ethical-and-legal-frameworks-for-decision-making-at-the-end-of-life.ppt

Bioethics

1. Ethical and legal frameworks
for decision making at the
end of life.
Dr Fiona Lisney
Consultant in Palliative Medicine
01753 634879

2. Question 3:
Is this end of life?
How end of life is it?
What is the right thing to do?

3. Work in context

Prognostication
What are we trying to achieve?

Ethics and Morality

Law = Process

4. Clinical outcomes
Increased survival
Symptom management
Restore independence/function
Decrease hospitalization

5. ‘end of life’ clinical outcomes
Planned death in the place of choice
Expert symptom management
Holistic care – including spiritual support
Support for bereaved family/carers
Care of the body after death
?increased survival

6. What decision do we have to make?

7. 4 ethical principles
1.Respect for autonomy
1.Nonmaleficence
1.Beneficence
1.Justice

8. What is in the
patient’s best
interests?
Patient values,
preferences
& self
determination

10. 
Western healthcare
ethics

Burdens > benefits

Withdrawal of life
sustaining ‘harmful’
treatment

Other healthcare
ethics

Maintenance and
protection of life

Forbid actions that may
harm/shorten life

Every day/moment
valued

No treatment can be
harmful if it prolongs life

Omnipotent God – Drs
agents for the will of God

11. 
Western healthcare
ethics

Informed consent

refusal

Other healthcare
ethics

Responsibility towards
God

Living in ‘social
coherence’ – influenced
by relatives and religious
leaders

Only the ‘right’ choices
are acceptable

May need to oppose
patient’s self
determination

12. 
Search for shared beliefs

Folk knowledge

Religious leaders

Emotional learning

Early identification

Continuity of care

Relationships and trust

Slow pace

Recognition and respect of non neutrality of
ethical principles in different cultures

Experts (SPC/religious leaders)

Language of dying

13. Law = Process
What decision do we have to make?

14. Patient choice
Does he have capacity?
YES NO
Support patient
participation in decision
making
MCA

15. Patient choice
the mental capacity act in practice
5 underlying principles

A presumption of capacity

Maximisation of capacity

The right to make ‘stupid’ decisions

Best interests

Restrict freedom/rights as little as possible

16. Question 1 – does he have capacity?
What decision does he have to make?
Assess capacity for that decision
Diagnostic
What is the diagnosis that makes him unable to make the
required decision?
Functional
Is he unable to:
Understand
Retain
Use The information needed to make the decision
Weigh up
Communicate
If no – can you maximise?

17. Best Interests Framework
Proxy decision makers
LPAs
IMCAs
Court appointed deputies

Management of financial assets

Unresolved family dispute

Series of linked welfare decisions

Not life sustaining treatment – court decision

18. Advance decisions to refuse tretament:
Not valid if:

Patient has capacity

Has been withdrawn

Subsequently created a lasting power of attorney

Behaved inconsistently with the advance decision

The treatment on question is not the specified
treatment in the decision

The circumstances do not apply

19. Without capacity:
Act in the patient’s best interests
Who? GP/Consultant with input from MDT
How? Weigh up possible benefits and burdens of
intervention
Never harm your patient
Be non-discriminatory
Consider all the relevant circumstances
Consider what the patient’s views/beliefs/values might
have been
Take in account the views of those close to the patient
Consider 2
nd
opinion
Consider Independent Mental Capacity Advocate
(IMCA)