1. MEDICAL ETHICS and The End of Life

6. ETHICAL THEORIES DEONTOLOGY CONSEQUENTIALISM VIRTUE ETHICS CRITICAL REALISM

7. PRIMA FACIE DUTIES AUTONOMY BENEFICENCE NON - MALEFICENCE JUSTICE UTILITY

8. AUTONOMY The ability to be self governing and self directing truth telling informed consent confidentiality “Every human being of adult years and sound mind has a right to determine what shall be done with his own body.”

9. AUTONOMY MAY BE TEMPORARILY IMPAIRED FLUCTUATE TOTALLY ABSENT RESTRICTED BY OTHERS - PATERNALISM Implies a duty on the part of health professionals to promote their patients’ autonomy or at least not interfere with it.

10. COMPETENT Understand information, retain it, believe it and make a decision on the basis of that information. Understand benefits and risks of treatment Understand what will happen if no treatment takes place Have the capacity to make a choice

11. AUTONOMY DOES IT IMPLY RIGHT TO DIE? OR RIGHT NOT TO BE KEPT ALIVE? OR RIGHT TO BE KEPT ALIVE?

12. BENEFICENCE/ NON - MALEFICENCE DOING GOOD ACT IN BEST INTERESTS? PRIMUM NON NOCERE first do no harm What if there are competing harms?

13. JUSTICE fairness, non discriminatory behaviour UTILITY the greatest good for the greatest number rationing resources availability of services

15. WITH-HOLDING AND WITHDRAWING TREATMENT Anthony Bland 1989 - ? TREATMENT Futility of treatment – Do not strive officiously DNR LCP Quality of life is believed to be so diminished that it is no longer desirable. Designed to prevent unnecessary suffering

16. DOCTRINE OF DOUBLE EFFECT Foreseeing is not the same as intention If the patient were not to die after my action would I feel that I had failed to accomplish what I had set out to do? Assisted suicide?

17. ADVANCE DIRECTIVES A mechanism whereby competent people give instructions about what is to be done if they subsequently lose the capacity to decide or communicate. It is most often used in decisions about medical treatment, particularly the treatment which might be provided as the patient approaches death.

18. ADVANCE DIRECTIVES Specify treatments they are refusing or requesting! Trigger event should be specified Be satisfied that it has not been revoked No change of mind or circumstances Written and witnessed Discussed with a health professional Reviewed and updated Any doubt - preserve life

19. Advantages Satisfy Autonomy Discussion Encourage naming of proxy Pressure off relatives and HPs Increased clarity about wishes Assurance that treatment accords with values and preferences Some indication is better than none

20. Problems ? Emergency treatment Non-specific Change of mind Obliged to have one Forms Time limits Insurance Insensitive Futile treatment?

22. EUTHANASIA A gentle or good death Voluntary - at their request Non-voluntary - no capacity to refuse Involuntary - competent people are killed against their will Physician assisted suicide - patient requires assistance to commit suicide

23. ACTIVE v PASSIVE EUTHANASIA Passive - don’t do some thing to keep them alive or stop doing something that is keeping them alive. Active - carries out act with intention of causing death. ? difference

24. Arguments Against Euthanasia Religious Ethical Practical Social Historical Inappropriate SLIPPERY SLOPE ARGUMENTS initial actions will eventually lead to undesirable or unwanted consequences.

25. THE LAW AROUND THE WORLD HOLLAND - unbearable suffering with no prospect of improvement AUSTRALIA - Rights of Terminally Ill Act OREGON - Death with Dignity Act BELGIUM 2002 SWITZERLAND - Dignitas

26. UK AND SCOTLAND Assisted Dying for Terminally Ill Bill Physician Assisted Suicide Bill DPP guidelines

28. DEALING WITH ETHICAL PROBLEMS 1. Get the story straight 2. Intuitive initial reaction. 3. Identify ethical problems. 4. Conflicts 5. Alternatives?

29. 6. Apply principles 7. Professional and legal requirements 8. Discuss with colleagues 9. Decision 10. Anticipate criticism, be prepared to justify your decision and reconsider

30. DECISION MAKING Guidelines Professional Bodies Regulatory Bodies Legal Considerations Personal Values - HPs and Patients Medical Ethics Common Sense

31. THANKYOU Niall.Cameron@nes.scot.nhs.uk

34. CK is a 74 year old woman who has a long history of phobic anxiety and depression, diverticulitis, COPD and was treated for Breast Cancer 10years ago. She attends you regularly and also sees the local community mental health team. She is on a large number of medications including anti-depressants. Her husband had given up work early to look after her. She developed increasing lower abdominal pain and was referred for GI review. Tests revealed a pelvic mass thought to be ovarian and her tumour markers were markedly raised. She was admitted for total hysterectomy and initially was given an encouraging prognosis from her surgeon. She was referred for chemotherapy but before starting this developed a fistula and need a surgery to form a colostomy. She then went on to complete a course of chemotherapy. Following this the tumour markers initially fell but soon after she developed increasing lower abdominal pain and the tumour markers were markedly elevated. She looked and felt very unwell with significant weight loss. When seen by the oncologists they suggested further chemo therapy and this was agreed to by the patient and her family. After two further treatments you were called to see her at home by her husband. He was concerned she was unwell and would not be able to attend for the next scheduled treatment.

35. PALLIATIVE CARE The active total care of patients whose disease is not responsive to curative treatment. Control of symptoms is paramount. The goal of palliative care is achievement of the best quality of life for the patients and their families.

36. PATIENT CONCERNS Symptom control Retain control Avoid prolongation of dying Decrease the burden on family Improve relationship with family