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Medical Ethics End-Of-Life Issues & Euthanasia

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Medical Ethics End-Of-Life Issues & Euthanasia Medical Ethics End-of-life Issues & Euthanasia Srivieng Pairojkul, MD. Department of Pediatrics Faculty of Medicine Khon Kaen University End-of-life Issues & Euthanasia Goals How we get there • To understand conflict • Review ethic between a physician’s duty to theories and save life and other values. principles • End-of-life decision making • Case analysis • Reflect on who should make base on ethic decision and how. theories and • Know the definition and type principles of of euthanasia.. ethics. Ethics and Medicine • Since medicine deals with the life and death of people, ethical problems naturally arise. • Doctors face ethical problems everyday. • But how well equipped are they to deal with the issues? • Basic principles: – Do No Harm. (Non-maleficence) – Do Good (Beneficence) – Be Fair (Justice) Ethic Theories Utilitarianism The greatest happiness principle Resource allocation Kantianism Duty-based theories “Deontology” Duty to save life Case Analysis in Clinical Ethics Medical Patient Indication Preferences Contextual Quality of Life Features Issues in End-of-Life Care • Ethical principles • Shared decision making • The right to refuse medical treatment • Forgoing treatment on the basis of medical futility • Killing vs allowing to die Principles of Medical Ethics • Respect for patient autonomy • Beneficence – “Benefit the sick” • Non-maleficence – “Do no harm” • Justice – Require social policy level Shared Decision Making Decision should be shared between physician & patient Physician Patient Inform the treatment options Receive information on the best medical interest Chose treatment Accept doctor ‘s Refuse treatment recommendation Right to Refuse Medical Treatment • Patient with decision-making capacity • Patient without capacity but had earlier expressed treatment preferences for EOL care • Patient without capacity, had made no prior expression • Patient who never had the capacity to make treatment decisions Patient without decision making capacity Proxy decision making Æ make “substituted judgment” Right to Refuse Medical Treatment State courts have identified social interests that must be balanced against a person’s right to refuse treatment • Preservation of life • Prevention of suicide • Protection of third parties • Preservation of the ethical integrity of medical profession Basis of Futility • Post-hoc futility • Predictive futility - Conceptual futility - Brain death - Probabilistic futility - survival chance - Physiologic futility - Doctor-patient goal disagreements – value differences Killing vs Allowing to Die When discontinue life-sustaining treatment Causing the patient’s death vs. Allowing the patient to die Withhold / withdraw life support Do Not Resuscitate Orders CPR – Set of specific supportive medical procedure When can CPR be withheld ? • When CPR is judged to be no medical benefit (medical futility) • When the patient with intact decision making capacity clearly indicates that he/she does not want CPR • What if CPR is not futile, but the patient wants a DNR order ? * Respect autonomy • What if the family disagrees with DNR order? * Write DNR order only with patient/family agreement. • What if the patient is unable to say what his/her wishes are? * Advance directive (Living will) * Surrogate decision maker Surrogate Decision Makers • Legal guardian with health care decision- making authority • Individual given durable power of attorney for health decision • Spouse • Adult children of patient (all in agreement) • Parents of patient • Adult siblings of patient (all in agreement) HumanHuman beingbeing AestheticAesthetic FreedomFreedom PeacePeace The brain-dead patient and the family’s dilemma A 15-year old patient, suffered major injuries is now brain dead. The parents have been explained everything. They do not want to let their loved one go, and want to continue treatment. • Can physicians take a decision to switch off the ventilator if it is needed by another patient? **** • Legal V.S. ethical issues Beneficence Non-maleficence Autonomy Justice Killing Brain death Family’s decision Patient’s suffering Family’s grief Resource allocation Continue life support Withdraw life support The terminal cancer patient A 50-year old man with metastatic cancer. You know that another trial of chemotherapy may prolong his life for several months, but he will suffer enormous pain. The family had already spent 100,000 Bahts for the treatment. He is poor and has 3 children with a wife who does not earn. • Will you offer this treatment to the family ? **** • If you had offered this treatment to the family , what will be your decision - If the family want to continue the treatment ? - If the family want to go back home? Beneficence Non-maleficence Autonomy Justice • Truth telling – offer treatment • Disease is incurable • Family values • Patient’s suffering • Family’s decision • Burden to family • Resource allocation Provide treatment Not offer the treatment according to family’s value Baby Theresa Theresa Ann Campo Pearson Anencephalic infant born in Florida in 1992 Parents volunteered her organs for transplant Is it justify to remove the infant’s organs, causing her immediate death to help other children? **** Baby Theresa • The benefits argument • The argument that we should not use people as means • The argument from the wrongness of killing Jodie and Mary In August 2000, a young women from Gozo carrying conjoint twins, she was transferred to England to have the babies delivered The babies shared one heart and one set of lung, the babies will die if operation was not performed to separate the babies Parents are Catholics, refused permission for the operation “If it’s God’s will that both of our children should not survive then so be it” **** Jodie and Mary The courts granted permission and on November 6th the operation was performed Jodie lived and Mary died Jodie and Mary • The argument that we should save as many as we can • The argument from the Sanctity of Human Life Dax’s Case Please Let Me Die! The Case of Dax Cowart • Due to a propane gas explosion a 25-year- old, single male (Dax) was critically injured. • Dax suffers from horrendous 2nd and 3rd degree burns on more than 68% of his body. • Both eyes, both ears and both hands are damaged beyond repair. • Large doses of narcotics are required to minimally reduce the excruciating pain he experiences The Case of Dax Cowart • Repeatedly wishes he had died in the explosion. • Continually begs that treatment be discontinued and that he be allowed to die. **** • Despite this demand the wound care was continued, skin grafts were performed, and nutritional and fluid support were provided • He was discharged totally blind, with minimal use of his hands, badly scared, and dependent on others for assistance Theresa Marie "Terri" Schiavo She collapsed in her home, and experienced cardiac arrest leading to 15 years of institutionalization and a diagnosis of persistent vegetative state. In 1998, her husband and guardian, petitioned the Court to remove her feeding tube. Her parents, opposed this. **** The court determined that Terri would not wish to continue life-prolonging measures. The battle stretched on for seven years and included involvement by politicians and advocacy groups. WhatWhat isis GoodGood DeathDeath ?? What is Happening in Modern Medicine ? • Huge technological advances • Runaway healthcare costs • Medicine getting more impersonal • Subspecialization on organ systems • Quantity rather than quality of life How People die? People do not die in the places they wish or with the peace they desire. Many die alone, in pain, terrified, mentally unaware, without dignity, or feeling alienated What is a Good Death ? Common Ideal Death Scenarios Mercy Killings A Good Death ? Tracy Latimer Tracy Latimer, a 12-year-old victim of cerebral palsy, was killed by her father in 1993 Mr. Latimer was tried for murder. The jury found him guilty only second-degree murder and ignore the 25-year sentence. He was sentenced to one year in prison **** The supreme court of Canada stepped in and ruled that the mandatory sentence must be imposed, Mr. Latimer is now in prison, serving the 25-year term Robert Latimer Robert Latimer (born March 13, 1953) is a Canadian farmer sentenced to life imprisonment without the possibility of parole for ten years for the murder of his daughter Tracy (born November 23, 1980), which occurred on October 24, 1993. This act sparked a significant national controversy on the ethics of mercy killings. From Wikipedia, the free encyclopedia Jack Kevorkian Between 1990 and 1998, Kevorkian assisted in the suicide of nearly one hundred terminally ill people Euthanasia ( From Greek: ευθανασία) A practice of terminating the life of a person or an animal because they are perceived as living an intolerable life, in a painless or minimally painful way either by lethal injection, drug overdose, or by the withdrawal of life support. Euthanasia • Active euthanasia – Physician assisted suicide • Passive euthanasia - Hastening the death of a person by altering some form of support and letting nature take its course. A machine that can facilitate Euthanasia through heavy doses of drugs. 20 mg/kg thiopental sodium IV 20 mg pancuronium dibromide (Pavulon) "One"One shortshort sleepsleep past,past, we we wakewake eternally..."eternally..." "...And"...And deathdeath shallshall bebe nono more;more; Death, Death, thou thou shaltshalt die!"die!".
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