End of Life care euthanasia and freedom for life

Learning Objectives
By the end of this session, students will be able to:
Explain the therapies used to alleviate suffering in patients at the end of life.
Discuss symptom control strategies including pain, dyspnea, nausea, delirium, and psychological distress.
Describe palliative interventions such as sedation, nutritional support, and non-pharmacological measures.
Understand the ethical principles of autonomy, beneficence, non-maleficence, and justice in end-of-life care.
Apply ethical and legal frameworks in decision-making to ensure compassionate, dignified, and lawful end-of-life care.

1. End-of-Life Care Therapies, Ethical and Medico-Legal Issues Dr. Govind Rankawat (Gold Medalist) MBBS, MD (General Medicine), FIDM, FICC Assi . Professor, Department of General Medicine SMS Medical College and attached hospital, Jaipur

2. Learning Objectives By the end of this session, students will be able to: Explain the therapies used to alleviate suffering in patients at the end of life. Discuss symptom control strategies including pain, dyspnea, nausea, delirium, and psychological distress. Describe palliative interventions such as sedation, nutritional support, and non-pharmacological measures. Understand the ethical principles of autonomy, beneficence, non-maleficence, and justice in end-of-life care . Apply ethical and legal frameworks in decision-making to ensure compassionate, dignified, and lawful end-of-life care.

3. Introduction • End-of-life care = holistic support for patients with life-limiting illness • Goals: Relief of suffering, dignity, quality of life, support to family

4. A 68 year old male with diagnosis of Metastatic lung carcinoma with brain and liver metastases, Past Medical History of Hypertension, COPD and Current Status of Bedbound , progressive weight loss, poor oral intake, increasing breathlessness, uncontrolled pain. History of Present Illness Admitted with worsening breathlessness and confusion for 3 days. Pain score: 8/10 despite NSAIDs. Unable to tolerate oral feeds, recurrent vomiting. Family reports increasing restlessness, anxiety, and insomnia . Examination Cachectic, drowsy but arousable . Respiratory rate: 30/min with accessory muscle use. Pulse: 110/min, BP: 90/60 mmHg. Oxygen saturation: 85% on room air. Multiple liver metastases palpable, ascites present

5. Investigations CXR: Progressive lung mass with pleural effusion. MRI brain: Multiple metastases. Labs: Deranged LFTs, mild renal impairment . Management Approach (End-of-Life Care) 1. Symptom Control Pain: Morphine infusion (opioid titration). Dyspnea: Oxygen therapy + low-dose morphine + fan therapy. Nausea/Vomiting: Haloperidol + Metoclopramide. Delirium/Agitation: Haloperidol, environmental calmness. Constipation prevention: Laxatives with opioids. 2. Palliative Interventions Palliative sedation considered for refractory distress. Nutritional support: Comfort feeding, sips of water, mouth care. Non-pharmacological: Family presence, spiritual counseling .

6. Ethical & Medico-Legal Aspects Autonomy: Patient had earlier expressed preference for comfort care only. Beneficence & Non-maleficence: Avoid futile ICU admission; focus on comfort. DNR order (Do not Resuscitate): Documented and communicated with family. Legal compliance: Following Indian Supreme Court guidelines on passive euthanasia. Family & Psychosocial Support Family counseling regarding prognosis. Emotional and spiritual support offered. Bereavement support planned. Outcome Patient kept comfortable with palliative sedation. Died peacefully surrounded by family. Family expressed satisfaction with compassionate care .

7. Therapies for Alleviating Suffering – Symptom Control • Pain management – opioids, adjuvant analgesics • Dyspnea – oxygen therapy, opioids, anxiolytics • Nausea/Vomiting – antiemetics • Delirium/Agitation – haloperidol, benzodiazepines • Constipation – laxatives, stool softeners • Anxiety/Depression – antidepressants, counseling

8. Pain Management Opioids (mainstay): Morphine – first-line for moderate to severe pain. Fentanyl – preferred in renal impairment or when morphine not tolerated. Oxycodone, Hydromorphone – alternatives in selected cases. Adjuvant Analgesics (for neuropathic or refractory pain): Antidepressants – amitriptyline, duloxetine. Anticonvulsants – gabapentin, pregabalin . Steroids – dexamethasone (for bone pain, liver capsule pain). NSAIDs – for bone metastasis or inflammatory pain. Non-Pharmacological Support: Relaxation therapy, physiotherapy, cognitive-behavioral therapy. Emotional & spiritual support to reduce pain perception. WHO Analgesic Ladder (3-step approach): Mild pain: Non-opioids (paracetamol, NSAIDs). Moderate pain: Weak opioids (codeine, tramadol) ± non-opioids. Severe pain: Strong opioids (morphine, fentanyl) ± adjuvants.

9. Therapies – Palliative Interventions • Palliative sedation (for refractory symptoms) • Nutritional & hydration support (comfort focused) • Non-pharmacological: massage, relaxation, spiritual support

10. Flow Diagram: Palliative Interventions in End-of-Life Care Palliative Interventions Palliative Sedation (for refractory symptoms) Nutritional & Hydration Support (comfort focused) Non-Pharmacological Support (massage, relaxation, spiritual care) Use of sedative medications to reduce consciousness for relief of intractable symptoms (e.g., pain, dyspnea, agitation, delirium). Drugs used: Midazolam, Lorazepam, Propofol (in ICU setting). Indications: When symptoms cannot be controlled by standard therapies. Ethical principle: Intention is relief of suffering, not hastening death . Goal : Maintain comfort, not prolong life at all costs. Approach: Oral feeding if safe and comfortable. Minimal hydration to relieve thirst and dry mouth. Artificial feeding (NG tube, IV fluids) – considered only if it improves comfort, not mandatory . Physical therapies: Massage, positioning, relaxation exercises. Psychological support: Counseling, reassurance, dignity therapy. Spiritual care: Chaplaincy services, prayers, rituals, meditation. Family involvement: Encouraging presence, communication, and emotional closure.

11. Psychosocial & Spiritual Care • Counseling, family meetings • Religious/spiritual support • Bereavement support for family

12. Euthanasia (Hospice) The practice (illegal in most countries) of killing somebody without pain who wants to die because they are suffering from a disease that cannot be cured. Euthanasia is legal in a number of countries, including Canada, Belgium, Colombia, Luxembourg, the Netherlands, New Zealand, Portugal, Spain, and Australia (in multiple states)

13. Passive Euthanasia: जीवन-रक्षक उपचार जैसे वेंटिलेटर, कृत्रिम पोषण को रोकना/हटाना, जब स्थिति अपरिवर्तनीय हो। उद्देश्य : कष्ट कम करना और प्राकृतिक मृत्यु को स्वीकार करना । Aruna Shanbaug Case (2011): सीमित मान्यता, HC अनुमति आवश्यक । Common Cause vs Union of India (2018): Passive Euthanasia व Living Will को मान्यता। Autonomy व Dignified Death का अधिकार। Medical Board + Judicial Magistrate की निगरानी । 1. वैध Living Will / Advance Directive होना चाहिए। 2. Living Will न होने पर परिवार आवेदन कर सकता है। 3. Medical Board मूल्यांकन करेगा। 4. District Collector व Judicial Magistrate को प्रस्तुत। 5. अनुमोदन के बाद ही उपचार हटाया जा सकता है । Active vs Passive Euthanasia ( कानूनी अंतर) Active Euthanasia : किसी दवा/इंजेक्शन द्वारा जानबूझकर मृत्यु देना → भारत में अवैध । Passive Euthanasia : उपचार रोकना/हटाना जिससे रोगी प्राकृतिक रूप से मृत्यु को प्राप्त करे → भारत में कानूनी (2018 निर्णय के बाद ) । भारत में Passive Euthanasia वैध है, बशर्ते कि: - रोगी की स्वेच्छा ( Living Will) या परिवार की सहमति हो। - मेडिकल बोर्ड और न्यायिक स्वीकृति हो। यह अधिकार अनुच्छेद 21 ( Right to Life with Dignity) से व्युत्पन्न है ।

14. Ethical Issues in End-of-Life Care Autonomy: Respecting patient’s right to choose/refuse treatment. Beneficence & Non-maleficence: Balance benefit vs harm of interventions. Justice: Fair allocation of resources. Withholding vs Withdrawing Treatment: Is stopping life support ethical? Do Not Resuscitate (DNR) Orders: Ethical decision-making & documentation. Palliative Sedation vs Euthanasia: Intention matters (relief of suffering vs deliberate ending of life).

15. Ethical Principles in End-of-Life Care Autonomy Respecting the patient’s right to make decisions about their own care. Includes: accepting or refusing treatment, advance directives, living will. Example: Patient’s choice to decline mechanical ventilation. 2 . Beneficence Acting in the best interest of the patient. Aim = maximize comfort, dignity, and quality of life. Example: Providing palliative sedation for intractable pain . 3. Non-Maleficence (“Do no harm”) Avoiding treatments that may cause more suffering than benefit. Example: Not starting aggressive chemotherapy in terminal illness when side effects outweigh benefits . 4. Justice Fair and equitable allocation of healthcare resources. Ensuring all patients have access to palliative care services. Example: Avoiding discrimination in offering pain relief or hospice support .

16. Medico-Legal Issues Informed Consent: Patient/family must understand prognosis & options. Advance Directives / Living Will: Legal documentation of patient’s wishes. DNR Orders: Proper documentation required to avoid litigation. Legal Status of Euthanasia: Active euthanasia – illegal in most countries (including India). Passive euthanasia – permitted under strict legal guidelines (Supreme Court of India, 2018). Physician-Assisted Suicide: Legal in some countries (e.g., Netherlands, Canada, some US states). Medical Council Guidelines: Must follow national/regional laws & ethics.

17. Conclusion • End-of-life care focuses on comfort, dignity, and respect • Aim: relieve suffering, not prolong suffering • Guided by ethical principles and medico-legal frameworks