Research Paper on "Ethical Decisions in a Patients Right to Die"

Research Paper 6 pages (2178 words) Sources: 7

[EXCERPT] . . . .

Ethical Decisions in a Patient's Right to Die

DYING AS AN OPTION

Ethical Decisions in a Patient's Right to Die

Studies showed that 29% of terminally ill and severely suffering patients make end-of-life decisions and 21% of them actually die afterwards. The rest of them seek termination of treatment, DNR or the withdrawal or withholding of life support. Age, a diagnosis of sepsis or cirrhosis, seriousness of illness and transfer from another hospital constitute common factors in the decisions. The rule of double effect enhances pain management but must develop from moral integrity. If the patient's family or guardian feels it is in the patient's best interest to withdraw or withhold life-sustaining treatment, the witness of the attending physician and the management of the health facility must be obtained and given due course.

Review of Literature

Epidemiology

A large study showed that 29% of patients who die in surgical intensive care units make end-of-life decisions in some form (Meissner et al., 2010). About 21% of deaths occurred after the decisions are made, 16 times more in cases of severe sepsis and/or septic shock than any other cases. Of the total, 2.7% made end-of-life decisions, 1.6% reached a DNR order, and 1.1% withdrew life support. Age, a diagnosis of sepsis or cirrhosis, seriousness of illness, and admission from another hospital were determining factors. The study surveyed 14,720 patients at the surgical intensive care units at the Friedrich Schiller University Hospital in Germany between September 2002 and July

2006 (Meissner et al.).



The study sought to identify the possible factors associated with end-of-life decisions in surgical ICUs in view of the increasing incidence of these decisions in these settings (Meissner et al., 2010). It has been observed that deaths follow in 60-80% of cases when life support is withdrawn. DNR or do-not-resuscitate orders are also resorted to in critical care settings prior to end-of-life care. Only 20% of patients who die in the ICU undergo cardiopulmonary resuscitation. The main findings were the prevalence of end-of-life decisions among surgical ICU patients; only 3.5% who made such decisions were eventually discharged; the decisions correlated with the severity of sepsis and/or septic shock at 51%; and older age, admission from another hospital, and a diagnosis of cirrhosis, sepsis and severe sepsis or septic shock (Meissner et al.).

Rule of Double Effect (Schwatz 2004)

This rule falls within the moral Catholic theology and covers acts or decisions with two opposing outcomes (Schwartz 2004). One is the intended effect, which is also the desired and desirable outcome. The other is not one of these but foreseen. Many clinicians often use this rule to justify administering high-dose opiates to terminally ill and suffering patients. The rule states that four conditions must first be met to justify the unintended bad consequences of an act or decision. The act itself is not intrinsically wrong or absolutely prohibited. The person making the decision or performing the act must intend only the good effect, although the bad effect is foreseen. The bad effect is not the means to obtain the good effect, such as relief of suffering. And the good effect must outweigh the bad effect, which is only permitted for a grave reason (Schwartz).

Many clinicians believe that the use of this rule may enhance end-of-life pain management (Schwartz 2004). It can reassure healthcare professionals that appropriately administering high-dose opiates does not hasten death. However, others argue that the use of this rule as justification contributes to the belief in the double effect of opiates. In turn, it increases clinicians' apprehension about hastening death and a resulting under-treatment of pain. Nurses and other clinicians must carefully consider their clinical practice and intentions in providing end-of-life interventions, in particular. These intentions must draw from moral integrity and courage. They must be aware of their personal moral values and beliefs and how these influence professional judgments they make. At times, they may have multiple, conflicting or ambiguous intentions. They may hope for death to end a patient's suffering or aggressively manage terminal symptoms without intending to cause death. At other times, a clinician may hold strong personal values or religious beliefs, which run opposite the decisions of the patient's family regarding life-sustaining measures. The prudent use of the rule can be helpful to the clinician in accepting the patient's informed consent to an intervention that will eventually hasten death. Foreseeable death does not negate respect for the patient's choice as it is not intended (Schwartz).

Some believe that such informed consent and the eventual hastening of death is much more important than the clinician's intention (Schwartz 2004). They argue that the crucial moral considerations are the patient's right to self-determination and bodily integrity, his informed consent, the lack of less harmful options, and the severity of his suffering. Nurses must consider these different views on the usefulness of the rule in rendering ethical decisions in end-of-life care. They need to evaluate and conclude if the rule helps or hinders in developing ethically justifiable end-of-life decisions (Schwartz).

Case Study: the Portuguese Intensive Care Society

Probability of survival and the patient's wishes were the chief criteria, which influence end-of-life decisions and decisions to withhold or withdraw treatment (Cardoso et al. 2003). This was the finding of a survey conducted with 175 Portuguese intensive care physicians belonging to the Portuguese Intensive Care Society. DNR orders were used in their ICUs along with 98.3% to withhold treatment and 95.4% to withdraw treatment. These decisions were made only by the medical groups in most of the respondent ICUs. Many respondents, however, hoped they could be more involved in the undertaking. The gender, experience and religious beliefs were also influencing factors.

Fewer than 15% of the respondents said they involved nurses, 9% patients and less than 11% patients' relatives in making end-of-life decisions. Those with more than 10 years experience involved nurses in these decisions. Agnostic or atheist doctors involved patients' relatives in deciding to withhold or withdraw treatment (Cardoso et al.).

Terminal Sedation

This is treatment resorted to when other palliative treatments fail to be adequate

(Bimbacher 2007). It is meant to keep a severely pained patient unconscious while approaching death. It is indicated for agitation, fear of suffocating, vomiting, sleeplessness and severe pain states. The term sedation refers only to a temporal incidence of sedation and does not link sedation to subsequent death. It only helps the patient make his last moments easier without casually contributing to death. It helps in dying, but not helping to die. It is when combined with non-palliative medical treatment that it creates ethical problems, such as by being a form of euthanasia. Terminal sedation is used in combination with withdrawing or withholding life sustaining treatment or nutrition and hydration in addition to withdrawing or withholding life sustaining treatment (Bimbacher).

The interest of society in these matters lies in applying euthanasia to address terminal suffering and in preventing abuse and misuse of this treatment (Bimbacher 2007). It is much preferable to assisted suicide in terminating terminal suffering. Terminal sedation does not require the patient's capacity to move his limbs or to swallow, the availability of appropriate substances or outside assistance to provide them. The physician is much more involved and contributory in assisted suicide than in terminal sedation. It has been generally held that termination of treatment is morally acceptable when further treatment proves ineffective in improving his condition or allowing him to live with a quality of life he deems acceptable. Termination of treatment is generally permissible but not obligatory in most cases. When permitted, the physician is still bound by duty to relieve symptoms proceeding from the termination of treatment. It is, however, obligatory when treatment is clearly detrimental to the patient or when he refuses treatment. Termination of treatment under terminal sedation becomes unjustified when not primarily attuned to the patient's well-being but at that of relatives or caregivers. It is also objectionable when better alternatives exist about which the patient has not been informed. Finally, termination of treatment under terminal sedation can be resorted to if the patient himself objects to being sedated but prefers to live through the experience (Bimbacher).

Refusing Treatment

The patient's basic right to control the course of medical treatment is largely unchallenged and recognized for hundreds of years (King 2007). This is the substance of documents like The Living Will, Advance Directives and Health Care Proxy. The law provides that a competent adult has the absolute right to determine what should be done to his own body. The decision-making standard for his best interest derives from his wishes, including his personal beliefs. It clearly and explicitly recognizes his personal dignity and uniqueness in making choices for the preservation of his life, relieving his suffering and the use of palliative care and pain management. The guardian's responsibility is to make an informed decision in providing for healthcare. But in withholding or withdrawing life-sustaining treatment, the attending physician must attest to the patient's lack of capacity to make the decision. This is then entered as… READ MORE

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