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Ethical Issues in Palliative Care

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					Ethical Issues in Palliative Care


          Erin Baldos, M.D.
    Hospice and Palliative Medicine
          Internal Medicine
                   Outline
•   History of Medical Ethics
•   Medical Ethical Principles
•   Medical Ethics and the Law
•   Iowa Code 144A
•   Informed Consent
•   Advance Care Planning and DNR
•   Medical Futility
                     Outline
• Role of the Ethics Committee
• Symptom Management and the Principle of
  Double Effect
• Physician Assisted Suicide and Euthanasia
• Withholding versus Withdrawing Life Sustaining
  Treatment
• Religious Beliefs of Different Religions on End of
  Life issues
• Catholic Doctrine on End of Life
       History of Medical Ethics
• Hippocratic Oath
• 1847 AMA Code of Ethics
• Bioethics evolved as a discipline in 1950’s as a
  reaction to medical technological
  advancement
• 1970 The Hastings Center was founded by Dan
  Callahan
• Several established universities offering
  bioethical courses
                             Hippocratic Oath
Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the
      goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To
      consider dear to me, as my parents, him who taught me this art; to live in common with him and, if
      necessary, to share my goods with him; To look upon his children as my own brothers, to teach
      them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never
      do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not
      give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to
      be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all
      intentional ill-doing and all seduction and especially from the pleasures of love with women or with
      men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men,
      which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all
      times; but if I swerve from it or violate it, may the reverse be my lot.
                             Hippocratic Oath
Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the
      goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To
      consider dear to me, as my parents, him who taught me this art; to live in common with him and, if
      necessary, to share my goods with him; To look upon his children as my own brothers, to teach
      them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and
      never do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not
      give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to
      be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all
      intentional ill-doing and all seduction and especially from the pleasures of love with women or with
      men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men,
      which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all
      times; but if I swerve from it or violate it, may the reverse be my lot.
                             Hippocratic Oath
Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the
      goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To
      consider dear to me, as my parents, him who taught me this art; to live in common with him and, if
      necessary, to share my goods with him; To look upon his children as my own brothers, to teach
      them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never
      do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not
      give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to
      be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all
      intentional ill-doing and all seduction and especially from the pleasures of love with women or with
      men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men,
      which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all
      times; but if I swerve from it or violate it, may the reverse be my lot.
                             Hippocratic Oath
Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the
      goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To
      consider dear to me, as my parents, him who taught me this art; to live in common with him and, if
      necessary, to share my goods with him; To look upon his children as my own brothers, to teach
      them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never
      do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not
      give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to
      be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all
      intentional ill-doing and all seduction and especially from the pleasures of love with women or with
      men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men,
      which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all
      times; but if I swerve from it or violate it, may the reverse be my lot.
                             Hippocratic Oath
Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the
      goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To
      consider dear to me, as my parents, him who taught me this art; to live in common with him and, if
      necessary, to share my goods with him; To look upon his children as my own brothers, to teach
      them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never
      do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not
      give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to
      be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all
      intentional ill-doing and all seduction and especially from the pleasures of love with women or
      with men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men,
      which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all
      times; but if I swerve from it or violate it, may the reverse be my lot.
                            Hippocratic Oath
Original, translated into English:

“ I swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, and I take to witness all the gods, all the
      goddesses, to keep according to my ability and my judgment, the following Oath and agreement: To
      consider dear to me, as my parents, him who taught me this art; to live in common with him and, if
      necessary, to share my goods with him; To look upon his children as my own brothers, to teach
      them this art.
I will prescribe regimens for the good of my patients according to my ability and my judgment and never
      do harm to anyone.
I will not give a lethal drug to anyone if I am asked, nor will I advise such a plan; and similarly I will not
      give a woman a pessary to cause an abortion.
But I will preserve the purity of my life and my arts.
I will not cut for stone, even for patients in whom the disease is manifest; I will leave this operation to
      be performed by practitioners, specialists in this art.
In every house where I come I will enter only for the good of my patients, keeping myself far from all
      intentional ill-doing and all seduction and especially from the pleasures of love with women or with
      men, be they free or slaves.
All that may come to my knowledge in the exercise of my profession or in daily commerce with men,
      which ought not to be spread abroad, I will keep secret and will never reveal.
If I keep this oath faithfully, may I enjoy my life and practice my art, respected by all men and in all
      times; but if I swerve from it or violate it, may the reverse be my lot.
         Medical Ethical Principles
•   Beneficence
•   Non-maleficence
•   Autonomy
•   Justice
•   Veracity
•   Confidentiality
•   Professional Integrity
       Medical Ethical Principles
Beneficence
• To act in the best interest of the patient
• To promote well-being
• Effective pain and symptom control
• Psychosocial and spiritual support
      Medical Ethical Principles
Non-maleficence
• “First do no harm”
• Importance of recognizing the risk and
  benefits
• May be defined by cultural contexts and
  individual values
• Principle of Double Effect
       Medical Ethical Principles
Autonomy
• The right to self-determination
• Is the basis for informed consent and advance
  directives
• Social reaction to “paternalistic medicine”
• Inhibited use of “soft paternalism” to the
  detriment of outcomes for some patients
• Can conflict with beneficence/non-maleficence
        Medical Ethical Principles
Justice
• Fair allocation of resources
• Developed as a reaction to rising medical costs,
  protection of vulnerable patients and promotion of the
  well being of a society
• Limits to personal autonomy when the needs of others
  impinge on the patients desires
• Society can not be expected to pay for futile treatments
  nor is society nor physicians are obliged to provide
  treatments that offer no reasonable expectation of
  benefit
• Medical Futility
    Medical Ethics and the Law

Conscience is the guardian in the individual of
  the rules which the community has evolved
            for its own preservation.

        William Somerset Maugham
Medical Ethics and the Law




        Ethics in Medicine, University of Washington
        School of Medicine
    Legal Myths that Serve as Barriers to End
                  of Life Care
                              JAMA 2000 Nov 15;284 (19):2495-501

Myth                                          Reality
•Foregoing life-sustaining treatment for      •Patients surrogate may relate this, or in
patients without decision-making capacity     most states, it was the patient’s probable
requires evidence that this was the           wish. Few states require clear and
patients act wish.                            convincing evidence. Some states may
                                              terminate life sustaining treatments with
                                              the surrogates permission if it is in the “
                                              best interest of the patient”.
•Withholding or withdrawing of artificial     •They may be withdrawn if patient refuses
fluids and nutrition from terminally ill or   and/or if appropriate surrogate decision-
permanently unconscious patients is           making are met.
illegal.
   Legal Myths that Serve as Barriers to
             End of Life Care
                         JAMA 2000 Nov 15;284 (19):2495-501

Myth                                          Reality
•Risk management personnel must be            •None such requirement. But different
consulted before life-sustaining medical      hospitals may make their own policies.
treatment may be terminated.

•Advance directives must comply with          •Best indication of a patients wishes at
specific forms, are not transferrable         the end of life even if legal formalities are
between states, and govern all future         not met. A living will or surrogate should
treatment decisions. Oral advance             not be consulted of patient has decision
directives are unenforceable.                 making capacity. Oral statements are
                                              legally valid.
•If a physician prescribes or administers     •If a patient inadvertently dies from the
high doses of medication to relieve pain      use of high doses of medication intended
or other discomfort in a terminally ill       to treat pain, the physician has not
patient, resulting in death, he or she will   committed murder or physician-assisted
be criminally prosecuted.                     suicide.
   Legal Myths that Serve as Barriers to
             End of Life Care
                         JAMA 2000 Nov 15;284 (19):2495-501
•Myth                                           Reality
•When a terminally ill patient’s suffering is   •Terminal sedation is a legally viable
overwhelming despite palliative care and        option. Physician assisted suicide is on
he or she requests a hastened death,            legally permissible in Oregon, Washington
there are no legally permissible options.       and Montana.

•The 1997 Supreme Court decisions               •States are free to prohibit it or legalize it.
outlawed physician assisted suicide.
                 Iowa Code 144A
• Life-sustaining Procedures Act
• Advance directives
   – May revoked it at any time
   – Commences when the declarant’s condition is considered
      terminal of when declarant is unable to make decisions
   – Can not be taken into effect if the patient is pregnant and
      the fetus can develop to the point of live birth
• Determination of terminal condition must be done by the
  attending physician and confirmed by another physician
                    Iowa Code 144A
• In the absence of a declaration, consultation or written agreement with
  any of the following, in the following order:
   – Attorney in fact
   – Guardian
   – Spouse
   – Adult child
   – Parent of Patient
   – Adult sibling
• Out of the hospital DNRs are acknowledged
• Out of the hospital DNRs shall not apply when a patient is need of
  emergency medical services outside of the scope of the patient’s terminal
  condition
• Personal wishes of family members of other individuals who are not
  authorized to act should not supersede a valid DNR
              Iowa Code 144A
• If an attending physician is unwilling to comply
  with the declaration of a qualified patient, or an
  out patient DNR the physician has the
  responsibility to transfer care to another
  physician.
• If policies of a health care provider preclude
  compliance with the declaration or out of the
  hospital DNR order of a qualified patient the
  provider should take reasonable steps to transfer
  the patient to another facility.
             Iowa Code 144A
• This chapter creates no presumption
  concerning the intention of an individual who
  has not executed a declaration or an out of
  the hospital DNR order with respect to the
  use, withholding, or withdrawal of life-
  sustaining procedures in the event of a
  terminal condition.
             Iowa Code 144A
• This chapter shall not be interpreted to
  increase or decrease the right of a patient to
  make decisions regarding use of life-sustaining
  procedures as long as the patient is able to do
  so, nor to impair or supersede any right or
  responsibility that any person has to effect the
  withholding or withdrawal of medical care in
  any lawful manner. In that respect, the
  provisions of this chapter are cumulative.
             Iowa Code 144A
• This chapter shall not be construed to
  condone, authorize or approve mercy killings
  or euthanasia, or to permit any affirmative or
  deliberate act of omission to end life other
  than to permit the natural process of dying.
    Informed Consent and Decision
           Making Capacity
• Hierarchy of decision making
  – Individuals own decision (Autonomy)
  – Advance directives
     • Living will, Advance directives
  – Previously stated preferences and values if known
  – Substituted judgment
     • Surrogate decision makers apply known or suspected
       preferences
  – Best-interests Method (Beneficence)
    Informed Consent and Decision
           Making Capacity
• Competence
  – Ability to understand risk and benefits
  – Is a legal term
• Decision making capacity
  – Understand relevant information and implication
    of various treatment choices
  – Reflect on information in accordance to personal
    values and draw conclusions
  – Make and communicate a choice
Advance Directives and DNR Orders
Barriers to effective discussion of DNR
– Unclear decision maker
– Procedure oriented rather than goal oriented
– Variability in skill, experience, providers
– Lack of confidence
– Lack of fact data and tools
– Lack of a patient advocate
– Non-conducive environment
– Medical jargon
– Assumptions
– Mixed messages
– Miscommunication
                  DNR Orders
• Difficult for Physicians
  – Fear of causing pain or being blamed for outcome
  – Fear of destroying hope
  – Avoidance of emotionally laden issues
     • Not knowing hope to cope with strongly expressed
       emotions from patient or family
     • Personal identification and vulnerability
     • Personal attachment to patient and/or family
                      DNR Orders
• Difficult for patients and families
  – Denial
  – Unrealistic expectations
     •   85% according to lay public
     •   67% on television
     •   30% overall
     •   0-5% in elderly and chronically ill
          NEJM 1996;334(24):1578-82
                    DNR Orders
• Grief
• Guilt
  – How surrogate decision makers feel about feeding
    tube decisions?
     •   58 surrogates consented for PEG tubes
     •   84% would repeat the decision to consent
     •   59% were satisfied with their decision
     •   Only 36% of them would have wanted a PEG if they had
         to make a decision for themselves
                     McNabney. J Am Geriatr Soc. 1994; 42(2):161-8
         When to discuss DNR
• Inpatients with new serious or life-threatening
  disease
• Inpatients or outpatients with an exacerbation
  of chronic illness
• Outpatients with stable but life-limiting
  chronic disease
• Healthy outpatients as part of routine
  outpatient discussion
    Advance Directives and DNR
• Patients and families deserve our best to
  balance truth with hope, objectivity with
  compassion
• False hope may detract from effective decision
  making and breed mistrust
       Language with unintended
            consequensces
• “Do you want us to do everything possible?”
• “Will you agree to discontinue (withdraw)
  care?”
• “It’s time we talk about pulling back.”
• “ I think we should stop aggressive therapy.”
• “I’m going to make it so he won’t suffer”
                  Medical Futility
• The existence of medical therapy does not mandate its use
• Doing everything possible to sustain life is not always
  beneficial to the patient or in keeping with the patient’s
  achievable goals and wishes
• It’s no ones best interest to ensure that every terminally ill
  patient dies on a ventilator in an ICU after receiving every
  conceivable form of treatment
• Regardless of treatment, patients with advanced
  malignancies, end-stage organ failure and other terminal
  conditions will eventually die of the disease or related
  complications
• Decisions about treatment should be guided by medical
  indications, benefits and burdens, and goals of care.
Is it worth it?
              Medical Futility
•   Poor communication
•   Stress of illness
•   Previous experience
•   Denial
•   Differing values
                    Medical Futility
• No accepted definition
    – Quantitative
       • Care that cannot achieve its intended outcome (1 out of
         100)
    – Qualitative
       • Care that cannot provide significant clinical benefit
•   Uncertainty
•   “Miracles”
•   Conflicts due differing Values
•   There is no Iowa Medical Futility LAW!!!
              Medical Futility
Physiological futility- permit a physician to with
  hold treatment modality on the basis of no
  impact on patient care
  – Need to meet professional standards
  – Need to inform patient and family
  – Opportunity to obtain second opinion
              Medical Futility
If issue is not physiologically futile, but
   appropriateness of sustaining a severely
   deteriorated life, then scope of professional
   judgment is limited
  – Should not be a unilateral medical judgment
  – Family and patient must be given opportunity to
    participate in decision making
  – May need an Ethics Consultation
             Medical Futility
• It is an elusive concept
• The term is used more to make value laden
  judgments
• Value is usually a “quality of life” concept
• Can be easily misinterpreted as rationing or
  medical paternalism
• Avoid using the word futility in documentation
  Effect of Ethics Consultations on Non-Beneficial Life-
   Sustaining Treatments in the Intensive Care Setting
                  JAMA 2003; 290: 1166-1172


• Prospective multicenter trial, RCT
• 551 patients whom value-related treatment conflicts arose
  during the course of treatment.
• Intervention was offering an ethics consultation
• Results showed reduction in hospital (-2.95) and ICU (-1.44)
  days and life-sustaining treatments with ventilation (-1.7)
• 87% of physicians, nurses and patient/surrogates agreed that
  ethics consultations are helpful.
• No difference in mortality rate between groups.
 Role of Ethics Committee and Consultations
        Singer, et. al. BMC Medical Ethics 2001, 2:1

Goals
• Education
• Institutional policy development
• Case consultation
  – To improve patient care and patient outcomes
  – Ethics consultant must be ethically and clinically
    competent, but does not need to be a physician
  – Recommendations are suggestion that the
    referring physician may refuse to accept or reject.
 Role of Ethics Committee and Consultations
        Singer, et. al. BMC Medical Ethics 2001, 2:1

Dangers of Ethics Committees and Consultations
• Abrogation of moral decision making by the
  referring physician
• Usurpation by moral decision making by ethics
  consultant
• Diffusion of responsibility within the ethics
  committee
Core Competencies of Bioethics Consultation
         Aulisio, et. al. Ann Intern Med 2000;133:59-69

• Ethics facilitation model
• Must possess knowledge of
   – Moral reasoning and ethical theory
   – Bioethical issues and concepts
   – Health care system
   – Clinical context
   – Knowledge of the local health care system in which the
     ethical consult is done
   – Beliefs and perspectives of patient and staff population
   – Relevant codes of ethics and professional conduct
   – Relevant health laws
 Core Competencies of Bioethics Consultation
    Aulisio, et. al. Ann Intern Med 2000;133:59-69

• Should have policies that address access,
  patient notification, documentation and case
  review
• Abuse of power and conflicts of interest must
  be avoided
• Ethics consultation must have institutional
  support
• Evaluation of process, outcomes and
  competencies is needed
    Process for Making Ethical Decisions
• Evaluate and communicate
     – Diagnosis and prognosis
     – Wishes of the patient, surrogate, and involved others
     – Patients life history
     – Benefits and burdens of proposed treatment
     – Decision making
•   Consider ethical principles
•   Make the decision
•   Document the decision
•   Implement the decision and change it when necessary
•   Respond to objections and challenges
             Lancet editorial
“..the ethics industry needs to be rooted in
   clinical practice and not in armchair moral
   philosophy. Debate on ethical matters is as
   much an integral part of everyday doctoring as
   choosing the best treatment for patients.
   Department of ethics that are divorced from
   the medical profession, wallowing in theory
   and speculation are quaintly redundant.”
          AMA Code of Ethics
“Physicians have an obligation to relieve pain
  and suffering and to promote the dignity and
  autonomy of dying patients in their care. This
  includes providing effective palliative care
  treatment even though it may foreseeably
  hasten death…”
       The Principle of Double Effect
            Gillon, R. BMJ 1986 Volume 292

• Developed in its earliest form by Aquinas to
  delineate conditions in which it is morally
  legitimate to cause or permit evil in the
  pursuit of good
• An attempt to confront the complexity of
  moral decision making
• Actions cannot be morally judged solely in
  terms of their consequences
         The Principle of Double Effect
               Gillon, R. BMJ 1986 Volume 292

• Doing an action that has a bad effect is
  permissible if
   – The action is good in itself (or at least morally neutral)
   – The intention is solely to produce the good effect.
     Although the bad effect may be foreseen but not
     intended
   – The good effect is not achieved through the bad effect
   – There is sufficient reason to permit the bad effect. The
     good effect must outweigh the bad effect.
      The Principle of Double Effect
           Gillon, R. BMJ 1986 Volume 292

• It is important to distinguish between
  – The intended end and the intended means to an
    end
  – The intended results, whether means or ends, of
    one’s actions and the unintended but foreseen
    risks of side effects of one’s action
  – The desired result and intended result
  – The overall result of one’s proposed action and
    the individual component of that overall result
    The Principle of Double Effect
The rule of double effect is conceptually and
  psychologically complex doctrine that
  distinguishes between permissible and
  prohibited actions by relying heavily on the
  clinician’s intent.
      Physician Assisted Suicide
• Death with Dignity vs Right to Life
• Legal in Oregon, Washington and Montana
• Undermines patient-physician relationship
• Against Hippocratic Oath
• Very rare that symptoms can not be controlled
  to relieve pain and suffering under expert
  hands
• The slippery slope to euthanasia
             Terminal Sedation
• 1997, US supreme court endorses terminal
  sedation as an alternative to PAS
• This intensified the debate on the “right to die”
  controversy
• However it was a palliative care option long
  before supreme court intervention
   – To relieve physical pain
   – To produce an unconscious state before withdrawal of
     life support
   – To relieve non-physical pain
             Terminal Sedation
• While objective criteria exists for quantifying and
  treating physical distress, evaluating
  psychological distress (existential suffering) is
  more difficult
• Many physicians find sedation for existential
  suffering to be ethically more challenging than
  similar treatment for physical suffering
• Complete psychological and spiritual assessment
  by a skilled clinician and/or clergy must be met
                 Terminal Sedation
• Patient must have a terminal illness.
• Thorough discussion of treatment plan, and intended and expected
  outcome. All palliative treatments must have been exhausted.
• Discuss and review plans on continuing/stopping artificial
  nutrition/hydration
• Full informed consent
• DNR must be in effect
• Assure a peaceful and quiet setting
• Confirm any specific goals to be met before starting sedation
• Confirm patient/family desire for chaplains/spiritual support prior
  to starting sedation.
• Intended effect is to provide effective palliative care
• Time limited trail (Respite Sedation)
            Terminal Sedation
“ Just as State may prohibit assisting suicide
   while permitting patients to refuse unwanted
   life saving treatment, it may permit palliative
   care related to that refusal which may the
   foreseen but unintended ‘double effect’ of
   hastening death”

                       Quill, 117 S S. Ct. 2293 n 11
             Terminal Sedation
• “ The risk of death is justified, not because it is
  unintended but because there is no
  alternative approach that makes the risk of
  death less likely and the alleviation of
  suffering possible.”

                        Fleischmann, A. J Pain & Symptom Management.
                        1998; 15:260-265
         The Story of Dr. Anna Pou
Katrina (Aug 29 to Sept 2)
• 2000 patients evacuated: initially the sickest patients were
  evacuated, when help was not imminent the standard of
  rescue changed to reverse triage
• 7th floor of the hospital was Life Care Hospitals, similar to our
  transitional vent unit
• 34 patients died during or after the storm, 9 had lethal
  amounts of morphine. Only a few had morphine as part of
  their MAR
• Dr. King another physician stated publicly “the discussion of
  euthanasia was more than talk”
         The Story of Dr. Anna Pou
• Life Care alleged that 9 patients may have been given
  lethal amounts of morphine
• 5 of the 9 reportedly had DNR orders
• “All these patients survived the adverse events of the
  previous days, and for every patient on a floor to have
  died in one three-and-a-half-hour period with drug
  toxicity is beyond coincidence.”
• Investigators believed that of the two dozen possible
  cases, they had the strongest case in the deaths of four
  of the patients who had died on the hospital's seventh
  floor.
      The Story of Dr. Anna Pou
• One patient, in particular, Emmett Everett,
  was alert oriented and interactive
• Pou administered the lethal cocktail of drugs
  because Everett was a paraplegic and weighed
  over 380 pounds; for these reasons, she didn't
  think the staff could reasonably assist him in
  the evacuation.
         The Story of Dr. Anna Pou
• July 17, 2006, Pou was arrested and charged with four counts of
  second-degree murder in connection with the deaths of four
  LifeCare patients; nurses Lori Budo and Cheri Landry were arrested
  and charged, but charges were dropped in exchange for their
  testimony
• This ignited a furious debate about whether sharp ethical
  boundaries can be drawn around decisions on patient comfort
  made in a crisis.
• February 2008 Frank Minyard , Orleans Parish Coroner, announce
  that he could not determine whether the patients died for natural
  causes or homicide
       The Story of Dr. Anna Pou
• Since then, the charges have since been
  expunged, the state of Louisiana has agreed to
  pay Pou's legal fees of over $450,000, and
  several Louisiana lawmakers have apologized
  for the accusations against her.
• Three wrongful-death lawsuits filed against
  Pou are still in progress, including one filed by
  Carrie Everett, widow of Emmett Everett.
       Withholding or Withdrawing
               Treatment
• Any or all life-sustaining interventions may be refused
  by a patient with a decision making capacity
• Initiating a treatment does not mandate its continued
  use until the patient dies
• Medical treatments are ethically neutral
• Benefits and burdens must be weighed
• Withdrawing burdensome and unwanted treatments
  are consistent with the principles of medical ethics
• Physicians are not required to prolong life against
  patients wishes
       Withholding or Withdrawing
               Treatment
• No ethical difference, although there may be a
  psychological difference
• Do not be afraid to offer an opinion
• Look for ways to respect the patient or the
  surrogate without unduly burdening them with
  decisions
• Look for ways to help
  – Ease guilt
  – Provide support
  – Achieve closure
  Various religions views on end-of-life decisions
  Bulow,H. et. al. Intensive Care Med. 2008; 34: 423-430
               Withhold Withdraw   Withdraw   Organ      Double   Euthanasia
                                   ANH        donation   effect
Catholics      yes      yes        no         yes        yes      no
Protestants    yes      yes        yes        yes        yes      some
Greek          no       no         no         yes        no       no
Orthodox
Muslims        yes      yes        no         most       yes      no
Orthodox       yes      no         no         Yes*       yes      no
Jews
Buddhists      yes      yes        yes        No*        yes      no
Hindu and      yes      yes        ?          yes        ?        some
Sihks
Taoism         most     most       ?          ?          ?        ?
Confucianism   no       no         ?          ?          ?        np
             Catholic Doctrine
• The duty to protect life
  – Life is a gift from God and not one’s own
    possesion
  – Physician assisted suicide and euthanasia is
    rejected
• Failure to use ordinary measures to preserve
  life is regarded as morally equivalent to
  euthanasia
• “Euthanasia by Omission”
            Catholic Doctrine
Humans must preserve life in the service of God,
 but not necessarily at all costs, since life on
 this earth is the foreshadowing of mankind’s
 ultimate, heavenly goal.

                     Evangelicum Vitae 1995
              Catholic Doctrine
         Bradley, C. J Pall Med. 2009;12(4):373-7

16th century Dominican theologian Franscico di
  Vitoria wrote

“If the depression of the spirit is so low and
  there is present such consternation in the
  appetitive power that only with the greatest
  of effort and as though by means of certain
  torture, can the sick man take food…he is
  excused…”
                Catholic Doctrine
Ordinary means of preserving life are all the medicines,
   treatments, and operation which offer a reasonable hope of
   benefit for the patient and which can obtained and used
   without excessive expense, pain or other inconvenience…
Extraordinary means of preserving life…mean all medicine,
   treatment, and operations, which can not be obtained
   without excessive expense, pain or other inconvenience, or
   which, if used, would not offer a reasonable hope of benefit.

                      Kelly,G. Medico-Moral Problems.
                               Catholic Hospital Association; 1958. p. 129
              Catholic Doctrine
         Bradley, C. J Pall Med. 2009;12(4):373-7

• Pope Pius XII addressed the First International
  Congress of Anesthesiologist
  – Extraordinary care: excessively costly, dangerous,
    painful, difficult or unusual when weighed against
    anticipated benefits
• USCCB’s Ethical and Religious Directives for
  Catholic Health Care Facilities
             Catholic Doctrine
• 1980 “Declaration on Euthanasia”
  – “..an action or omission which of itself or by
    intention causes death, in order that all suffering
    may in this way be eliminated.”
  – If the withdrawal of treatment allows death to
    ensue from an already fatal pathology, the
    omission of therapy does not itself cause death,
    nor does it intend it…the fatal disease causes the
    death…agent is accepting death’s inevitability
• 1995 Pope John Paul in “Evangelium Vitae”
  – Allows withholding and withdrawing medical
    treatment if is extraordinary, burdensome,
    dangerous or disproportionate to the expected
    outcome
  – “ In such situations when death is clearly
    imminent and inevitable, one can in conscience
    refuse forms of treatment that would only secure
    a precarious and burdensome prolongation of
    life..”
             Catholic Doctrine
• 2004 Pope John Paul II discussed the issue of
  ANH on persistent vegetative states
  “A man, even if seriously ill or disabled in the of his
    highest functions, is and always will be a man…the
    administration of water and food, even when
    provided with artificial means, always represents a
    natural means of preserving life, not a medical
    act.”
• ANH is an ordinary and proportionate
  measure
            Catholic Doctrine
• 2007 USCCB posed 2 questions the
  Magisterium

  Is the administration of food and water to a patient
    in a “vegetative state” morally obligatory except
    when they cannot be assimilated by the patient’s
    body or cannot be administered to the patient
    without causing significant harm?
               Pope Benedict
• Yes…..ANH is in principle, an ordinary and
  proportionate means of preserving life. It is
  therefore obligatory to the extent to which,
  and for as long as, it is shown to accomplish its
  proper finality, which is hydration and
  nourishment of the patient.
            Catholic Doctrine
When nutrition and hydration are being
 supplied by artificial means to a patient in a
 “permanently vegetative state,” may they be
 discontinued when competent physicians
 judge with moral certainty that the patient
 will never recover consciousness?
             Catholic Doctrine
• No…PVS patients must, therefore, receive
  ordinary and proportionate care which
  includes, in principle, the administration of
  water and food even by artificial means.
               Catholic Doctrine
         Congregation for the Doctrine of the Faith

• Extreme poverty such that ANH was
  impossible to administer
• An inability for the patient to assimilate the
  nutrients contained in food or liquids
• A complication, possibly related to the ANH
  itself that make it extremely painful or
  burdensome
                  Catholic Doctrine
             Bradley, C. J Pall Med. 2009;12(4):373-7

• Ordinary care is always obligatory
• The responses does not lessen the moral obligation to
  maximize patient’s quality of life and relieve suffering
• Appropriate and timely palliative care is integral to reaffirming
  human dignity
• Church continues to uphold the principle of double effect
• Extraordinary care is morally optional
• Catholic teaching continues to assert that patients have the
  right to direct their care
• Advance directives contrary to Catholic Moral Teaching cannot
  be honored in Catholic Health Care facilities
Thank you !

				
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