ethical issues in palliative care larry librach md,ccfp,fcfp professor & head, division of...

Ethical Issues in Palliative Care

Larry Librach MD,CCFP,FCFP Professor & Head, Division of Palliative Care, Dept. of Family Medicine, Sun Life Financial Chair & Director Joint Centre for Bioethics, University of Toronto

Temmy Latner Centre2

Objectives

1. What is “bioethics”?2. Describe the basic principles of

bioethics.3. Describe & discuss the major

bioethical issues in HPC


What is bioethics?

• Health care system is complex interplay of biology, organizations, ecology, medicine, research and human values

• Bioethics is that broad discipline that provides a link for all those issues in order to help health care professionals and their patients make decisions that will improve care outcomes and the quality of that care


What is bioethics?

• Integral part of all health careabout “doing right”, reflecting

the values and integrity of the health care system and of individual health care providers


What is bioethics?

• Bioethics involves a thoughtful systematic exam of beliefs that underpin our attitudes, decisions and actions that are crucial for quality systems and organizations and that are crucial for the patient’s quality of life


What is bioethics?

• Also advises health care providers as they deal with the inevitable conflicts that arise in providing care to patients and their families

• As health care becomes more complex and exciting new discoveries are made, the role of bioethics as a discipline and as partners in care has increased


The Four Principles

• Respect for autonomy• Beneficence• Non-maleficence• Justice


Bioethics and PEOLC

• Area is rife with ethical issues and conundrums


The Right to Pain Control

• Basic issue is an issue for BEDo people have a right to pain

control?• IASP and WHO say so• Is it then unethical to leave

someone in pain when you could treat the pain?How would physicians respond

to that? Or nurses?


Decision Making

• Issues of competency to make decisions?CapabilityUnderstanding

• Confidentiality of information?• Being involved in decision-

making?


Advance Care Planning

• One of the major issues confronting us

• Translating goals of care into a plan for care

• Dealing with wishes and preferences

• Substitute decision makers


Palliative Sedation Therapy

• Providing relief for intractable physical suffering by continuous deep sedationWhat is intractable?What about existential

suffering?Who makes the decision?What are your guidelines?When do you do it?


Palliative Sedation Therapy

• Need to use effective medicationMidazolamBarbituratesSedating antipsychotics

• Need to monitor carefully• What about food and fluids?


Withdrawing and Withholding Food and

Fluids• Careful assessment• Need clear decision-making

Patient first• Dealing with family angst about

starvation and dehydrationNeed for flexibilityOveruse of G-tubes &

discussion of nil option


Withdrawing and Withholding Food and

Fluids• If replacing fluids, need to be conservative but not silly

• Observe for heart failure• Need for flexibility• Time trials


Withdrawing and Withholding Treatments

• Life prolonging treatmentsNeed for time trialsDiscussion of options for

ventilation• Careful management of suffering• Nil options

Education & family conferences with the team


Withdrawing and Withholding

Chemotherapy• Need for discussion of options and clear definition of expectations for survivalRisks and benefitsWay information is relayed is

important• Ethics of using a resource like

chemo off label or guidelines


Physician-assisted suicide / euthanasia . . .

• Ancient medical issue• Aiding or causing a suffering

person’s deathphysician-assisted suicide

• physician provides the means, patient acts

euthanasia• physician performs the intervention


. . . Physician-assisted suicide / euthanasia

• Many physicians receive a request

• Requests are a sign of patient crisis


Palliative care & PAD

• Why are we involved in the debate?

• Why should we be involved?• Is palliative/hospice care the

answer to the issue of PAD?


Why patients ask for PAS• Asking for help

• Fear ofpsychosocial, mental

sufferingfuture suffering, loss of

control, indignity, being a burden

• Depression• Physical suffering• Media coverage• An intellectual & reasoned

approach


What is palliative care about?

• Palliative care was developed to provide better care to the dyingRelieve unnecessary sufferingComprehensive, holistic

patient & family centred careRespecting & addressing the

needs of patients & families• Dealing with a variety of choices



• Palliative care concerns itself with the quality of dyingJust because we want to have

a longer time with patients & families we should not forget that we are about the “good death”

Promoting hope may be “nasty”



• Palliative care is NOT an alternative to PADIt is a philosophy of caring for

the dyingPAD is an action to end a life

because of intractable suffering

• So if we are about dying, we must confront the issues in PAD


• However, despite access to high quality end-of-life care, a small number of Canadians may still choose to have control over their own death. As hospice palliative care practitioners, we will respect their right to choose & will not abandon them. We will continue to provide the same compassionate care to these individuals & their families, but we also have a choice not to participate or to be expected to assist in any efforts that intentionally hasten death.

CHPCA Draft Statement


Legalizing PAD

• Should it be legalized?Will any one law ever cover the

complexities & diversities of human beings/nature? (Roy)

• Giving power of PAD to MDs who cannot communicate (Roy)What are they to listen to?Do they know what to say?


Legalizing PAD

• Can we trust legislators with this difficult task?

• Will a public referendum be worthwhile?The issues are complex


The slippery slope argument

• Posits a very negative impression of humanity lawless, unjust, inhumane

• Based often on the eugenics & genocide of the Nazi regime to frighten us

• Do we really believe that our society is that vulnerable?

• Is PAD a matter of descending into an abyss of evil?


Can HPC & PAD co-exist?

• Oregon experience has shown that PC & PAD can co-existIn that jurisdiction has focused

attention more on PC• Netherlands was an anomaly

initially but now there is a legal framework & palliative care

• Belgium & Switzerland


Can HPC & PAD co-exist?Bernheim JL, Distelmans W, Mullie A, Bilsen J, Deliens L. Development of palliative care & legalisation of euthanasia: antagonism or synergy? BMJ 2008

“Within Belgium we found few professional stances contending that palliative care & legalisation of euthanasia are antagonistic, no slippery slope effects, & no evidence for the concern of the European Association for Palliative Care that the drive to legalise euthanasia would interfere with the development of palliative care. Rather, there were many indications of reciprocity & synergistic evolution.”


“Regulatory & professional organisations implicitly or explicitly endorsed or accepted the concept of integral palliative care, which recognises the right of patients to decide that further conventional palliative care is futile & to request & obtain physician assisted death.”


“Beyond that, the societal debates made clear that most values of palliative care workers & advocates of euthanasia are shared. If Belgium’s experience applies elsewhere, advocates of the legalisation of euthanasia have every reason to promote palliative care, & activists for palliative care need not oppose the legalisation of euthanasia.”


Summary

• Bioethics deals with difficult issues

• Bioethics can be preventive• Clearly need more knowledge

about issues

ethical issues in palliative care larry librach md,ccfp,fcfp professor & head, division of...

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