Ethical and Legal Issues

related to End of Life Care

 Death: an event
 Dying: a process
 Unique
 Individual
Changes in Death and Dying

 Late 1800’s
 Early to mid 1900’s
 In America
 Causes
 Demographic/social trends
 Location
Death and Dying in America

 Disparity between the way people die/

the way they want to die
 “live until you die” (philosophy of
Hospice)
 Patient/family perspective
Factors Influencing End of
Life Care
Factor: Advances in Techonology

 Can be victims of
technology
 Dying can be
extended beyond
what is reasonable
Factor: Aging Population
 Possibility of
physical decline
 Possibility of
mental decline
 Fear of nursing
home placement
Factor: Medical Futility
 Fear of what  Mental
medicine can’t cure deterioration
 Wasting away of
body
 Disfigurement
 Loss of energy
 Loss of control
 Pain
 Psychological
anguish
Factor: Social/ Family systems
 Fear of not being
taken seriously as
persons
 Fear our rights will
be slighted
 Violation of our
meaning of life
 Fear someone else
will control us
Factors: Health Care
 Lack of professional
knowledge
 Fear of litigation
 Access to hospice
 Legal/ bureaucratic
obstacles
 Reimbursement
Factor: Search for Life’s Meaning

 What does Life Mean

for a human being?
 Can human life be
equated with mere
biological functioning?
 Can one cease being a
person while still in
some sense be alive?
Factor: Search for Life’s Meaning

 What meaning do
we give to
 dependency on
others
 decline and aging
 Pain and suffering
 Illness and death
Issues Related to End of Life

 Communication and Decision-making

 Prolongation of live vs quality of life
 Withholding or withdrawing treatment
 Caring and Comfort
 Medical Futility
 Assisted Suicide
 Research
Issues of Decision Making and
Communication
 Consent
 Confidentiality
 Disclosure
 Advanced Care
planning
 Patient Self-
Determination
 Advanced directives
Difficulties with
Communication
 Difficulties come when families:
 Do not want to address issue of death
 Want to protect loved ones through
silence
 Are faced with death “out of sequence”
Issue: Prolongation of Life and
Quality of Life
 Acute Therapeutic
care
 Palliative treatment
 Artificial life
support
 Resuscitation
Issues of Withholding/
Withdrawing Treatment

 Based on right to
self determination
 Balance of benefit
vs. burden
 Examples:
 Artificial feeding
 Hydration
 Ventilation
 dialysis
Do Not Attempt Resuscitation/ no
Code
 Confirms that no
measure to prolong
life be carried out
 Written MD order
required
 Often required by
emergency response
systems
Issues of Care and Comfort

 Professional-patient relationship
 Provision of palliative care
 Control of symptoms
 Principle of Double Effect
Assisted suicide/Euthanasia
 Assisted Suicide
 The ultimate choice
 Fear loss of control

 Does autonomy extend to actively

ending our lives
 Oregon Law
 1994
 1997 Supreme Court upholds law

 Request often signify crisis,

unrelieved suffering, plea for help
Medical Futility

 Conflicts over benefits of treatment

 Often involve communication failures
 Care should be guided by values and
goals
Issue of cost of end of life care

 Futile care is costly

 Current system
creates severe
family burden
 Limits to medical
interventions
 Hospice care as a
cost effective
option
Research at the End of Life
 Need for appropriate
research
 Sense of obligation
may exist
 Issues of non-
malfeasance, autonomy
Health Care professional role

 How do we address the ethical issues

 Values clarification
 Support for the professional
 Advocacy
 Member of interdisciplinary team

 Use of ethics resources

Facilitating Ethical and legal
practice
 As professionals in
health care
 Practice within the
standards of care
 Communicate
wishes of patient
in collaboration
with
interdisciplinary
team
Facilitating Ethical and legal
practice
 If patient or family are
unsure of options
 Communications among
family members
 With clergy or spiritual
guide
 Physicians and other
healthcare professionals
Conclusion
 Victor Frankl (1959) “ We must never
forget that we may also find meaning
in life even when confronted with a
hopeless situation when facing a fate
that cannot be changed. . . When we
are no longer able to change a
situation. . . We are challenged to
change ourselves (Frankle, 1984, p.
135)