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Ethics at the End of LifeAs soon as a person is born, it must at once and necessarily be said: He will not escape death. Of all things in the world, only death is not uncertain. -AugustineCertain and Necessary...The human mortality rate is holding steady at around the 100% mark

Is it the task of the physician to stave off death?How well are we able to come to terms with the limits of medical care?

Remember...EthicalOutline principles of medical ethics- And their application to difficult end-of-life decisionsClarify ethical distinctions and criteriaThat inform medical care for EOL patients

Social / CulturalIdentify social and cultural attitudes towards ageing and dying and their influence on end-of-life decision-makingReview more ways to address patients fears and concerns during the final stages of lifeObjectives...The backdrop...We are living in an ageing society

Population Ageing: Statistics ONS (2012 Updates)

Other Cultural Trends:Individualism: autonomy, self-relianceCult of Youth: anti-ageing industry / fears of ageingTechnological control: power to alter circumstances of lifeEXTERNAL (environment)INTERNAL (self)Medical Advances: longer lifespan, cures for acute illnesses, increasing chronic illness and old ageDistance from death: sanitised out of the home, death denying and death defying culture, psychological refusal to acknowledge mortality

The backdrop...The last 100 years, and especially the last 50 years has shown us the most advances in medicine

Extended lifespan has increased chronic illness

See The Denial of Death Becker, (1973/4)

The backdrop...Illustration...DEMENTIA- Affects1 in 6 of 80+; 1 in 3 of 90+Alzheimers most common form dementiaIncreasing incidence due to ageing populationDisease becomes a symbol of frightening burdensOld age and dyingFear of becoming dependentFear of having others dependent upon usDependence & Disability in an ageing societyLIFE HISTORY OF DEPENDENCE: it is part of the whole of human life

Common fear with ageing:Becoming a burden on othersDependency undignified?Life always begins with dependence Preborn, newborn, young childLife often ends with dependenceOld age and sicknessLoss of capacities1st PRINCIPLE: Human dignity and personhoodNot something we have at some points in our lifeWe remain persons with dignity throughout the whole of lifeDependence & Disability in an ageing societyDIMENSIONAL:Scale of disability on which we all fallMatter of more or lessDifferent periods in our lives different points on the scale When we pass from one point to another: we remain the same individual we were before making the transition we dont lose our personhood, dignity, or basic rights human dignity is given (not granted) can be respected or violated

Modern Views...MODERN PSYCHIATRYMight be seen as viewing dependence in pathological termsDependent personality disorderCo-dependent couples etcMODERN PHILOSOPHYSelf-sufficiency superior to dependencyMoral philosophy emphasisesIndividual autonomyCapacity for making independent choicesBut, emphasis might be seen as TOO ONE-SIDEDExaggerated fears of dependency in old age...Failure to recognise:Extent of dependence throughout lifespanIllusion of total control, complete autonomy:Fostered by technological advancesIndividualistic cultural attitudes:Devalue social ties, mutual solidarityRealities of ageing population:May help correct one-sided valuesFoster acceptance of care, encourage social solidarityAgeing, dependence and disability for you, for me, now and in the future...Typically think of disabled, the elderly, the dependent, as them rather than us; a special class or interest group

They are actually US as we have been as we are as we will beMedical Decisions at the End of LifeAn area that provokes a lot of anxietyPatients and family members can be ambivalent, afraid of making wrong decisionsDoctors can be uncertain especially in borderline cases

> Ethical Principles....Basic Principles / Values...Hippocratic starting point....

Doctors are healers: never directly aim at or intend death

Sometimes it may be ethically justified to withhold or withdraw potentially life-extending medical treatments> Is this aiming at or intending death??

Distinctions...When treatment is withheld/withdrawn we are aiming to dispense with the treatment, not the patientMight it be that we need not do everything to ensure the longest possible life?We allow cars on the road, even though we know their potential to destroy lifeOur decisions may hasten deathDoes not imply aiming at death, right?

Ethical Criteria: withholding/withdrawing treatmentWhen treatment is judged to be futileWhen treatment is judged to be excessively burdensome to the patientLittle expected benefits, high burdens/risksWhat choice..?Refusing futile or excessively burdensome treatment:NOT choosing death, rather a different quality of LIFENot rejecting life, as such, but rather rejecting a life with added burdens of aggressive treatmentNOT choosing death, but perhaps one of several LIVES open to us, even if a shortened lifeNote about terms...Useless / futile / burdensomeRefers to potential treatment / interventionDoes not refer to value of patients lifeRefusal to treat / rejection of treatment because of feeling of being a burden (to family, society etc)Rejection is not of treatment but of life itselfEthically unacceptable? Prejudiced?Proportionate TreatmentNot too painful, burdensome, expensiveReasonable chance of workingEthically obligatoryPt has right to this; duty not to reject itTo refuse may imply suicidal intentionExample: psychiatric consult Otherwise healthy young patient Refusing insulin injectionsDepressed, did not want to live (suicidal intent)

Disproportionate TreatmentExcessively burdensome or uselessFor given patient in particular circumstancesAcceptance/refusal prudential decisionCan justifiably be withheld or withdrawnDoes not imply doctors intention to kill or patients intention to die

Proportionately beneficial vs disproportionately burdensome (futile)Importance of context:treatment in one context might be right for one, but not appropriate for anotherEg. DIALYSIS: Young acute renal failure patient vs end stage cancer patientThese terms do not simply describe a treatment, the describe a treatment within a particular clinical contextJudgement is relative to individual patient and the particular circumstances of the caseTough Cases...Nutrition and Hydration in EOLCIs it medical treatment or ordinary care?Is it always proportionately beneficial?Is it, in some circumstances, disproportionate?FutileExcessively burdensome?N & H: Treatment or care?TreatmentMedical interventionsMedicationsSurgery/proceduresCareNatural means for preserving life, along withShelter, warmth, turning to avoid sores, cleaning wounds etcIn most cases:N&H is careAim is nourishment and sustenanceAim is not alteration of disease processTrue even when delivered by artificial means

Exceptions...Where food and water no longer achieve their desired aim:No longer provide nourishment and sustenanceCan be true of spoon-feeding or tube feedingFUTILE OR EXCESSIVELY BURDENSOMEEg patient in process of dying: organ systems failing- no longer absorb food or assimilate nutrition- Chronic patient: excessive discomfort, aspiration riskLearning to be aware of limitations...Do you agree that we are not advocating......that extending life at all costs is always the imperative?...that a dying person should not be allowed to die?...that we are obliged to use all extraordinary means to keep a person alive?

Quality of life considerationsaffecting the decisions around EOLCOBJECTION: shouldnt the decision be based on quality of life?This objection appeals to our empathy for the patientIt may arise from legitimate fears That a person may be brutalised by technologys ability to prolong lifeFear of living a life of prolonged sufferingA Slippery Slope...No universal standard to judge the quality of lifeMay start with altruistic motivesJudgments will eventually be determined byEconomic pressuresPolitical pressuresArbiters of quality of life:Initially patient, proxy, medical staffEventually those with economic interestsDecision-making power open to abusesHippocratic Oath:Into as many houses as I may enter, I will go for the benefit of the ill...Placed at the service of the individual sick personNot an administrator of social resources or political programsNot an agent of state power/authorityHippocratic Paradigm...Physician Assisted Suicide, Euthanasia...Intentionally causing/intending death, in order that suffering may be eliminatedSometimes proposed as a solution to burdens of care-giving, suffering, or prolonged illnessBecoming / has been legalised in certain placesHuman Life and Human Goods...Human life not merely instrumental good, but inherent goodNot something we have or possessIt is what we are, living, beingOur life is our personWithout life, we can possess no other goods precondition for all other human goodsInc. Autonomy, independence, rationality etc

Human Life: Value...For your reflection:Life is a goodOf the personNot just for the personTo treat our life as a thing that can be disposed of or authorise another to terminate is:Contradictory, dehumanisingDestroys every other human good (inc autonomy in exercising our autonomy, we destroy our autonomy)Physician Assisted Suicide...Misguided attempt to completely control deathIrony: trying to master one event that finally shows our lack of complete masteryOpposed by GMCErodes ethic of healingRepresents a palliative care failureRequests cease when symptoms and pain and depression treatedLegitimate Fears...Rise of medical technology: mixed blessing?People fear they will be kept alive beyond what they can endureBUT...Ethical criteria can guide complex decisionsRecommend and provide proportionately beneficial treatmentRecommend against or withdraw futile or disproportionately burdensome treatmentYour role as physician...Addressing fears:We do not live in a society where futile care is typically refused:Eg have one more round of experimental chemoDo not want to give up hopeBut we may unintentionally subject people to harmFalse medical hope in last daysImportant to educate patients / proxyUnderstand what they are accepting / rejectingWhat we learn...We understandably want some control over lifeOver-zealous attempts to completely control life/death can be seen as dehumanisingLimits to medical technologyFutile / disproportionately burdensome interventions need not be attemptedNever abandon careEven when cure is impossibleLimits to human autonomyWe are not the sole author of the story of our lifeWe are dependent rational animalsTo be a physician is to be part of this interdependence

Ageing and Dying...Against our confidence in mastery and control, we need to remember that old age and dying are not problems to be solved but human experiences that must be faced. In the years ahead, we will be judged as a people by our willingness to stand by one another, not only in the rare event of a natural disaster but also in the everyday care of those who gave us life and to whom we owe so much.-Dr Leon Kass, Washington Post article