End-of-life Essay

End-of-life care is a form of medical treatment which is usually provided for terminal illnesses, when the condition is no longer curable and every effort should be made at improving the quality of life rather than increasing the duration of life. Cancer is one condition which is incurable during the advanced stages. End-of-life usually does not involve provision of anticancer treatment but concern for lowering the physical symptoms (especially pain so that the patient is comfortable), addressing the psychosocial issues and the spiritual concerns, so as to improve the quality of life. Often an ethical dilemma exists at the situations under which end-of-life care should be started. The need to provide end-of-life care arises out the physician’s obligation to ensure that the patient can live and die with dignity, compassion, comfort and respect. Two of the cases which demonstrate the physician’s obligations to the patients were the Ann Quinlan case (1976) and the Cruzan V. Harmon case (1988) (Meisel, 2005 & Rekel, 2007). In the Quinlan case, Ms. Quinlan suffered irreversible damage to the brain cortex and was left in a permanent vegetative state. She required ventilator support, artificial nutrition and artificial hydration to maintain her medical and nursing care. She could be kept alive for any duration, but this was morally not required and not in the patient’s best interest. The physician’s refused to remove ventilator support and hence the family had to go to the New Jersey Court. The court in the landmark decision permitted to remove ventilator support as it was not in the patient’s best interest. The court had said that although the patient was in a permanent vegetative state and did not have to ability to make a decision about withdrawing ventilator support, it did not mean that she could not exercise her choice and give her decision. The decision-making could be made by a surrogate who would be doing so in the best interest of the patient. In the Roe vs. Wade case, the court gave the decision that the patient could control their medical treatment and had the right to make decisions. In the Cruzon case, after the ventilator was removed, the patient survived for about 10 years. The Missouri court in this case did not follow the advice of the parent’s on removing life-saving support. The court said that all measures should be done in best interest of the patient, and if there were not clear evidence of the patient’s wishes, then the legal guardian should be acting in the patient’s best interest. The court said that even if there was a need to prolong life through ventilator support, if there was no evidence that the patient’s best interest would be fulfilled. In the case Westchester County Medical Ctr (1988), the New York court said that there had to exist clear and convincing evidence whenever important decisions had to be taken by the surrogate (Meisel, 2005 & Rekel, 2007). Some of the common ethical issues regarding medical treatment have been ‘beneficence’ and ‘non-maleficence’. The physician should do treatment that benefits the patient and does not cause more harm. They should help reduce the suffering and help the patient to return to health. However, in the end-of-life issues, the patient would be dying due to the terminal cancer condition, and using life-sustaining treatment would not have any potential benefits, as it would prolong life, but not improve the quality. In this case medical treatment is doing lot harm than benefits, and hence using it would be inappropriate. However, a clear judgment has to be made in the clinical-decision making and one of the most important issues is whether the patient has made the intention of withdrawing all the life-saving treatment and instead goes into palliative care (in which symptomatic treatment would be provided so as to improve the quality of life during the last few days). Having the patient make this decision is based on another ethical principle known as ‘autonomy’. The patient has the right to choose or disregard whichever treatment he/she wants as the have the right to control any act that is done with their body (Walker, 1999 & Meisel, 2005). Implications of risk management – †¢ Mainly with the use of opioids to manage pain (especially from its prolonged use) †¢ Clinical practice guidelines and protocols should be followed to ensure the greatest amount of benefits for the patient in the form of improved quality of life and lowered discomfort levels (Hoffman, 1998). The right to autonomy of the patient should not be disregarded under any circumstance. The patient has the right to choose palliative treatment or reject it based on their own choices. The patient may also want to undergo curative treatment for cancer even though the survival rate may be low. The patient should be informed of the benefits, risks, options, outcome and costs of all forms of treatment available. The physician should answer all the queries the patient has of all the available forms of treatment. No treatment should be done against the will and intention of the patient. If the patient is not able to make a reasonable decision as they may not be legally competent, then the surrogate (including the family member or a legal guardian) of the patient should make a decision on the patient’s behave, keeping in mind the clear interests of the patient (Walker, 1999, Meisel, 2005 & Rekel, 2007). There may be a lot of competing loyalties between the patient and the organization:- †¢ The organization may try to keep the interest of the patient in mind and may do all that it can to reduce sufferings, improve the quality of life and ensure a peaceful end †¢ The organization may demonstrate a greater opinion towards anticancer treatment as it would involve higher costs (even though it is not beneficial to the patient anywhere) †¢ Even though the patient can benefit to a reasonable extent from anticancer treatment, the organization may force end-of-life care on the patient, as the family members have provided consent. In this case the family members would be having conflicting interests with the patient and may want a faster end to the patient. To prevent any conflicting interest of other parties, it is important that any decision made regarding use of anticancer treatment of initiation of end-of-life care should be clearly justified and documented through evidence-based findings. An ethical approach should be initiated to ensure that all issues are sorted out keeping the patient’s interest in mind:- †¢ The physician should ensure maintaining autonomy of the patient at all stages †¢ If the patient is not competent enough to make a decision by himself, decision-making should be done by the surrogate keeping in mind the patient’s interest and choices †¢ It is the obligation of the physician to ensure that the patient lives †¢ The patient’s competence needs to be determined so that a reasonable decision can be ensured †¢ The patient has to be informed of all the alternative choices available at all the stages †¢ In case of diagnosis of a terminal illness, confirmation should be taken from two physician’s (second opinion) †¢ In case of terminal illness, and the patient choice palliative care, efforts should be made at all stages to improve the quality of life (through symptomatic treatment of physical problems, addressing the psychosocial and spiritual issues), rather than on prolonging life The other issues which need to be addressed include:- 1. Active Euthanasia – This is legal in only a few states of the world including Netherlands and Belgium. The patient should make a reasonable decision, and should be a native from that state in which euthanasia is legalized. The physician himself would take the active step of ending the patient’s life. The patient should be diagnosed with a terminal illness 2. Physician-Assisted Suicide – This has been legalized in the US state of Oregon, PAS has been legalized. The patient would perform the active step of ending life and the physician would merely assist the patient. The patient should be diagnosed with a terminal illness (in which death would be certain within 6 months). The patient should be legally competent to make a reasonable decision (Rekel, 2007). References: Hoffmann, D. E. (1998). â€Å"Pain Management and Palliative Care in the Era of Managed Care: Issues for Health Insurers†, Journal of Law, Medicine & Ethics, 26(4), 267-289. http://www. aslme. org/research/mayday/26. 4/26. 4c. php Meisel, A. (2005). Ethics, End-of-Life Care, and the Law: Overview, Retrieved on August 16, 2008, from Hospice Foundation Website: http://www. hospicefoundation. org/teleconference/books/lwg2005/meisel_jennings. pdf National Cancer Institute (2002). End-of-Life Care: Questions and Answers, Retrieved on August 16, 2008, from NCI Website: http://www. cancer. gov/cancertopics/factsheet/Support/end-of-life-care Rekel, R. (2007). Rakel: Textbook of Family Medicine, 7th ed, Philadelphia: Saunders Elsevier. Walker, R. M. (1999). Ethical Issues in End-of-Life Care, Cancer Control, 6(2):162-167. http://www. medscape. com/viewarticle/417700_1