End of Life

1. End of Life DivyaBappanad May 6, 2010

2. Issues to Address • Advance Directives Do Not Resuscitate/Do Not Attempt Resuscitation • Cessation of Feeding and Advanced Life Support • Palliation

3. Guiding Principles in Medical Ethics • Autonomy • The right of individuals to self-determination • Beneficence • Physicians should act in the best interest of their patients • Non-maleficence • Physicians should not cause harm to their patients • Justice • Fairness and equality

4. Advance Care Planning • Start at any time, with illness progression, or at key points in life: • Life changing event, e.g. the death of spouse or close friend or relative • Following a new diagnosis of life limiting condition eg cancer or motor neurone disease • Significant shift in treatment focus e.g. chronic renal failure where options for treatment require review • Assessment of the individual’s needs • Multiple hospital admissions

5. Examples • 54 year old woman with cancer of the colon with liver metastases. She develops jaundice which cannot be treated and is feeling increasingly weak and tired. This lady is now recognising she has a progressive disease and may wish to discuss her future care. • 76 year old man with heart failure with increasing breathlessness on walking who finds it difficult to leave his home, has had two hospital admissions in the last year and is worried about the prospect of any more emergencies and coping with the future. • 81 year old lady with COPD, heart failure, osteoarthritis and increasing forgetfulness, who lives alone. She fractured her hip after a fall, eats a poor diet and finds mobility difficult. She wishes to stay at home but is increasingly unable to cope alone and appears to be ‘skating on thin ice’.

6. Setting the stage • Full knowledge of patient’s medical condition, treatment options and social situation • Time and setting should be appropriate for a private discussion • Patient centered dialogue, focus on the views of the individual, although they may wish to invite their carer or another close family member or friend to participate • Maintain confidentiality

7. Advance Care Planning • the individual’s concerns and wishes • their important values or personal goals for care • their understanding about their illness and prognosis • their preferences and wishes for types of care or treatment that may be beneficial in the future and the availability of these.

8. Advance Directives • Statement of wishes and preferences • Not legally binding • Advance Decision • Can be made by someone over the age of 18 who has mental capacity • Refusal of specific treatment and may be in specific circumstances • If an advance decision includes refusal of life sustaining treatment, it must be in writing,signed and witnessed and include the statement ‘even if life is at risk’ • Written or verbal • Legally binding • In effect when patient lost capacity • Circumstances in which can be questioned

9. Advance Directive • Lasting Power of Attorney • Statutory form of power of attorney created by the Mental Capacity Act 2005 • Anyone who has the capacity to do so may choose a person (an ‘attorney’) to take decisions on their behalf if they subsequently lose capacity. • Must specify whether the appointed holder of the LPA has the authority to make decisions on life sustaining treatment. • Any decisions taken by the appointed person must be made in the individual’s best interests

10. Incapacitated Adults • Medical best interest + person’s known values • Any statement made when the person had capacity and discussion with those close to the patient. • Proxy decision maker • Only asked once patient lacks capacity • Advocate • IMCA, but cannot give consent

11. Patient’s Best Interest • Not make any judgement using the professional’s view of the individual’s quality of life • Consider all relevant circumstances and options without discrimination • Not be motivated by a desire to bring about an individual’s death • Consult with family partner or representative as to whether the individual previously had expressed any opinions or wishes about their future care e.g. ACP • Consult with the clinical team caring for the individual • Consider any beliefs or values likely to influence the individual if they had capacity • Consider any other factors the individual would consider if they were able to do so • Consider the individual’s feelings

12. Patients rights • Can refuse treatments/procedures • Cannot insist on clinically inappropriate treatment • Can insist on artificial nutrition and hydration

13. CPR • If the clinical team believes that CPR will not re-start the heart and maintain breathing, it should not be offered or attempted. • Responsibility rests with the most senior clinician currently in charge of the patient’s care. • May delegate the task to another person who is competent to carry it out. • Wherever possible, a decision should be agreed with the whole healthcare team.

14. CPR • Where no explicit decision has been made in advance there should be an initial presumption in favor of CPR. • A Do Not Attempt Resuscitation (DNAR) decision does not override clinical judgement in the unlikely event of a reversible cause of the patient’s respiratory or cardiac arrest that does not match the circumstances envisaged. • choking, induction of anesthesia, anaphylaxis or blocked tracheostomy tube • procedures • DNAR decisions apply only to CPR and not to any other aspects of treatment.

15. Informing patients • Clinicians discussing or communicating such decisions should: • offer patients as much information as they want • provide information in a manner and format which patients can understand( i.e. interpreter) • answer questions as honestly as possible • explain the aims of treatment.

16. Withdrawal of care • Medical treatment can legally and ethically be withdrawn when it is unable to benefit the patient. • It should be withdrawn when it is not in the patient's best interest or if the patient has refused it

17. Assisted Suicide • BMA policy opposes euthanasia and does not believe that doctors should participate in actions deliberately intended to hasten death. • Rejects all forms of assisted dying • Emphasise the importance of improving palliative care services.

18. Bibliography • www.bma.org.uk/ethics • http://www.mcpcil.org.uk • www.endoflifecareforadults.nhs.uk