Palliative Care Education Program-
Decisions for the incapacitated
Primary Care
Module 3
Module 3.1
Ethical and Legal Issues
Objectives
 Describe ethical and legal
consensus points
 List common ethical and legal
myths and potential pitfalls
Law and Ethics
 Lawmakers
legislatures, judges, executive agencies
 Enforcement
- criminal, civil, administrative
Resolving difficult cases
 Law
 Ethics committees / consultants
Informed consent
 Information-giving standards
- standard professional
- reasonable person
- specific patient
 Elements of information
- nature of procedure
- risks, common or severe
- benefits
- alternatives
 Consent
- understanding
- voluntary
Procedures of informed consent
 Documentation
 Process of deliberation
 Shared decision making
 Communication of news
 Physicians have direct
responsibility
Treatment limitation at the end of life
 Right to refuse medical
interventions
 All patients have rights, even
incapacitated
 Withholding / withdrawing
not homicide or suicide
orders to do so are valid
 Courts need not be involved
Determining incapacity
 Determining decision making
capacity
- Is there a decision?
- Is the information understood?
- Is the reasoning logical and with
appreciation for consequences?
- Is the decision sensible?
 Reassess for each decision
 Hospital legal counsel
represents the institution
 Best interests
 Substituted judgment advance MODULE 3.2
directives
surrogacy laws
Medical Futility
Terminology of advance directives
 Advance care planning
Objectives
 List factors that might lead to
- process of discussion, documentation,
futility situations
implementation
 Understand
 Advance directives
- how to identify common factors
- instructional statement
- how to communicate and negotiate to
- living will
resolve conflict directly
- values history
- the steps involved in fair processes to
- personal letter
resolve intractable conflict
- medical directive
 Proxy designation
Physicians and futility
- health care proxy  Patients / families may be
- power-of-attorney for health care
invested in interventions
 Protection for physicians
 Physicians / other professionals
 Advisory
may be invested in interventions
- patient wishes  Any party may perceive futility
Surrogate decision maker
Definitions of medical futility
 Decision maker once
 Won’t achieve the patient’s goal
incapacitated
 Serves no legitimate goal of
 Surrogacy laws
medical practice
 Next-of-kin hierarchy
 Ineffective more than 99% of
 Surrogate decision making
the time
- Interpreting advance directives  Does not conform to accepted
- Preponderance of evidence standard
community standards
- Clear and convincing evidence
standard
Is this really a futility case?
Appropriate use of opioids in end-of-
 Unequivocal cases of medical
life care futility are rare
 Drug enforcement, professional  Miscommunication, value
licensure, and drug regulation agencies differences are more common
 Concern about abuse and  Case resolution more important
than definitions
addiction
 Awareness of the important role
Conflict over treatment
of opioids in medical practice
 Unresolved conflicts lead to
 Principle of double effect
misery most can be resolved
Physician-assisted suicide
 Try to resolve differences
 Provision of medication or other  Support the patient / family
interventions with the intention to cause  Base decisions on
death - informed consent, advance care -
 Criminal offense in most places planning, goals of care
Futility Differential diagnosis of futility
 Futile for what goal situations
 Inappropriate surrogate
 Objective determinations of
benefit
 Misunderstanding
 Use ethics consultation /  Personal factors
committees  Values conflict
 Transfer of care
Surrogate selection
Legal counsel and risk  Patient’s stated preference
 Ethics committees and  Legislated hierarchy
consultants should not be mistaken for  Who is most likely to know what
legal advisors the patient would have wanted?
 Who is able to reflect the
 Variations of opinion and
patient’s best interest?
unresolved issues
 Does the surrogate have the
 Direct responsibility for patient
care cognitive ability to make decisions?

Misunderstanding of diagnosis /
prognosis
 Underlying causes
 How to assess
 How to respond
Misunderstanding: underlying causes
 Doesn’t know the diagnosis
 Too much jargon
 Different or conflicting
information
 Previous overoptimistic
prognosis
 Stressful environment
 Sleep deprivation
 Emotional distress
 Psychologically unprepared
 Inadequate cognitive ability
Misunderstanding: how to respond
 Choose a primary
communicator
 Give information in
- small pieces
- multiple formats
 Use understandable language
 Frequent repetition may be
required
 Assess understanding
frequently
 Do not hedge to “provide hope”
 Encourage writing down
questions
 Provide support
 Involve other health care
professionals
Personal factors
 Distrust
 Guilt
 Grief
 Intrafamily issues
 Secondary gain
 Physician / nurse
Types of futility conflicts
 Disagreement over: goals,
benefit
Difference in values
 Religious
 Miracles
 Value of life
A due process approach to futility
 Earnest attempts in advance
 Joint decision making
 Negotiation of disagreements
 Involvement of an institutional
committee
 Transfer of care to another
physician
 Transfer to another institution
MODULE 3.3
Withholding / Withdrawing Treatment
Objectives
 Know the principles for
withholding or withdrawing therapy
 Apply these principles to the
withholding or withdrawal of
- artificial feeding, hydration
- ventilation
- cardiopulmonary resuscitation
Role of the physician
 The physician helps the patient
and family
- elucidate their own values
- decide about life-sustaining treatments
- dispel misconceptions
- determine the goals of care
 Facilitate decisions, reassess
regularly
 Discuss alternatives, including
palliative and hospice care
 Document preferences, support
with appropriate medical orders
 Involve, inform other team
members
 Assure comfort,
nonabandonment
Common concerns
 Are physicians legally required
to “do everything” possible?
 Is withdrawal, withholding
euthanasia?
 Are you killing the patient when
you remove a ventilator or treat pain?
 Can the treatment of symptoms
constitute euthanasia?
 Is the use of substantial doses
of opioids euthanasia?
Life-sustaining treatments
Depending on the clinical scenario, these
treatments can be considered life-
sustaining
 Resuscitation
 Elective intubation, mechanical
ventilation
 Surgery
 Dialysis
 Blood transfusions, blood
products
 Diagnostic tests
 Artificial nutrition, hydration
 Antibiotics
 Other treatments
 Future hospital, ICU admissions
8-step protocol to discuss treatment
preferences
1. Be familiar with policies, statutes
2. Appropriate setting for the discussion
3. Ask the patient, family what they
understand
4. Discuss general goals of care
5. Establish context for the discussion
6. Discuss specific treatment preferences
7. Respond to emotions
8. Establish, document, disseminate and
implement the plan
Aspects of informed consent
 Problem that treatment would
address
 What is involved in the
treatment / procedure
 What is likely to happen if the
patient decides not to have the treatment
 Treatment benefits
 Treatment burdens
Example 1: Artifical feeding, hydration
 Physicians frequently perceive
these discussions to be difficult.
 Food and water are widely held
symbols of caring, so withholding of
artificial nutrition and hydration may be
misperceived as neglect
Review goals of care
 Establish overall goals of care
 Will artificial feeding, hydration
help achieve these goals?
Address misperceptions
In a dying patient due to far-advanced
cancer (or other disease):
 Poor hydration and nutrition is
the main cause of disability and fatigue
 Relief of dry mouth requires IV
fluids
 Delirium always requires IV
fluids
 Poor urine output requires IV
fluids
Help family with need to give care
 Identify feelings, emotional
needs
 Identify other ways to
demonstrate caring; teach the skills they
need
Normal dying
 Loss of appetite and decreased
oral fluid intake are part of the normal
dying process
 Patients usually will not suffer
from thirst or hunger
 Artificial food / fluids may make
situation worse
- breathlessness, edema, ascites,
nausea / vomiting
 dehydration in an imminently
dying patient may have some benefits:
- pulmonary secretions, vomiting, and
urinary incontinence may be less
- may stimulate the production of
endorphins and other mediators that help
to contribute to a peaceful, comfortable
death
Example 2: Ventilator withdrawal
 Rare, challenging
 Ask for assistance
 Assess appropriateness of
request
 Role in achieving overall goals
of care
Immediate extubation
 Remove the endotracheal tube
after appropriate suctioning
 Give humidified air or oxygen to
prevent the airway from drying
 Ethically sound practice
Terminal weaning
 Rate, PEEP, oxygen levels are
decreased first
 Over 30–60 minutes or longer
 A Briggs T piece may be used in
place of the ventilator
 Patients may then be extubated
Ensure patient comfort
 Anticipate and prevent
discomfort
 Have anxiolytics, opioids
immediately available
 Titrate rapidly to comfort
 Be present to assess,
reevaluate
Prevent symptoms
 Breathlessness: opioids
 Anxiety: benzodiazepines
Preparing for ventilator withdrawal
 Determine degree of desired
consciousness
 Bolus 2-20 mg morphine IV,
then continuous infusion
 Bolus 1-2 mg midazolam IV,
then continuous infusion
 Titrate to degree of
consciousness, comfort
Prepare the family
 Describe the procedure
 Reassure that comfort is a
primary concern
 Medication is available
 Patient may need to sleep to be
comfortable
 Involuntary movements
 Provide love and support
 Describe uncertainty
Prior to withdrawal
 Prior to procedure
- discussion and agreement to
discontinue
- with patient (if conscious)
- with family, nurses, respiratory
therapists
- document on the patient’s chart
Withdrawal protocol–
part 1
 Procedure
- shut off alarms
- remove restraints
- family is invited into the room
- parents may hold child
Withdrawal protocol–
part 2
 Establish adequate symptom
control prior to extubation
 Have medications IN HAND
midazolam, lorazepam, or diazepam
 Set FiO2 to 21%
 Adjust medications
 Remove the ET tube
Withdrawal protocol–
part 3
 Invite family to bedside
 Washcloth, oral suction
catheter, facial tissues
 Reassess frequently
 After the patient dies
talk with family and staff
provide acute grief support
 Offer bereavement support to
family members
follow up to ensure they are okay
Example 3: Cardiopulmonary
resuscitation
 Establish general goals of care
 Use understandable language
 Avoid implying the impossible
 Ask about other life-prolonging
therapies
 Affirm what you will be doing
Write appropriate medical orders
 DNR
 DNI
 Do not transfer
 Others
MODULE 3.4
Physician Assisted Suicide and
Euthanasia
Objectives
 Define physician-assisted
suicide (PAS) and euthanasia
 Describe their current status in
the law
 Identify root causes of suffering
that prompt requests
 Understand a 6-step protocol for
responding to requests
 Be able to meet most patients’
needs
Physician-assisted suicide /
euthanasia
 Ancient medical issue
 Aiding or causing a suffering
person’s death
physician-assisted suicide-physician
provides the means, patient acts
euthanasia- physician performs the
intervention
 Many physicians receive a
request
 Requests are a sign of patient
crisis
Why patients ask for PAS
 Asking for help
 Fear of: psychosocial, mental
suffering
future suffering, loss of control, indignity,
being a burden
 Depression
 Physical suffering
The legal and ethical debate
 Principles
- obligation to relieve pain and suffering
- respect decisions to forgo life-
sustaining treatment
 The ethical debate continues
 In most countries, people do not
have a right to PAS
 PAS is illegal in most countries
 In contrast to the PAS debate,
the right to palliative care is uniformly
acknowledged
6-step protocol to respond to requests
1. Clarify the request
2. Assess the underlying causes of the
request
3. Affirm your commitment to care for the
patient
4. Address the root causes of the request
5. Educate the patient and discuss legal
alternatives
6. Consult with colleagues
Step 1: Clarify the request
 Immediate, compassionate
response
 Open-ended questions
 Suicidal thoughts, plans?
 Be aware of
personal biases
potential for counter-transference
Step 2: Assess underlying causes
 The 4 dimensions of suffering
- physical
- psychological
- social
- spiritual
 Particular focus on
- fears about the future
- depression, anxiety
Assess for clinical depression
 Underdiagnosed, undertreated
 Source of suffering
 Barrier to life closure, “good
death”
 Diagnosis challenging
no somatic symptoms
helplessness, hopelessness,
worthlessness
 Treatment choices depend on
time available
- fast-acting psychostimulants
- SSRIs
- tricyclic antidepressants
Psychosocial suffering, practical
concerns
 Sense of shame
 Not feeling wanted
 Inability to cope
 Loss of
- function
- self-image
- control, independence
 Tension with relationships
 Increased isolation, misery
 Worries about practical matters
- who caregivers will be
- how domestic chores will be tended to
- who will care for dependents, pets
Physical suffering
 Pain
 Breathlessness
 Anorexia / cachexia
 Weakness / fatigue
 Loss of function
 Nausea / vomiting
 Constipation
 Dehydration
 Edema
 Incontinence
Spiritual suffering
 Existential concerns
 Meaning, value, purpose in life
 Abandoned, punished by God
questions faith, religious beliefs
anger
Common fears
 Future
 Pain, other symptoms
 Loss of control, independence
 Abandonment, loneliness
 Indignity, loss of self-image
 Being a burden on others
Step 3: Affirm your commitment
 Listen, acknowledge feelings,
fears
 Explain your role
 Commit to help find solutions
 Explore current concerns
Step 4: Address root causes
 Professional competence in:
- withholding, withdrawal
- aggressive comfort measures
- palliative care principles
- local palliative care programs
 Address suffering, fears
Address psychological suffering
 Treat
- depression
- anxiety
- delirium
 Individual, group counseling
 Specialty referral as appropriate
Address social suffering, practical
concerns
 Family situation
 Finances
 Legal affairs
 What setting of care
 Who caregivers will be
 How to manage domestic
chores
 Who will care for dependents,
pets
Address physical suffering
 Aggressive symptom
management
 Engage physical, occupational
therapy
exercises
aids to optimize function
Address spiritual suffering
 Explore
- prayer
- transcendental dimension
- meaning, purpose in life
- life closure
- gift giving, legacies
 Consult chaplain, psychiatrist,
psychologist
Address fear of loss of control
 Explore areas of control,
independence
 Right to determine one’s own
medical care
- accept or refuse any medical
intervention
- life-sustaining therapies
 Select
- personal advocate(s)
- proxy for decision-making
 Prepare advance directives
 Plan for death
 Make a commitment to help
patient maintain as much control as
possible
Address fear of pain, other symptoms
 Explain about
- control of pain, other symptoms
- sedation for intractable symptoms
 Commitment to manage
symptoms
Address fear of being a burden
 Establish specifics
worry about caregiving
- family willing
- alternate settings
worry about finances
- resources, services available
 Refer to a social worker
Address fear of indignity
 Discuss what indignity means to
the individual
- dependence, burden, embarrassment
 Importance of control
 Explore resources to maintain
dignity
 Reassure patient
Address fear of abandonment
 Assurance that physician will
continue to be involved in care
 Resources provided by hospice
and palliative care
Step 5: Educate, discuss legal
alternatives
 Information giving
 Refusal of treatment
 Withdrawal of treatment
 Declining oral intake
 Sedation
Decline oral intake
 Any person can decline oral
intake
 Force-feeding not acceptable
 Ensure food, water always
accessible
 Accept / decline artificial
hydration, nutrition
 Educate, support family
members, caregivers
- refocus their need to give care
End-of-life sedation
 When symptoms are intractable
at the end of life
 Continuous, intermittent
 Death attributed to illness, not
sedation
 Benzodiazepines
 Anesthetics
 Barbiturates
 Continue analgesics
Step 6: Consult with colleagues
 Seek support from trusted
colleagues
 Reasons for reluctance to
consult

Key Points for Module 3
3.1 Ethical and Legal Issues
1. The law is an important factor to take
into account in the care of patients at the
end of life. However, the law does not
always prescribe the ethically appropriate
medical decision.
2. State laws can vary from the prevailing
legal consensus on end-of-life care (eg,
in the degree of certainty that a surrogate
should have about a patient’s wishes). It
is important for physicians to become
familiar with the laws of their state on
end-of-life care.
3. Listen carefully and empathically, and
communicate clearly. A quality
professional relationship may be your
greatest protection against legal action.
Pearl: A quality professional relationship
may be your greatest protection against
legal action.
Informed consent
4. The informed consent process is one
of discussion, shared decision making,
and documentation of the process and
the decisions. The patient must be
informed and free of coersion.
5. Even though reimbursement and
incentive issues may exert considerable
pressure, physicians remain both
ethically and legally responsible for
providing patients with accurate
information (in the manner in which they
request to receive it), for offering
appropriate therapies, and for the
decisions they make.
Treatment limitation at the end of life
6. Patients with decision-making capacity
may refuse unwanted medical treatment
even if this may result in their death, and
even in cases where the patient does not
have a life-threatening illness.
7. Continuing treatment in violation of
patient or surrogate wishes can be both
ethically inappropriate and legally
perilous.
Surrogate decision making
8. Patients who lack capacity to make the
decisions at hand have the same rights
as those who have capacity. Only the
process in which these rights are
exercised is different.
9. If a patient is determined to be
incapacitated to make a health care
decision, the physician should document
the basis for that determination (inability
to understand, evaluate, and
communicate). Unless a patient is
permanently incapacitated, a patient’s
decision-making capacity should be
reevaluated for each major medical
decision.
Potential pitfall: Forgetting that patients
who cannot communicate or who have
some mental incapcity may still make
some valid decisions.
10. Authorized surrogate decision
makers may make decisions to limit
treatment for patients who lack decision-
making capacity. Surrogate decision
makers may make decisions by using the
substituted judgment standard (what the
patient would want under the
circumstances, if known) or the best
interest standard. The approach will
depend in part on whether the patient
has executed an advance directive.
Withholding or withdrawing treatment
11. Decisions to withhold or withdraw life-
sustaining medical treatment under
appropriate circumstances are not
considered either homicide or suicide
12. There are no limitations to the type of
treatment that may be withheld or
withdrawn.
13. Most decisions to limit treatment may
be made without going to court.
Pearl: A general comment made by the
patient that he or she “would not never
want
to live as a vegetable ” does not give a
great deal of guidance to discontinue life
support. Probe for more elucidation.
Appropriate use of opioids
14. Physicians have a responsibility to be
aware of the realistic risks associated
with the treatments they offer.
15. It is ethically inappropriate to provide
inadequate treatment of pain and
symptoms for patients at the end of life
because of fears of unintentionally
hastening death.
16. Physicians should feel comfortable
providing medication, including opioids,
using accepted dosing guidelines to
alleviate a patient’s pain and suffering,
even if the unintended secondary effect
of the administration of medication might
be to shorten the patient’s life
Physician-assisted suicide
17. Provision of medication with the
intent to produce death is considered to
be assisting suicide, a criminal offense in
most states.
18. When the (US) Supreme Court ruled
that there was no constitutional right to
assisted suicide, it also reaffirmed the
difference between withholding or
withdrawing lifesustaining treatment and
assisted suicide.
Futility
19. Physicians’ recommendations
regarding limitation of treatment should
be based on objective determination of
ineffectiveness, rather than subjective
opinions about the worth of the
intervention or of the patient’s continued
life.
Pearl: Where there is concern, seek a
second opinion.
Confidentiality
20. Confidentiality concerns are not
usually different for patients facing the
end of life.
Role of counsel
21. Ethics committees and consultants
can be helpful in resolving ethical issues
in end-of life care.
Potential pitfalls: Turning to ethics
committees for legal advice. They are not
legal advisors.
22. An institutional legal counsel’s
primary duty is to protect the client-
institution from legal liability, not
necessarily to facilitate ethical practice.
Physicians have a separate responsibility
to make ethical decisions in the care of
patients at the end of life.
3.2 Futility
1. Most so-called futility situations are not
straightforward. Persistent conflicts
usually represent conflict about the
relative value of treatments.
2. Physicians and health care providers
may seek futile therapies just as patients
and families may.
Nature and limitation of futility
definitions
3. Disagreements about futile care may
be the result of misunderstandings or
lack of attention to the family’s emotional
reaction to the patient’s dying. Thus, it is
critical to understand why there is
disagreement.
4. Most disagreements about futile care
are the result of misunderstandings or
lack of attention to the family’s (or
physician’s) emotional reaction to the
patient’s dying.
Pearl: Clarify the overall goals of care.
Differential diagnosis of futility
situations
5. Are we talking to the appropriate
decision maker?
6. Does the patient/surrogate understand
the physician’s view of prognosis?
Pearl: Never use the phrase “do
everything.”
7. Are there personal factors?
Potential pitfall: Hiding behind
information. Facts alone won’t help deal
with emotions.
Potential pitfall: Defensive medicine.
Mistaken notions of legal requirements
often drive poor judgment.
Potential pitfall: Mistrust. Patients and
families may not trust the information
they are being given.
Potential pitfall: Missing a diagnosis of
anticipatory grief. Reactions may be the
result of anticipatory grief or guilt.
8. Are there genuine value conflicts (ie,
not based on misunderstandings)? They
are typically of 2 types:
a. parties differ over goals
b. parties differ over treatment benefit
9. Failure to acknowledge and explore
cultural and religious values, beliefs, and
practices may exacerbate or prolong
conflict and disagreement.
10. Differentiate “futile” therapy from
“low-yield” therapy during discussions.
Potential pitfall: Using anecdotes to make
decisions.
Potential pitfall: Projection. Be careful not
to let your personal values interfere with
decision making.
Due process approach
11. Negotiate an understanding in
advance of conflict.
12. Use joint decision making.
13. Suggest participation of others.
14. Transfer care to another physician.
15. Transfer care to another institution.
3.3 Withholding, Withdrawing Therapy
1. Patients have the right to refuse any
medical treatment, even life-sustaining
treatments.
Pearl: Discuss overall goals before
discussing specific treatments.
2. Withdrawal or withholding of treatment
is a decision/action that allows the
disease to
progress on its natural course. It is not a
decision/action intended to cause death.
Pearl: Acknowledge emotional
components of decisions.
Potential pitfall: Avoid loaded slogans like
“do everything,” “starve to death.”
3. In rare circumstances, opioids and
other drugs are rapidly titrated to treat
physical symptoms following accepted
dosing guidelines. They might be
perceived to contribute to death.
Provided the intent was genuinely to treat
the symptoms, then such use is not
euthanasia.
Pearl: Stress from symptoms may be the
only thing keeping the patient alive.
4. Physicians must familiarize
themselves with the policies of the
institution and pertinent statutes where
they practice.
5. Impediments to good care include
misconceptions about legal and ethical
issues, as well as unfamiliarity with the
practical aspects of withholding or
withdrawing treatment. Institutional
policies may be written in response to the
general legal imperative to err on the
side of prolonging life in cases of
uncertainty or in emergencies.
6. Patients may be transferred to the
acute care setting where life-sustaining
measures are administered because the
appropriate treatment plan and
physician’s orders have not been
completed and placed in the patient’s
chart, or physician’s orders may not
transfer across settings.
Nutrition/hydration
7. If the patient and family hope to see
improved energy, weight, and strength,
artificial fluid and nutrition may not help
accomplish those goals.
8. If the patient is close to dying, make
sure the family knows that a dry mouth
may not improve with intravenous fluids.
Relief is much more likely with attention
to mouth care and oral lubricants.
9. Dehydration is a natural part of the
dying process. Artificial fluids and
hydration will not help the patient feel
better.
10. Artificial fluids and nutrition may
make edema, ascites, pulmonary and
other secretions, and dyspnea worse,
particularly if there is significant
hypoalbuminemia.
Pearl: Dehydration may stimulate the
production of endorphins and other
anesthetic compounds that help to
contribute to a peaceful, comfortable
death for many patients.
Withdrawing ventilation
11. When removing a patient from the
ventilator, it is critical that the patient be
comfortable before, throughout, and after
the procedure.
12. If the patient is conscious, determine
whether he or she would like to remain
conscious as the ventilator is withdrawn.
Pearl: Carbon dioxide narcosis may
stimulate endorphin release and further
sedate the patient.
13. A combination of opioid and
anxiolytic therapy should be used to
ensure comfort.
14. Have medication immediately
available at the bedside so that it can be
rapidly titrated to the level appropriate to
ensure the patient’s comfort.
Potential pitfall: Not having the attending
physician at the bedside when
withdrawing the ventilator.
15. There is no need to increase the
dosage of medication once comfort and
the desired level of sedation have been
achieved.
16. Since there is uncertainty involved, it
is important for the physician to prepare
the family for the range of outcomes that
might occur. Explain that there is always
some uncertainty as to what will happen
after the ventilator is withdrawn. Caution
the family that, although death is
expected, it is not certain; the patient
may survive.
17. Encourage the family to spend as
much time at the bedside as they require.
Potential pitfall: Forgetting anxiolytics.
Opioids only have transient and
unreliable anxiolytic effects in opioid-
naive patients and should not be used to
relieve anxiety.
Cardiopulmonary resuscitation/do-
not-resuscitate orders
18. In the setting of advanced
progressive illness where the prognosis
is limited, consider carefully whether
cardiopulmonary resuscitation (CPR) will
help achieve the goals that the patient,
family, and physician have collectively
determined.
19. Establishing do-not-resuscitate
(DNR) order is but one aspect of
advance care planning. Avoid discussing
it as an isolated decision.
20. Before discussing a DNR order,
confirm the patient’s understanding about
his or her overall medical condition, and
the context in which you are discussing
the use of CPR.
21. Before ending the discussion, affirm
what you will be doing for the patient.
Confirm the active interventions that are
being or will be done for the patient. For
many patients, full medical interventions
to reverse disease and sustain life are
appropriate even with a DNR order in
place.
22. Beside a DNR order in the chart,
include all positive orders that relate to
symptom control and those that guide
intensity of care. Communicate this to
other caregivers.
23. DNR status should never be
addressed in isolation. The phrases,
“She is a DNR” and,
“He is a full code” betray the bizarre way
in which decisions about resuscitation
are sometimes extrapolated to presume
an entire care plan.
24. CPR decisions are the least stable
and least useful in inferring other wishes.
They tend to make people more
concerned rather than comfortable about
the moment of death.
Pearl: When the patient and family are
fearful of immediate death, it may be
helpful in reestablishing perspective and
control discuss goals and treatment or
care choices by presenting them in a
range of scenarios.
Pearl: Avoid implying that the impossible
is possible. The convention of initially
discussing CPR as “starting the heart” or
“putting on a breathing machine” implies
a false sense of reversibility, or suggests
that heart and lung functions are isolated
problems. Pearl: Explicitly acknowledge
the context in which CPR would be
administered to a patient who is dying.
Potential pitfall: Describing CPR as
“doing everything.” This implies that not
doing CPR is “doing nothing.”
3.4 Physician Assisted Suicide
1. Physicians have an obligation to
relieve pain and suffering and to promote
the dignity of dying patients in their care.
2. Physicians must respect patients’
competent decisions to forgo life-
sustaining treatment.
Why patients request PAS
3. A request for physician-assisted
suicide may be the first expression of
unrelieved suffering.
4. Each person will have a unique set of
needs and reasons for a request.
Step 1: clarify the request
5. Listen carefully to the nature of the
request.
Pearl: Empathic listening can have a
therapeutic effect.
Pearl: Talking about suicide or hastened 18. Patients may choose to decline
death, if the patient is thinking about it, regular oral intake of food and/or fluids.
may reduce, not increase their risk. Potential pitfall: Forgetting families and
6. Try to understand the type of request caregivers. They may need to be
that is being made, and the underlying educated and supported, and their need
causes for it. to give care refocused.
7. Be aware of personal biases and the 19. For the rare patient with unbearable
potential for countertransference. and unmanageable pain, or other
Potential pitfall: Prematurely affirming intractable symptoms, who is
any perspective can propel both parties approaching the last hours or days of his
to stark choices. or her life, the induction and maintenance
Step 2: determine the underlying of a state of sedation is an ethical option
causes for the request when all other available and reasonable
8. Clinical depression occurs frequently therapies have been tried unsuccessfully.
and is underdiagnosed, undertreated, Step 6: consult with colleagues
and a frequent motivator for requests. 20. Don’t address requests for physician-
Pearl: The question “Do you feel assisted suicide in isolation – consult
depressed?” is a sensitive and specific with trusted colleagues early.
screening question in the medically ill.
9. Emotional and coping responses to
life-threatening illness may include a END OF MODULE 3
strong sense of shame, feelings of not
being wanted, and/or inability to cope.
10. Worries about practical matters can Acknowledgement
create considerable distress. Medina MF. The Philippine Palliative Care
11. Many patients are fearful about what Education Program. Curriculum for Primary
the future will be like (pain and other Care. PCEP-PC. 2008; Adapted from
symptoms, loss of control/independence, Emanuel LL, von Gunten CF, Ferris FD, eds.
abandonment, loneliness, indignity, loss The Education in Palliative and End-of-life
Care (EPEC) Curriculum. The EPEC Project,
of selfimage, being a burden).
1999, 2003.
Pearl: Pain and other physical symptoms
are less frequent motivators than many
think.
Pearl: Fears and the need to have some
control are fundamental issues.
Step 3: affirm your commitment to
care for the patient
12. Make a commitment to help find
solutions to the issues of concern, both
current and anticipated.
Step 4: address the root causes of the
request
13. Knowledge of appropriate
approaches for the withdrawal or
withholding of life-sustaining
interventions and aggressive comfort
care is essential.
14. Assess and manage any anxiety,
delirium, depression, physical symptoms,
social dysfunction, and practical
concerns.
15. Assess and address fears of being a
burden, abandonment, loss of control,
indignity, future pain, and other
symptoms.
16. Assess and address the sense of
loss of meaning and purpose by assisting
with life closure, gift giving, creation of
legacies.
Potential pitfall: Delaying inclusion of
other skilled members of the health care
team.
Step 5: educate the patient, discuss
legal alternatives
17. Patients should be clear that they
have the right to consent to, decline, or
stop any treatment or settings of care at
any time if they seem too burdensome.