Deciding life and death in the courtroom. From Quinlan to Cruzan, Glucksberg, and Vacco--a brief history and analysis of constitutional protection of the 'right to die'

Ethical Concerns in the Care of Patients with Advanced Kidney Disease: a National Retrospective Study, 2000-2011

BACKGROUND

Understanding ethical concerns that arise in the care of patients with advanced kidney disease may help identify opportunities to support medical decision-making.

OBJECTIVE

To describe the clinical contexts and types of ethical concerns that arise in the care of patients with advanced kidney disease.

DESIGN

Retrospective cohort study.

PARTICIPANTS

A total of 28,568 Veterans with advanced kidney disease between 2000 and 2009 followed through death or 2011.

EXPOSURE

Clinical scenarios that prompted clinicians to consider an ethics consultation as documented in the medical record.

MAIN MEASURES

Dialysis initiation, dialysis discontinuation, receipt of an intensive procedure during the final month of life, and hospice enrollment.

KEY RESULTS

Patients had a mean age of 67.1 years, and the majority were male (98.5%) and white (59.0%). Clinicians considered an ethics consultation for 794 patients (2.5%) over a median follow-up period of 2.7 years. Ethical concerns involved code status (37.8%), dialysis (54.5%), other invasive treatments (40.6%), and noninvasive treatments (61.1%) and were related to conflicts between patients, their surrogates, and/or clinicians about treatment preferences (79.3%), who had authority to make healthcare decisions (65.9%), and meeting the care needs of patients versus obligations to others (10.6%). Among the 20,583 patients who died during follow-up, those for whom clinicians had considered an ethics consultation were less likely to have been treated with dialysis (47.6% versus 62.0%, adjusted odds ratio [aOR] 0.63, 95% CI 0.53-0.74), more likely to have discontinued dialysis (32.5% versus 20.9%, aOR 2.07, CI 1.61-2.66), and less likely to have received an intensive procedure in the last month of life (8.9% versus 18.9%, aOR 0.41, CI 0.32-0.54) compared with patients without documentation of clinicians having considered consultation.

CONCLUSIONS

Clinicians considered an ethics consultation for patients with advanced kidney disease in situations of conflicting preferences regarding dialysis and other intensive treatments, especially when these treatments were not pursued.

Completion of advance directives among U.S. consumers

BACKGROUND

Current, ongoing national surveys do not include questions about end-of-life (EOL) issues. In particular, population-based data are lacking regarding the factors associated with advance directive completion.

PURPOSE

To characterize U.S. adults who did and did not have an advance directive and examine factors associated with their completion, such as the presence of a chronic condition and regular source of health care.

METHODS

Data were analyzed in 2013 from adults aged 18 years and older who participated in the 2009 or 2010 HealthStyles Survey, a mail panel survey designed to be representative of the U.S. population. Likelihood ratio tests were used to examine the associations between advance directive completion and demographic and socioeconomic variables (education, income, employment status); presence of a chronic condition; regular source of health care; and self-reported EOL concerns or discussions. Multiple logistic regression analyses identified independent predictors related to advance directive completion.

RESULTS

Of the 7946 respondents, 26.3% had an advance directive. The most frequently reported reason for not having one was lack of awareness. Advance directive completion was associated with older age, more education, and higher income and was less frequent among non-white respondents. Respondents with advance directives also were more likely to report having a chronic disease and a regular source of care. Advance directives were less frequent among those who reported not knowing if they had an EOL concern.

CONCLUSIONS

These data indicate racial and educational disparities in advance directive completion and highlight the need for education about their role in facilitating EOL decisions.

Ethics of ongoing cancer care for patients making risky decisions

Patients who decline conventional cancer therapy yet seek to continue follow-up while pursuing alternative therapy can pose an ethical challenge. The potential benefits and harms of an ongoing clinical relationship need be assessed on a case-by-case basis. Ongoing efforts at communicating, understanding the patient’s basis for decision making, and seeking to negotiate evidence-based care that is respectful of the patient’s preferences may improve outcomes.13 However, respect for the patient’s autonomy does not require support for inappropriate care and should not require that the oncologist check his or her professional judgment at the door.

Lost in translation: the unintended consequences of advance directive law on clinical care

BACKGROUND

Advance directive law may compromise the clinical effectiveness of advance directives.

PURPOSE

To identify unintended legal consequences of advance directive law that may prevent patients from communicating end-of-life preferences.

DATA SOURCES

Advance directive legal statutes for all 50 U.S. states and the District of Columbia and English-language searches of LexisNexis, Westlaw, and MEDLINE from 1966 to August 2010.

STUDY SELECTION

Two independent reviewers selected 51 advance directive statutes and 20 articles. Three independent legal reviewers selected 105 legal proceedings.

DATA EXTRACTION

Two reviewers independently assessed data sources and used critical content analysis to determine legal barriers to the clinical effectiveness of advance directives. Disagreements were resolved by consensus.

DATA SYNTHESIS

Legal and content-related barriers included poor readability (that is, laws in all states were written above a 12th-grade reading level), health care agent or surrogate restrictions (for example, 40 states did not include same-sex or domestic partners as default surrogates), and execution requirements needed to make forms legally valid (for example, 35 states did not allow oral advance directives, and 48 states required witness signatures, a notary public, or both). Vulnerable populations most likely to be affected by these barriers included patients with limited literacy, limited English proficiency, or both who cannot read or execute advance directives; same-sex or domestic partners who may be without legally valid and trusted surrogates; and unbefriended, institutionalized, or homeless patients who may be without witnesses and suitable surrogates.

LIMITATION

Only appellate-level legal cases were available, which may have excluded relevant cases.

CONCLUSION

Unintended negative consequences of advance directive legal restrictions may prevent all patients, and particularly vulnerable patients, from making and communicating their end-of-life wishes and having them honored. These restrictions have rendered advance directives less clinically useful. Recommendations include improving readability, allowing oral advance directives, and eliminating witness or notary requirements.

PRIMARY FUNDING SOURCE

U.S. Department of Veterans Affairs and the Pfizer Foundation.

End-of-life care in the treatment of heart failure in the elderly

Much of the literature dedicated to the topic of medical care of dying patients has revolved around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.

Withdrawing Life-Sustaining Treatment: Ethical Considerations

Withdrawing life-supporting technology from patients who are irremediably ill is morally troubling for caregivers, patients, and families. Interventions that enable clinicians to delay death create situations in which the dignity and comfort of dying patients may be sacrificed to spare professionals and families from their elemental fear of death. Understanding of the limits of treatment, expertise in palliation of symptoms, skillful communication, and careful orchestration of controllable events can help to manage the withdrawal of life support appropriately.

End-of-life care in the treatment of heart failure in the elderly

Much of the literature dedicated to the topic of medical care of dying patients has revolves around terminal care provided to patients who have neoplastic diagnoses. Heart failure (HF) presents its own unique challenges to the clinician. This article focuses on specific clinical recommendations and an analysis of some of the ethical issues involved in the provision of care to elderly patients in the terminal stages of HF.

Ethical analysis

Critical care nurses care for patients at the end of their lives on a daily basis. Ethical dilemmas are often encountered while caring for these patients and their families. This article reviews a case scenario along with a framework for ethical analysis.

Ethical and legal issues in palliative care

This article reviews the ethical principles underlying palliative care, stressing the importance of respecting patient's rights to withdraw or withhold life-sustaining treatment, including artificial hydration and nutrition. There is no ethical or constitutional right to receive physician-assisted suicide or voluntary active euthanasia. This article discusses current ethical controversies in palliative care, including futility, medication dosage and double-effect, terminal sedation, legalization of physician-assisted suicide and euthanasia, and patient refusal of hydration and nutrition. Relevant legal issues are discussed in tandem with the ethical issues.

Elective discontinuation of life-sustaining mechanical ventilation on a chronic ventilator unit

Withdrawal of medical interventions has become common in the hospital for patients with terminal disease. Despite the widespread feeling that medical interventions may be futile in certain patients, many patients, families, and medical staff find withdrawal of care difficult and withdrawal of mechanical ventilation to be the most disturbing secondary to the close proximity of withdrawal and death. Presented is a 6-year retrospective review of elective withdrawal of life-sustaining mechanical ventilation on a chronic ventilator unit (CVU) in an academic nursing home. Of the 98 patients admitted to the 19-bed CVU during this period, only 13 underwent terminal weaning (TW). Statistically, these 13 patients did not differ significantly in age, gender, race, route of nutrition, decisional capacity, or length of stay on the unit compared with the 85 patients who were not terminally weaned (t-test P > .05). Stepwise logistic regression found that patients who were more alert at admission were more likely to have participated in TW (chi2 = 5.22, coefficient for alertness P < .036). The decision to terminate mechanical ventilation was made by patients in eight cases and by family in five cases. The first step in the process leading to TW was a discussion with the patient and family about plan of care, including the patient's desires for attempted resuscitation, rehospitalization, advance directives, and family contacts. Plan of care was reviewed informally in a weekly multidisciplinary round and formally, to address each patient's care plan, in a multidisciplinary family meeting on a regular basis. The second step was to address TW when brought up by the patient, family, or medical staff. A request for TW by a patient or surrogate was referred to the medical staff, who screened the patient for depression or other remediable symptoms. The third step was to refer the patient and family to another formal meeting to discuss the request for TW and, if needed, in the case of multiple family members, to allow questions to be answered and consensus to be formed. Additional meetings were scheduled as needed. The next step occurred once a consensus was reached to proceed with TW; a date and time was set to reconvene the patient, family, and anyone else who wanted to be present at the TW. The TW process began when a peripheral intravenous catheter was placed and the patient was premedicated with low doses of morphine sulfate and a benzodiazepine. After premedication, the patient was removed from the ventilator. The physician, nurse, family, and physician assistant remained at the bedside and additional morphine or benzodiazepine was given, as needed, for symptom management. Death from TW occurred in all patients, at times ranging from 2 minutes to 10.5 hours (average 6.2 hours). A mean total dose of 115 mg morphine and 14 mg diazepam was given for symptom control. There was no correlation between dose of these medications and duration of survival off the ventilator.

Life shortening and physician assistance in dying: euthanasia from the viewpoint of German legal medicine

BACKGROUND

Around the world heated debates have broken out on the topic of active euthanasia. Specialists in the field of 'forensic medicine' have taken full part in these discussions.

OBJECTIVE

The present survey from the point of view of forensic medicine begins with a look at current terminology and at the laws pertaining to euthanasia in Germany. These laws are then contrasted with actual practice, including a description of the increasing acceptance of active euthanasia by the German population and its legalization in Holland. The main argument against active euthanasia is that its formal acceptance in law would cause the dam of restraint to burst, culminating in widespread misuse, as already seen in recent serial killings by nurses in hospitals and homes for the elderly around the world.

CONCLUSIONS

Contrasted to this are the arguments for taking active steps at the end of life, including emotional considerations such as the revulsion against mechanized medicine and the fear of pain and rational arguments such as the necessity to end a 'life unworthy of life', to save medical costs, and obtaining prior consent in 'living wills'. Such considerations have put in jeopardy the moral integrity of the medical profession - and thus the layperson's trust in physicians - around the world. In Germany especially the history of mass killing during the Nazi era constitutes a fundamental argument against active euthanasia. As a consequence, in Germany active euthanasia will not receive legal sanction, although recommendations on rendering dying more bearable are permitted.