End-of-life choices 生死的抉擇

1. End-of-life choices生死的抉擇 TSE Chun-Yan 謝俊仁

2. 70歲男士，末期癌症，神智清醒 • 身心極度痛楚 • 不時接受無效用的化療 • 死時還施行心肺復甦 • 慘不忍睹 • 為什麼不把安樂死合法化，讓病者可以安祥地離世？

3. Why should we not vote at this stage? What do you mean when you say “euthanasia”?

4. To relieve the suffering of the patient • Should we provide good palliative care (紓緩冶療), including the provision of strong opioids, e.g. morphine? • Should futile (無效用) life-sustaining treatment (維持生命治療) be forgone (放棄)? • Should we kill the patient by a lethal injection?

5. Which option is classified as euthanasia? • Euthanasia could be defined narrowly or broadly

6. Medical and legal field: narrow definitions

7. Medical Council of Hong Kong does not support euthanasia, which is defined as “direct intentional killing of a person as part of the medical care being offered” • The term refers to “active euthanasia”

8. One says “Euthanasia is legalized in the Netherlands and Belgium” • The term refers to “voluntary active euthanasia”

9. In public debates and in bioethics literature • forgoing life-sustaining treatment (LST) is often considered as one form of euthanasia, labeled as “passive euthanasia”

10. Problems • forgoing LST is legally acceptable in most parts of the world in appropriate situations • wish of a mentally competent patient • when the treatment is futile • active euthanasia is illegal in most parts of the world

11. To avoid any unnecessary confusing connotations • the term “passive euthanasia” is not recommended by the medical and legal field • the term is not used in relevant guidelines and legislations

12. Forgoing LST is itself a complex ethical issue, and what constitutes futility is not easy to define • non-controversial: forgoing cardiopulmonary resuscitation in a terminally ill • controversial: withdrawal of ventilator support in a conscious quadriplegic patient

13. It would not help public discussion to lump all these together under the label of “euthanasia”

14. Forgoing futile LST is a necessary sequel of advancement of medical technology. • Acceptance of forgoing futile LST does not necessarily lead to the acceptance of euthanasia.

15. Loose usage of the Chinese term安樂死 • sometimes used to describe the state of the dying process or even palliative or hospice care

16. Such a loose usage of the term euthanasia or 安樂死 leads to difficulties in public discussion. • Public opinion in support of euthanasia may actually include support for forgoing futile life-sustaining treatment and support for palliative care.

17. This confusion is totally unnecessary and should be avoided.

18. To relieve the suffering of the patient • Should we provide good palliative care (紓緩冶療), including the provision of strong opioids, e.g. morphine? • Should futile (無效用) life-sustaining treatment (維持生命治療) be forgone (放棄)? • Should we kill the patient by a lethal injection?

19. Forgoing (放棄) life-sustaining treatment(維持生命治療) • Life-sustaining treatment (LST) refers to “all treatments that have the potential to postpone the patient’s death”.

20. Appropriate to withhold (不提供) or withdraw (撤去) LST • When it is the wish of a mentally competent patient: principle of autonomy • When the treatment is futile (無效用): principles of beneficence and non-maleficence

21. Determination of futility • balancing the burdens and benefits of the treatment towards the patient, and asking whether the treatment is in the best interests of the patient. • involves quality of life considerations and can be value-laden.

22. The decision-making process in most cases is thus a consensus building process between the healthcare team and the patient and family.

23. Forgoing futile LST implies the acceptance of the fact that human is mortal. • This is medically and legally distinct from euthanasia. • Many medically advanced countries in the world have issued guidelines on this.

24. Hospital Authority guidelines of 2002: If the patient is not mentally competent • Medical decisions are based on the best interests of the patient. • A decision on futility of LST involves consensus building between the healthcare team and the family if possible.

25. Sometimes, such decisions are difficult especially if the prior view of the patient is not known. • In the recent years, the concepts of advance care planning 預設護理計劃 and advance directives 預設醫療指示 are promoted in various parts of the world.

26. Special points • There are no legal or necessary morally relevant differences between withdrawing and withholding LST. • The withdrawal of artificial nutrition and hydration is controversial except when death is imminent and inevitable, or it is the wish of a mentally competent patient.

27. Must remember • Forgoing LST in appropriate circumstances does not at all mean abandoning the patient. • Basic care, symptom control, care and concern should always be offered.

28. Thank you!