9/11/2019 Handbook for Health Care Ethics Committees, 2nd Ed. Chapter 10: Palliation (Post & Blustein, 2015) Valerie Violi Satkoske, PhD Director of Ethics Wheeling Hospital Associate Director WVU Center for Health Ethics and Law Consortium Ethics Program Seminar September 13, 2019 Technology/Medical Advances • Life sustaining treatments • Ventilators 1950s • Early 70s became a fixture in ICUs • CPR…. • Mouth to Mouth had been around since the 1700s but CPR (combining closed chest compression with mouth to mouth) wasn’t invented until early 1960s • Artificial Nutrition and Hydration • 1960s—Dr. Stanley Dudrich—TPN (large vein) • 1976—DobbHoff—Drs. Dobbie and Hoffmeister • 1979—PEG—Dr. Gauderer—Pediatrician • 1962 First Outpatient Dialysis in Seattle 1 9/11/2019 Organ Transplantation • 1954—first living donor kidney transplant between twins • 1962—first successful cadaver donor kidney transplant • 1967—Thomas Starzl first liver at Univ of Colorado • 1967—Christiaan Barnard first heart in South Africa • 1968—Uniform Anatomical Gift Act: The 1968 UAGA created the power, not yet recognized at common law, to donate organs, eyes and tissue, in an immediate gift to a known donee or to any donee that might need an organ to survive. Death became a failure of modern medicine and technology rather than an inevitability. The focus became cure rather than comfort…so either curing / or comforting…rather than both curing and comforting Palliative care as a discipline has successfully reintroduced the notion that relieving pain and suffering is central to the complete and authentic practice of medicine. Its defining philosophy is that cure and comfort are consistent objectives that may assume greater or lesser prominence, depending on the patient’s condition, prognosis, and values. (p. 162) 2 9/11/2019 Whatever the clinical setting, medical condition, or technological sophistication, one caregiver mandate remains constant and compelling—the relief of pain. This obligation is central to the therapeutic interaction, unquestioned and universal, transcending time and cultural boundaries…p.164 • The imperative is so powerful that it gives rise to the presumption that, unless patients explicitly object, they would want their pain relieved. • The incapacitated patient who is clearly in pain must not be deprived of relief because she is unable to provide informed consent 169 • No explicit informed consent required. It would be indefensible not to provide pain relief simply because a family finds it objectionable. (p. 169) 3 9/11/2019 Neutral term “Opioid” instead of “Narcotic”…? Management of Chronic Pain in Adults Living With Sickle Cell Disease in the Era of the Opioid Epidemic: A Qualitative Study “This study suggests that from the perspective of adult patients, the opioid epidemic may have negatively affected the care of patients with SCD by increasing barriers to care. Patients reported decreased access to opioids, increased stigmatization regarding opioid use, and physician preoccupation with opioid dosage without attention to multimodality care or alternative therapies.” Sinha CB, Bakshi N, Ross D, Krishnamurti L. Management of Chronic Pain in Adults Living With Sickle Cell Disease in the Era of the Opioid Epidemic: A Qualitative Study. JAMA Netw Open. Published online May 24, 20192(5):e194410. doi:10.1001/jamanetworkopen.2019.4410 The Principle (Doctrine) of Double Effect Determine the permissibility (ethical/moral/legal) of taking an action from which two or more effects result, some of which are good and intended and some of which are “bad” and foreseeable but unintended Kelly, DF. Contemporary Catholic Health Care Ethics. Georgetown University Press, Washington, D.C. (2004). 4 9/11/2019 Conditions that must be met • The act itself must be morally good or at least morally neutral. • The agent may not positively will / intend the bad effect but may permit it. If he could attain the good effect without the bad effect he should do so. • The good effect must flow from the action at least as immediately as the bad effect. In other words the good effect must be produced directly by the action, not by the bad effect. Otherwise the agent would be using a bad means to a good end, which is never allowed. • The good effect must be sufficiently desirable to compensate for the allowing of the bad effect (the bad effect must not outweigh the good effect) Pain Medication (end of life) • Prescribing pain medication • Intending to palliate pain, potential to hasten death is foreseeable • The good and intended effect (pain relief) results from the administration of the pain medication • The good effect cannot be caused by the bad effect • The good effect must outweigh or be proportional to the bad effect Patient doesn’t die in pain. Withholding / Withdrawing (end of life) • Withdrawing ventilator support • Relieve patient of unwanted, excessively burdensome treatment or medically ineffective treatment, recognizing that the action may also result in death • The good effect is the result of being liberated from the ventilator, not of dying • Dying comfortably vs Dying 5 9/11/2019 Physician Aid in Dying • At the request of the patient, physician provides the means for the patient to engage in direct self‐ killing. • States where it is legal • Oregon • Vermont • Washington • California • Montana • Colorado • Hawaii • Washington, DC • Maine Physician Aid in Dying • Prescribing sedating medicine (Seconal) • Assist patient in dying—both intended and foreseeable side effect • It does not pass the second condition, thus impermissible Euthanasia • Generally with the intention of ending the pain and/or suffering of another, a direct action is taken to bring about death in another. – Voluntary—at the patient’s request – Passive or involuntary—in the absence of the patient’s request – Illegal in all 50 states and most countries 6 9/11/2019 Quill TE, Ganzini L, Truog RD, Pope TM. Voluntarily Stopping Eating and Drinking Among Patients With Serious Advanced Illness—Clinical, Ethical, and Legal Aspects. JAMA Intern Med. 2018;178(1):123–127. doi:10.1001/jamainternmed.2017.6307 Voluntarily Stopping Eating and Drinking Patient driven Option in states where PAD isn’t legal Can take several weeks After a period of time support is required Debate about obligation of clinicians to support Can the options be exercised by a surrogate? What is patient loses capacity during the process? Case • 80 y.o. woman • Massive stroke leaving her flaccid on right side • Alert and Oriented but lacks insight into her condition • Will never be independent again • Told son she would not want to be alive if she couldn’t care for herself • Son requests food and water be withheld from the patient and put a sign above her bed • Patient asking for food and water 7.