility determination should conform with professional standards of care MEDICAL FUTILITY
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Discussion of futility with family/surrogate. Identification of goals of treatment. Discuss rationale for withholding or withdrawing medical interventions. Obtain consensus and an unified position of all consultants and healthcare workers involved with care Obtain help from third parties, second opinion, psychiatry, and risk management If no consensus, may resort to patient transfer, independent mediation or probation for court-appointed guardian MEDICAL FUTILITY
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What is the view of the state of OHIO?? MEDICAL FUTILITY
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CURRENT OHIO LAW Ohio Dept. of Health Rule 3701-62-03(H): DNR statute does not require provision of CPR if, in judgment of attending physician, CPR would be futile MEDICAL FUTILITY
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CURRENT OHIO LAW However, no immunity for a physician issuing a DNR order if: The order is contrary to reasonable medical standards, or The physician knows, or has reason to know, that the order is contrary to the patient or the patient’s legally-authorized decision-maker, unless in judgment of physician, CPR would be futile MEDICAL FUTILITY
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Dr Jack Kevorkian performed first PAS on a woman with early Alzheimer’s disease in Michigan in 1990. Charges were dropped for no law outlawed suicide or assisting in it He helped more than 40 people proceed with PAS He Crossed the line by euthanizing a patient himself and airing the tape on “60 minutes” Convicted of second degree murder and jailed for eight years While 60% of terminally ill patients support PAS, only 10.6% consider it PHYSICIAN ASSISTED SUICIDE
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Now legal in Oregon, Washington, and Vermont States The Oregon Death with Dignity Act passed 1994 (51.3% of vote) Patients with terminal illness (< than 6 month survival) Written request by patient Two witnesses attest that patient is competent (one not family member) Law used 77 times in 2012 PHYSICIAN ASSISTED SUICIDE
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Alternative to adequate care in un/underinsured patients Spread of use to patients who are not decisional May be chosen by patients to avoid burden on family Society ridding itself of the vulnerable and dependent Technical problems PHYSICIAN ASSISTED SUICIDE CONCERNS
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Physician intentionally ends a patient’s life at the patient’s request and with the patient’s full informed consent Illegal in the USA Legal only in Belgium and The Netherlands EUTHANASIA
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1. Uptodate2. Michele Nichols, RN, BSN, MA Medical Ethics for Physicians 2013 References
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BIOETHICSHISTORY PATIENT SELF-DETERMINATION ACT of 1991 Providers must offer written information to all adult patients regarding their rights under state law to accept/refuse treatment and to make advance directives Record should document whether patient has advance directives Institutions must provide education regarding advance directives Institutions have the affirmative obligations to comply with state law regarding advance directives Legislation was created to keep EOL medical decision-making issues out of courts and in the appropriate arena: patient/family and healthcare workers
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Determine the facts Define the precise ethical issue Identify the major principles, rules, and values Specify the alternatives Compare values and alternatives Assess the consequences Make a decision Seven-Step Model for Examining Ethical Dilemmas