ETHICAL ISSUE IN PALLIATIVE CARE

1. Dr. Anjalatchi Muthukumaran
Vice principal
Era College of Nursing

3.  In those with life-threatening disease, prognosis is
unpredictable. Communication with the patient and family
must guide the clinician, always weighing up the benefits
against the risks and burdens of any intervention, and
recognizing when interventions are futile in the face of
irreversible deterioration.
 There is no evidence that patients’ lives are shortened
when opioids and other drugs are used to control pain and
other symptoms, which challenges the usual examples for
double effect (having good and bad consequences) as
given in many standard textbooks.
 Some patients make advance decisions to refuse
treatment, in the event of losing decision-making
capacity.

4.  Ethical issues in palliative care often arise because of concerns
about how much and what kind of care make sense for someone
with a limited life expectancy.There is often conflict between
clinicians, nurses, other health care team members, patients, and
family members about what constitutes appropriate care,
particularly as patients approach death.
 This topic will discuss ethical issues in palliative care. Other issues
regarding the legal aspects of end-of-life care, advance care
planning, how to approach requests for potentially inappropriate
and futile therapies, and discussing goals of care are discussed
separately. In addition, issues related to specific symptoms for the
patient in palliative care and/or at the end of life are discussed
separately.

8.  Caring for patients nearing the end of their
life poses many challenges as professionals
strive to make decisions that are morally
justified.Where the wishes of patients,
relatives and professionals conflict, and
where care is limited by the scarcity of
resources, it will often be impossible to
satisfy all demands.

12.  Four ethical principles (non-maleficence,
beneficence, respect for autonomy and
justice) are core tenets for clinical decision-
making, ensuring important factors have not
been overlooked.
 Decisions reached can then be morally
justified, although principles may conflict,
leaving professionals to judge the ultimate
course of action.

19.  Many patients lose the capacity to make
decisions about their management at some
stage in their disease although this usually is in
the last hours of life. When patients have
expressed their wishes for future care before
their condition deteriorated, it is easier to
respect their autonomy.
 When formally expressed in writing, the
advance decisions of patients are normally
legally binding for professionals.
 Where no discussion has taken place and no
such advance decision exists, it is important to
find out what the patient probably would have
wanted, and it is morally appropriate and
legally justified to provide care in ways that
ensure that obligations of beneficence, non-
maleficence and justice are also fulfilled.
 These decisions, taken in the best interest of
the patient as a person, are now described in
the Mental Capacity Act which provides a
framework for making ‘best interests
decisions‘ in such circumstances.

20.  Advance care planning (ACP) is a
process that supports adults at
any age or stage of health in
understanding and sharing their
personal values, life goals, and
preferences regarding future
medical care [1].The goal of ACP
is to help ensure that people
receive medical care that is
consistent with their values,
goals, and preferences [1].The
timing and nature of ACP may
vary depending on whether the
person is healthy, has mild to
moderate chronic illness, or has
an advanced life-threatening
illness and is thought likely to die
within the next 12 months [

22.  A decision about the appropriateness of attempting CPR
has to be made and reviewed regularly for those with life-
threatening disease as sudden irreversible deterioration
may occur unexpectedlyand, of course, the
pathophysiology of all expected deaths involves a
cardiorespiratory arrest.
 For some patients it is very clear that attempting CPR
would be physiologically futile, and risks psychological
distress to other patients, an undignified death for the
patient and calling the cardiac arrest team away from
other duties.
 Overall the chances of a patient with advanced malignant
disease surviving a cardiorespiratory arrest are very
limited.

23.  The term assisted dying encompasses the concepts of euthanasia (the deliberate
ending of a patient’s life by lethal injection) and physician-assisted suicide (the
deliberate ending of a patient’s life when he takes a lethal cocktail of medications
prescribed by a doctor). Patients who ask for assisted dying usually do so as they
fear what lies ahead, believe they will not have control over their care and often
have witnessed distressing deaths in the past; these requests for
euthanasia/assisted suicide very rarely persist when addressed and discussed
openly.
 Although proponents argue that a change in the law would give greater choice
about the place and timing of death, this must be balanced against the risks of
short cuts in care and of coercion that a change in the law would bring about for
the many vulnerable patients who already feel burdensome
 There are many practical problems with the systems that are supposed to
regulate assisted dying in other countries. Pragmatism suggests that any scrutiny
of clinicians and procedures ought to occur before the death of the patient (not
afterwards as in the Netherlands andOregon)
 and that lethal medications should not be left unsupervised to prevent diversion
into the community should the patient die naturally.

24.  All clinicians must make difficult decisions about
withholding or withdrawing treatment;
however, they are particularly common when
caring for a patient entering the very terminal
phase, as there are no longer any reversible
causes of his deterioration.
 Symptom control and comfort are paramount,
and all interventions must further this goal.
 Interventions that do not contribute to comfort
and are not effective at prolonging life are, by
definition, futile and should cease

25.  Decisions to withdraw treatments must be
explained to relatives and carers, who may
otherwise interpret that it was the lack of these
measures that caused death (rather than the
underlying disease).7
 They may also feel that professionals are ‘giving
up’ on the patient, so it is crucial to explain the
importance of ongoing comfort measures and
that although priorities may have changed, the
patient’s needs are still at the forefront of care.

26.  The doctrine of double effect describes best practice when
balancing the potential benefits of a therapeutic intervention with
the known burdens and possible risks, distinguishing between
intended outcomes (the beneficial effects of an intervention) and
outcomes that can be predicted but are unintended.
 Evidence has accrued that the appropriate use of medication, such
as opioids, for symptom control does not shorten life;
 double effect is not ‘euthanasia by the backdoor’. However, it
remains important in many areas of clinical practice.
 For example, the intended effect of chemotherapy is elimination
of malignant cells, but this benefit must be balanced against the
unintended but predictable risk of death from neutropenic sepsis.

27.  Palliative sedation (sometimes termed terminal sedation) is very
occasionally needed for a patient with intractable distress,
 often associated with agitation, in the last days and hours of a
patient’s life.The intention of palliative sedation must always be
to relieve symptoms, not to cause or hasten the death of the
patient, and the level of sedation must be maintained as lightly as
is compatible with control of symptoms.
 If at all feasible the possibility of palliative sedation should be
discussed with the patient before it is undertaken, and in all
circumstances it should be discussed with relatives and carers.
 If the patient is judged to be in the last hours or days of life,
artificial hydration is not necessary (as there will be insufficient
time for dehydration to develop). If the patient appears to have a
longer prognosis, it may be appropriate to commence artificial
hydration by simple measures such as subcutaneous or
intravenous fluids, or even artificially maintained nutrition

28.  Advances directives (ADs) are the documents a
person completes while still in possession of
decisional capacity about how treatment decisions
should be made on their behalf in the event they lose
the capacity to make such decisions.They are legal
tools directing treatment decision-making and/or
appointing surrogate decision-makers.Although a
component of advance care planning (ACP), an AD
does not imply that ACP occurred, and thorough ACP
does not always yield ADs (eg, if the patient does not
voice any choices or declines to have their choices
recorded).

29.  Caring for patients is a challenging task that requires not only a holistic
view of the patient but also understanding the family, social, legal,
economic, and institutional circumstances surrounding them, especially
as they approach end of life. Unfortunately, there are many myths and
misconceptions about what may or may not be legal in this setting [65].
One legal consideration in the United States is that the Patient Self-
DeterminationAct states that institutions must inform patients of the
right to:
 ●Participate in and direct their own health care decisions
 ●Refuse medical or surgical treatment
 ●Prepare an advance directive (AD)
 ●Review information on the institutional policies governing these rights
 Understanding the legal aspects of end-of-life care will give the
practicing clinician the confidence and freedom to act reasonably.This
topic is discussed in detail separately. (See "Legal aspects in palliative
and end-of-life care in the United States".)

34.  One of the most difficult issues raised by the
need to provide palliative care within the
context of limited resources is how to decide
what should and should not be provided.23
 The stated aim of palliative care is to
enhance patients’ quality of life.2
 One of the difficulties inherent in
attempting to improve the subjective
experiences of patients in an holistic way is
that there is no clear boundary between
what a patient needs and what he might
want.
 Attending to both needs and wants will
improve his quality of life. Another difficulty,
which clinical research may resolve over
time, is knowing which interventions are
actually beneficial.2
 Without outcome measures, it will be
difficult for those commissioning care to
justify using scarce resources on
interventions which are believed to work but
for which no benefit has been demonstrated.

35. •Good care requires open
discussion about imminent
death and what can be done
to ensure care is given in a
way that enhances the
patient’s dignity
•Opioids and other drugs given
appropriately for symptom
control do not shorten the
patient’s life
•As death approaches, all
aspects of care must be
reviewed to avoid futile
interventions, to ensure the
patient’s needs are met and
that symptoms are well
controlled

36.  Till now we have discussed about palliative care
and its issue facing by health care worker and
patients in day today life
Advance care planning (ACP) is an ongoing process in
which patients, their families or other decision-
makers, and their health care providers reflect on
the patient’s goals, values, and beliefs, discuss
how they should inform current and future
medical care, and ultimately use this information
to accurately document the patient’s future
health care choices. (See 'Introduction' above.)
Clinicians bear the responsibility of informing patients
about their prognosis, exploring treatment
options, and helping formulate preferences based
upon a risk-benefit analysis and their values,
whenever circumstances allow. (See 'Advance
care planning' above.)

37.  I hope you all understand the about palliative
care and issues facing the health care workers
an patients. I hope you all apply this
knowledge if you handle the patient in future
with confidently .

38. President's Commission for the Study of Ethical Problems in Medicine and Biomedic
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mplications of informed consent in the patient-practitioner relationship. United S
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 Lorenzl S. End of one's life--Decision making between autonomy and
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 Roeland E, Cain J, Onderdonk C, et al.When open-ended questions don't work:
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 Jacobsen J, Blinderman C, Alexander Cole C, JacksonV. "I'd Recommend …" How
to IncorporateYour Recommendation Into Shared Decision Making for Patients
With Serious Illness. J Pain Symptom Manage 2018; 55:1224.
 Billings JA, Churchill LR. Monolithic moral frameworks: how are the ethics of
palliative sedation discussed in the clinical literature? J Palliat Med 2012; 15:709.
 BeauchampTL, Childress JF. Principles of Biomedical Ethics, 8th ed, Oxford Unive
rsity Press, 2019.