Ethical Palliative Care and End of Life Issues

1. Ethical Palliative Careand End of Life Issues A. Reed Thompson, M.D. Palliative Care Program University of Arkansas for Medical Sciences Central Arkansas Veterans Healthcare System

2. Objectives To present the major ethical concerns in Palliative Care To help define the ethical issues in Palliative Care using case studies

3. Are Palliative Care and Hospice Care Different?

4. Defining Palliative CareVeterans Healthcare System 2004 Palliative Care is a broad term that includes hospice care as well as other care that emphasizes symptom management in persons with life-limiting disease but is not restricted to persons near the end of life.

5. More on Defining Palliative Care A new specialty of medicine that uses an interdisciplinary team to manage patients with an advanced illness, in whom the goal of care is symptom control rather than disease control.

6. More on Defining Palliative Care The care of patients who are in an advanced stage of an incurable illness.

7. Hospice CareDefinition A philosophy of medical care that emphasizes symptom management in persons with life-limiting disease and with a primary focus on quality of life.

8. HospiceDefinition Hospice is a interdisciplinary program of palliative and supportive services funded by third-party payers that is provided both in the home and in institutional settings for persons with weeks or months to live so that they may live as fully and as comfortably as possible.

9. Dichotomy Division into two mutually exclusive, opposed, or contradictory groups Dictionary.com

10. A False Dichotomy That palliative care and hospice are fundamentally different

11. Palliative Care & Hospice Care:What do they share? Philosophy of care Interdisciplinary Team The honoring of patient preferences Focus on symptom control rather than disease control

12. Palliative Care & Hospice Care:What do they share? Clinical expertise in symptom control Addressing of multiple domains of suffering Bereavement care Provided in institutional and home settings

13. Palliative Care & Hospice Care:What don’t they share? Payment mechanism

14. Palliative Care & Curative Care Another False Dichotomy? That Palliative Care and Curative Care are fundamentally different

15. Palliative Care & Curative CareReally a dichotomy? Cannot separate disease control and symptom control

16. Palliative Care & Curative Care A True Dichotomy Palliative Care & Curative Care are fundamentally different

17. Dichotomy Division into two mutually exclusive, opposed, or contradictory groups Dictionary.com

18. Palliative Care & Curative Care Why a dichotomy? Primary goal of care is different

19. Questions/Comments?

20. Ethical Issues in Palliative Care

21. Ethics The discipline dealing with what is good and bad and with moral duty and obligation Webster’s Online Dictionary

22. Medical Ethics A system of moral principles that apply values and judgments to the practice of medicine. As a discipline, medical ethics encompasses its practical application in clinical settings. Wikipedia.com

23. Morals (from the Latin “moralitas” - manner, character, proper behavior Morality is the differentiation among intentions, decisions, and actions between those that are good (or right) and bad (or wrong). Webster’s Online Dictionary

24. Ethical Issues in Palliative Care Autonomy/Beneficence Advance directives/surrogacy DNR/POLST Withdrawing/withholding life support Double effect

25. Ethical Issues in Palliative Care Medical futility Informed consent Responsible resource allocation Euthanasia/Physician Assisted Suicide Truth-telling

26. Ethical Issues in Palliative Care Honoring patient preferences Non-abandonment Sedation for intractable symptoms Competency/decisional capacity

27. Competency vs Capacity • Competency • Decided by a court/judge • Typically chronic alteration • Expected to permanent • Capacity (decision-making capacity) • Decided by physicians • Typically acute in onset • Fluctuates

28. Arkansas Rights of the Terminally Ill or Permanently Unconscious Act (ARTIPUA) Arkansas Act § 20-17-201 (1987) Addresses patients only in one of these two conditions Living Will Healthcare proxy is appointed Two physicians are required to declare that the patient does not have decision-making capacity

29. Durable Power of Attorney for Health Care Arkansas Act § 20-13-104 (1999) May appoint a durable power of attorney for health care in addition to a health care proxy Durable power of attorney for health care can all make decisions except those covered by ARTIPUA

30. P.O.L.S.T. Physician orders for life-sustaining treatment An type of advance directive signed by patient and physician Travels with the patient across healthcare venues Helps prevent unwanted medical interventions, such as CPR Arkansas does not have P.O.L.S.T., but over 30 states have adopted some form of it

31. Organizational EthicsDefinition The ethics of an organization, and how an organization ethically responds to an internal or external stimulus.

32. Organizational EthicsComponents Written code of ethics and standards Ethics training to executives, managers, and employees Availability for advice on ethical situations Systems for confidential reportings

33. Questions/Comments so far?

34. Approaches to Problem Solving

35. Problem solving approaches • Utilitarian - consequentalist • Deontological - intentionalist

36. Approaches to care of patients with advanced illness • Hubristic: Traditional medicine • Nihilistic: Hospice • Hegelian: Palliative Care Thesis Synthesis Antithesis Adapted from Amos Bailey, M.D. Birmingham VA

37. Break Time

38. TESTEthics in Hospice/Palliative Care

39. Objective To help apply knowledge of ethics in your hospice/palliative care practice