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Journal watch: Ethics

Journal watch: Ethics. March 2013 Hannah Zacharias. Objectives. Journals from last 3/12 Not specific to medical ethics journals Summary of interesting articles from: JPSM European Journal of Palliative Care BMC Medical Ethics BMC Palliative Care.

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Journal watch: Ethics

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  1. Journal watch: Ethics March 2013 Hannah Zacharias

  2. Objectives • Journals from last 3/12 • Not specific to medical ethics journals • Summary of interesting articles from: • JPSM • European Journal of Palliative Care • BMC Medical Ethics • BMC Palliative Care

  3. Artificial feeding in terminally ill cancer patients with bowel obstruction. • Herodotou N. European Journal of Palliative Care, 2012; 19(5) • 3 case reports of use of PEG/TPN/venting gastrostomy • Patients aged 38, 32, 44yrs • All estimated to be in last couple of months of life. • Reasons: • Hunger, lethargy – PEG used as feed and VG • Prolongation of life to see child born (TPN) • Intractable vomiting – VG during day and PEG feed O/N

  4. Discussion re. the 4 ethical principles • Very few studies evaluating benefits of feeding these patients in last weeks of life • Cochrane review: insufficient evidence to recommend • For: enhancing QOL, providing hope, using PEG as venting device • Against: futility, health economics and risk of harm. • Brooksbank et al 2002: VG for N/V in advanced cancer. 92% relief of symptoms. Median survival 17 days

  5. Organization position statements and the stance of “studied neutrality” in Euthanasia in Palliative Care • Johnstone M-J, JPSM Dec 2012. 44(6) • Careful or premeditated practice of being neutral in a dispute. • Intended to foster a respectful culture among people of diverse views and to guide action that does not afford material advantage to a partisan group on the euthanasia issue. • Neither opponents nor proponents happy. • Proponents: official indecision and disrespect of patient’s decision to chose death when life unbearable. • Oponents: ‘going soft’ and weakening political resistance

  6. The ethical decisions UK doctors make regarding advanced cancer patients at the end of life – the perceived (in) appropriateness of anticoagulation for VTE: A qualitative study. • Sheard L et al. BMC Medical Ethics 2012, 13:22 • In depth interview with 45 doctors from Oncology, Palliative medicine and GP. Framework analysis. • Cancer patients high risk, esp advanced disease • Decisions placed on a shifting continuum. • Is the action ‘appropriate’. Prognosis and patient wishes key features. Opinion can be polarised even of doctors of same grade and specialty • ‘nice way to go’ – not supported by evidence and not always fatal • Treatment for VTE intrinsically bound to the doctors own moral and ethical framework

  7. Can physicians’ judgements of futility be accepted by patients?: A comparative survey of Japanese physicians and lay people. • Kadooka Y, BMC Medical Ethics 2012, 13:7 • Vignettes used for physicians to assess whether they would offer potentially futile treatments to patients at EoL • Physicians: medical info, QOL • Lay people: treatment wishes of the family and psych impact of treatment on pt • Wide variety in threshold of judging futility in both groups

  8. 88% physicians had provided futile treatment due to communication difficulties with pt and lack of systems regarding futility or foregoing treatment. • Lay people more supportive of providing futile treatments than physicians, explained by importance of medical info, family’s influence to decision making and QOL • Threshold of futility is arbitary

  9. 40% physicians provided futile treatment several times a year • Reasons for providing treatment judged to be futile: • 66% request by the patient • 38% to satisfy patient • 32% request from pt’s family • 21% pt’s lack of understanding about the futility of Rx

  10. End of life medical decisions in France: a death certificate follow-up survey 5 yrs after the 2005 act of parliament on patients’ rights and end of life • Pennec S, BMC Palliative Care 2012, 11:25 • Nationwide retrospective study of a random sample of adult patients who died in Dec 2009. Questionnaires were mailed to the physicians who certified the deaths. • 47% of all deaths followed at least one decision that may certainly or probably hasten death • End of life decisions are common in France, most in compliance with 2005 law. Some decisions made where not all legal obligations met and some where the decision was totally illegal.

  11. Medical decision to withold treatment increases steadily with age and implementation of LPT decreases. • 70% cases when an EoL decision was made, the persons when competent were involved in the decision. The greater likelihood that the decision would hasten death, the more frequently it was discussed with the patient, if competent. • Discussed with family / MDT etc in vast majority of cases • 3% given medicine with intention of hastening death. Only 1 in 5 of these cases had the patient explicitly requested this.

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