ETHICAL & LEGAL ISSUES IN PALLIATIVE CARE

1. ETHICAL & LEGAL ISSUES IN PALLIATIVE CARE

2. OUTCOMES • To review the field of ethics and ethical principles. • To identify ethical and legal issues in Palliative Care. • To establish the limitations on decision making in end of life care.

3. WHAT ARE ETHICS? Concerned with human actions, their effect and the value of those actions (Rumbold, 1999) Used interchangeably with morals to indicate the general rights and wrongs in theory and practice of human behaviour (Thompson et al, 2000) Ethics is about moral choices. It is about the values that lie beneath them, the reasons given, the language used to describe them .. the exploration of human virtues, vices, rights and duties (Thompson, 2000)

4. ETHICAL THEORIES ETHICS OF CONDUCT What actions we should take Consequentialism or Deontology ETHICS OF CHARACTER What sort of people we should be Virtue Theory

5. CONSEQUENTIALISM UTILITARIAN THEORY An action is right if it promotes the best consequences. Doing the greatest good for the greatest number.

6. DEONTOLOGY KANTIAN ETHICS An action is right if it follows a moral rule or principle To act in a ethical manner The essence is one of duty towards another. This is the basis for codes of conduct.

7. VIRTUE THEORY ARISTOTLE An action is right if it is what a virtuous person would have done Emphasis on moral character: trustworthiness, truth telling, honesty, kindness, care, compassion, empathy, respect.

8. ETHICAL PRINCIPLES AUTONOMY (Respect for persons) BENIFICIENCE (Doing good, protecting best interests) NON-MALIFICENCE (Avoiding harm) JUSTICE (Fairness and non-discriminatory) Beauchamp & Childress (2008)

9. SEEDHOUSE ETHICAL GRID Blue = Health care purpose Red = ethical duties Green = consequences & priorities Black = practical consdierations

10. END OF LIFE ISSUES Fear and avoidance of death. Euthanasia. Withdrawal or withholding treatment. Time and place of death.

11. FEAR AND AVOIDANCE Distinguish between the manner of dying e.g. pain, torment, discomfort. (process issues) And the journey beyond e.g. the next world, the void, the afterlife, the unknown. The former is tackled by good palliative care. The latter is tackled through spirituality and understanding / support.

12. EUTHANASIA ‘A good death’ 1) THE PATIENT MAY CHOOSE TO DIE - VOLUNTARY EUTHANASIA 2) THE DOCTOR MAY CHOOSE WHEN THE PATIENT CANNOT EXPRESS A VIEW 3) AGAINST THE WISHES OF THE PATIENT - INVOLUNTARY EUTHANASIA

13. ACTIVE EUTHANASIA CAUSING DEATH IS UNLAWFUL. INTENTIONAL KILLING IS MURDER OR MANSLAUGHTER. FAILURE TO KEEP A PATIENT ALIVE MAY BE UNLAWFUL. THE LAW DOES NOT DISTINGUISH BETWEEN ACTIVE & PASSIVE EUTHANASIA.

14. PASSIVE EUTHANASIA PERMISSABLE UNDER THE LAW PROVIDING THE HEALTH PROFESSIONALS OBLIGATION TO KEEP THE PERSON ALIVE IS OUTWEIGHED BY THE PATIENTS RIGHT TO DIE. ENGLISH LAW DOES NOT REQUIRE LIFE TO BE SUSTAINED WHATEVER THE CIRCUMSTANCES.

15. IT IS NOT UNLAWFUL TO ALLOW A PATIENT TO DIE, PROVIDING THAT AT LEAST A RESPONSIBLE BODY OF PROFESSIONALS WOULD FIND THE DECISION ACCEPTABLE.

16. Resuscitation or DNAR CPR – term has existed since 1960 (mouth to mouth, chest compression and defibrillation) Lower success rate than ever because of (i) inappropriate use (ii) professionals overoptimistic and (iii) default obligation “English law does not allow patients or proxy to demand therapies which are likely to be futile” (M Bass) But how do we define futility? Should CPR be discussed and why?

17. WHO DECIDES AND WHEN? The senior clinician (medical practitioner) in consultation with the patient or their official advocates. Orders should be signed on an appropriate form and left with the patient’s documents. All care staff should be aware. Orders should be reviewed in case of changes to the patient’s condition. This should be part of Advanced Care Planning.

18. CPR – Think Points Patient not obliged to share information with next of kin or family Senior clinician – who is this? How does DNAR information get communicated? DNAR may NOT be indefinite decision

19. DUTY OF CARE HEALTH PROFESSIONALS HAVE A DUTY OF CARE AND ARE AT RISK OF PROSECUTION FOR MANSLAUGHTER IF THEIR PATIENT DIES AFTER A NEGLIGENT FAILURE TO TREAT THEM.

20. LEGAL IMPLICATIONS NON-PROFESSIONALS HAVE BEEN FOUND GUILTY OF MANSLAUGHTER FOR FAILING TO LOOK AFTER RELATIVES FOR WHOSE CARE THEY HAVE TAKEN RESPONSIBILITY THE SUICIDE ACT 1961 ALLOWS A PERSON TO COMMIT OR ATTEMPT AN ACT OF SUICIDE, BUT MAKES ASSISTING THAT ACT ILLEGAL.

21. LETTING DIE If life is being preserved through extraordinary means. Irrefutable evidence exists that biological death is imminent. The family agrees.

22. RELIEF OF SUFFERING IF KNOWLEDGE OF GIVING PAIN RELIEF CAN RESULT IN THE PATIENTS DEATH, THE DRUG CANNOT BE ADMINISTERED BECAUSE IT IS MORALLY WRONG TO DO SO. 1) PATIENT MUST BE TERMINALLY ILL 2) DRUGS USED MUST BE THE RIGHT AND PROPER TREATMENT. 3) MOTIVATION FOR TREAMENT MUST BE TO RELIEVE SUFFERING.

23. LEGAL JUSTIFICATION ‘IF THE FIRST PURPOSE OF MEDICINE –THE RESTORATION OF HEALTH – COULD NO LONGER BE ACHIEVED, THERE WAS STILL MUCH FOR THE DOCTOR TO DO, AND HE WAS ENTITLED TO DO ALL THAT WAS PROPER AND NECESSARY TO RELIEVE PAIN AND SUFFERING EVEN IF THE MEASURES HE TOOK MIGHT INCIDENTALLY SHORTEN LIFE BY HOURS OR EVEN LONGER’ (R vs ADAMS 1957)

24. DOCTRINE OF DOUBLE EFFECT ETHICAL PRINCIPLE NON-MALEFICIENCE ‘ONE OUGHT NOT TO INFLICT EVIL OR HARM’ AN ACTION HAS A GOOD INTENTION AND CONSEQUENCE CONSEQUENCE 1 A GOOD BENEFICIAL OUTCOME CONSEQUENCE 2 AN UNINTENDED BUT FORESEEN BAD EFFECT

25. CONDITIONS FOR ACTION 1) THE ACTION MUST NOT BE INTRINSICALLY WRONG, BUT BE MORALLY GOOD OR NEUTRAL. 2) THE AGENT MUST INTEND THE GOOD EFFECT, NOT THE BAD EFFECT. 3) THE GOOD EFFECT MUST BE ACHIEVED DIRECTLY BY THE ACTION, NOT BY WAY OF THE BAD EFFECT. 4) THE GOOD RESULT MUST OUTWEIGH THE EVIL PERMITTED.

26. Liverpool Care Pathway Pensioner placed on Liverpool Care Pathway WITHOUT family's permission dies after spending eight days without food or water(This pathway is now forbidden) If the act of withholding nutrition and fluids leads to the patient’s death in a situation where the act and the consequences are linked is this euthanasia? Is the stopping of basic life activities right in the context of the dying patient?

27. TRUTH TELLING A moral obligation? In all circumstances? Does the obligation to tell the truth overcome the desire to avoid harm? Or vice versa. Is the harm real or imagined? Glaser & Strauss and their concept of ‘pretence’ Does the patient know even though they have not been told?