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Topic: End of Life Care
March 25, 2013 | Posted By Marleen Eijkhjolt, PhD

This blog post solicits for your opinion, so please stick with me. 

There are two prominent sad realities in my clinical ethics fellowship. The first is that many cases deal with end-of-life issues. The second is that there are many ‘lonely’ patients, who often die in the hospital ‘alone’. The two issues combined tend to raise some unfortunate but fascinating clinical PELSI (Policy, Ethics, Legal and Social Issues). One such issue is: Who should make medical decisions at a patient’s end-of-life when this patient lacks capacity and there is no surrogate? 

In the State of New York, we have the Family Health Care Decisions Act (FHCDA) that governs many of these issues, including end-of-life decisions in absence of a surrogate. (I will explain the legislative scheme below) However, this legislation does not solve all problems, as the written word leaves leeway for different interpretations and practices. One of these problems is related to decisions to withhold or withdraw life-sustaining treatment, and can be phrased as: Who should be the second, independent concurring physician in such decisions, in cases where the patient lacks capacity and there is no surrogate?

Let me explain. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

January 11, 2013 | Posted By Wayne Shelton, PhD

As someone who has done clinical ethics consultations for many years I long ago reached the conclusion that many of the so-called ethical problems that we encounter during ethics consultations could be prevented if only a more constructive line of communication had been established from the beginning of the patient’s hospital stay. Let me specify just what kind of patients and families I have in mind, the kind of communication I am talking about and the type of intervention that is needed.

Let’s face it, most patients come to the hospital with an identifiable medical problem about which there is little controversy, so the physician can diagnose and treat with a predictable, usually favorable, outcome. These are not the cases for which we get called on to do ethics consultations, nor are they the cases that take excessive amounts of time and create significant emotional stress such as cases that involve conflicts. In the less common cases where serious conflicts between various parties emerge, we are usually dealing with patients who have more medical problems, which often involve the risk of dying. The patient often lacks capacity and is unable to speak his or her mind about the goals of care and how far to use aggressive medical interventions. This means that families or loved ones of the patient must speak for the patient, i.e. serve as surrogates, and communicate with physicians about care plan goals and the appropriateness of particular procedures such as CPR in the event of cardio-pulmonary arrest.  To say the least, this is a stressful role for families and loved ones.

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

 

November 12, 2012 | Posted By Wayne Shelton, PhD

The issue of physician suicide has been on the public agenda in the United States for the past 25 years or more. Legitimate worries about medical overtreatment, unnecessary suffering and loss of dignity have motivated a growing number of Americans to consider this issue more favorably. People are rightly concerned about loosing control over what happens to them once they enter the hospital when the are very sick and risk dying. Instead of being at the mercy of technological forces beyond their control, free individuals want to have a say over how they make the final exit from life. The key factor, in my opinion, is more about self-control than it is about actually the strong desire to take a lethal dose of medications at the time of the patient’s choosing. But let’s be clear what we are talking about. 

Oregon was the first state to legalize physician-assisted suicide, which occurred in 1994 in the Death With Dignity Act. This law gives patients with capacity facing a clearly diagnosable terminal illness within 6 months or less to live the right to receive (and the right of the physician to prescribe) a prescription for a lethal dose of medication for the expressed purpose of ending their lives at the time of their choosing. Because we have had many years to collect empirical data about the effects of this law, we can use Oregon as a case study. As of 2011, 935 people have had prescriptions and 596 have died from ingesting medications they received based on this law. For about 90% of these patients, the primary concern about end of life care was “loss of autonomy”, but “inability to make life enjoyable” and “loss of dignity” were also major concerns. Moreover, based on the data, there is no evidence of any kind of abuse to any particular segment of the population, as some feared might happen. In fact the utilization rate of hospice care is up.  Following Oregon, Washington and Montana also have legalized physician-assisted suicide and we will have to wait and see the data of these laws continue to yield generally positive results. But overall the data gathered so far supports physician-assisted suicide a beneficial service. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

October 30, 2012 | Posted By Michael Brannigan, PhD

Here is cardiac surgeon Christiaan Barnard's account of his conversation with Louis Washkansky just before he performed on him the first human heart transplant, in 1967:

"'We know you have a heart disease for which we can do nothing more. You have had all possible treatment, and you are getting no better. We can put a normal heart into you, after taking out your heart that's no longer any good, and there's a chance you can get back to normal life again.'

"'So they told me. So I'm ready to go ahead.'

"Washkansky said no more. His eyes remained on me but with no indication he wanted to know anything more.

"'Well, then ... goodbye,' I said.

"'Goodbye.'"

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit ourwebsite.

August 14, 2012 | Posted By Jane Jankowski, LMSW, MS

Tis the season for family vacations, and like others, our clan tries to incorporate visits with extended family into our routes or final destination. This year, I was able to spend some time with an almost 95 year old grandparent who had some strong views on what she wanted for end of life care. Now, keep in mind, this lady puts most of us to shame with her daily swims, daily reading of the Wall Street Journal, efficient home economics, and speed at calculating Cribbage points. I was struck by the progressive stances held by this wise woman, and was forced to recognize the real risk that her preferences could easily be overlooked in an emergent medical situation.

Sitting in the yoga studio at the assisted living center where she resides, I notice a rather substantial silver bracelet dangling from her left wrist. Unusual for a jewelry minimalist, I asked about it. It is a DNR bracelet. My bioethicist ears perk. Upon closer examination, I see the engraved words, “DO NOT RESCUSITATE” marking the surface.  “Many of us have them,” I am told. Explaining the pervasive concerns shared by her peer group that EMTs will perform CPR no matter what, the message is clear that in this cohort of older adults there is a fear that no matter how well documented and verbalized their preferences may be, these wishes may be overlooked. And this fear is not without merit. 

The Alden March Bioethics Institute offers a Master of Science in Bioethics, a Doctorate of Professional Studies in Bioethics, and Graduate Certificates in Clinical Ethics and Clinical Ethics Consultation. For more information on AMBI's online graduate programs, please visit our website.

July 9, 2012 | Posted By Jane Jankowski, LMSW, MS

Historically, palliative care has not been associated with pediatrics. In western societies children are expected to outlive their parents, and we prefer to avoid the sad reality that kids do sometimes die. This social dismay could, in part, explain why the development of palliative care programs for children has lagged behind the adult programs. Not to be confused with Hospice, palliative care is a medical specialty which focuses on symptom management for patients with serious, often life threatening, illnesses. Admission to most Hospice programs requires a six month maximum life expectancy, whereas palliative care may be offered alongside curative treatments to alleviate burdensome side effects and symptoms. In the US, the passage of The Patient Protection and Affordable Care Act of 2010 has improved access to end of life care for children because the legislation permits concurrent coverage of medical treatment and Hospice services. Though a significant step forward, gaps in service may remain because children can live longer with serious illnesses and not meet the six month life expectancy criteria required for admission to a Hospice program. A better prognosis ironically leaves them without access to Hospice’s aggressive symptom management and compassionate, holistic care model. Pediatric palliative care services are emerging to meet the needs of children who have life limiting conditions, but are not expected to die in six months or less. Perhaps the most important feature is that palliative service can be provided alongside treatments for serious illnesses with very good prognoses. 

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

June 19, 2012 | Posted By Michael Brannigan, PhD

Does the case for terminal sedation actually weaken the case against physician-assisted suicide?

Terminal sedation, more clinically referred to as "palliative sedation," is a legally sanctioned alternative to physician-assisted suicide, a last resort in palliative treatment. It involves inducing and maintaining unconsciousness in a terminally ill patient until the patient dies, and is often accompanied by withholding or withdrawing medical feeding and hydration.

For example, if, in my advanced cancer, I experience intolerable pain, delirium, dyspnea or distress, to alleviate these unmanageable symptoms I let my physician sedate me into unconsciousness until I die. Sort of like undergoing anesthesia before surgery, without waking up.

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

May 2, 2012 | Posted By Michael Brannigan, PhD

The year is 2029. After discussing schedules, I've picked early afternoon April 28 as my day. That works for most of us. My wife will have returned from her conference. My sisters can fly in after their dance recital. My brother rescheduled his interviews.

Cousins can drive in from the coast. Some nieces and nephews can't make it, but that's all right. They're busy. Dr. Landis assured us it would be brief. I'll just take the pill the good doc gives me and fall quickly asleep, peacefully, forever. No pain. I'm doing what's right. It is better for all of us.

As we face dying's three dreads — pain, abandonment, helplessness — what is the practical allure of physician-assisted suicide?

July 27, 2011 | Posted By Ricki Lewis, PhD

Like Alvy Singer, Woody Allen’s character in Annie Hall, I’m obsessed with books about the end of humanity, which sometimes involves the end of the world, and sometimes just that of Homo sapiens. Midsummer is a good time to contemplate how bioethics would come into play in such unlikely scenarios, which raise issues of utilitarianism, justice, paternalism, death and dying, and misuse of technology. 

I prefer the human-wrought disasters to the more celestial imagined ends, such as the film “Asteroid”, which was so bad that my husband dubbed it “Hemorrhoid”. My favorite, after many years of wallowing in these depressing depictions, is "Swan Song," by Robert McCammon, in which survivors of a nuclear holocaust stagger about, drinking wolf’s blood to avert starvation. I can still picture, practically smell, when 6-year-old Swan picks the first apple to grow after a nuclear winter. Another favorite is “The Road,” in which Cormac McCarthy recounts the journey of a father and son as they traverse post-apocalyptic terrain, searching for others. What led to the destruction of society? How does it rebuild? Is a messiah, like Swan, essential?

I also savor novels that alter the human life cycle, tweaking age cohorts. “The Children of Men,” an excellent book by P.D. James and a terrible film, envisions a world with no more children. Time ticks down to the inevitable end of our species, with the drama centering around a pregnant woman. That’s a scenario that would welcome reproductive cloning!

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

July 11, 2011 | Posted By Ricki Lewis, PhD

”Dignity therapy" is a “novel psychotherapeutic approach” that gives patients with a 6-month life expectancy “an opportunity to reflect on things that matter most to them or that they would most want remembered.” In these days of medical experts such as Sarah Palin equating reimbursed end-of-life discussions to death panels killing granny, an outcomes evaluation of any such intervention is essential. Harvey Max Chochinov, of the University of Manitoba and colleagues in the U.S. and Australia did just that. Their impetus: “… although much progress has been made in our ability to achieve physical comfort for patients who are dying, few novel interventions have been designed to address the psychosocial, existential, and spiritual dimensions of end-of-life care.”

In an admittedly difficult-to-design study, the investigators randomized 326 patients (most of whom had cancer) to one of three interventions: dignity psychotherapy, palliative care, and client-centered care (which focuses on the “here and now” as opposed to the past and future perusal of dignity therapy). Their article in Lancet Oncology provides 9 questions that a trained dignity therapist might pose to a patient. Responses are recorded and typed up, then presented to the patient as a “generativity document.” Various before-and-after rating scales as well as patient comments revealed improvement in quality of life and family relationships with dignity therapy, although general distress was not significantly alleviated with any intervention. 

Oddly, for Dr. Chochinov is an award-winning palliative care expert, the report mentions “hospice” only as a possible physical setting! In fact, hospice volunteers have been providing dignity therapy for decades. 

The Alden March Bioethics Institute offers graduate online masters in bioethics programs. For more information on the AMBI master of bioethics online program, please visit the AMBI site.

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BIOETHICS TODAY is the blog of the Alden March Bioethics Institute, presenting topical and timely commentary on issues, trends, and breaking news in the broad arena of bioethics. BIOETHICS TODAY presents interviews, opinion pieces, and ongoing articles on health care policy, end-of-life decision making, emerging issues in genetics and genomics, procreative liberty and reproductive health, ethics in clinical trials, medicine and the media, distributive justice and health care delivery in developing nations, and the intersection of environmental conservation and bioethics.
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