Moral and Ethical Dilemmas in End of Life Care and Dementia.
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Transcript of Moral and Ethical Dilemmas in End of Life Care and Dementia.
Moral and Ethical DilemmasMoral and Ethical Dilemmas in End of Life Care and in End of Life Care and
DementiaDementia
Ethical DilemmasEthical Dilemmas• Truth Telling• Consent• Confidentiality• Hydration• Feeding• Justice• Euthanasia• Symptom Management
Ethical FrameworksEthical FrameworksPrinciples basedDuties basedConsequentialistNon-consequentialistUtilitarian
Ethics – not universalEthics – not universalTimePlaceSocietyCultureReligion
Principle Based Approach to Principle Based Approach to BioethicsBioethics
BeneficenceNon-malficenceRespect for autonomyJustice
BeneficenceBeneficence
Non-malficenceNon-malficence
AutonomyAutonomyRespect for the autonomy of others
in so far as such respect is compatible with respect for the autonomy of others
Make decisions based on deliberation and values
AutonomyAutonomyCapacity – situation specificAffected by cognitive (and
communication) deficits
Bodily AutonomyBodily AutonomyResistive behaviour to care
JusticeJusticeFairness
JusticeJusticeDistributitive justiceRights based justiceLegal justice
JusticeJusticeTreat equals equallyTreat unequals unequally
Ethical Aspects of Symptom Ethical Aspects of Symptom Management in DementiaManagement in Dementia
Patient report essentialLimited evidence baseNo effective symptom-
assessment tools? Under management
Artificial Feeding in Advanced Artificial Feeding in Advanced DementiaDementia
No evidence of reduction in pressure sores, infection, improved function, comfort, survival
Finucane, Christmas, TravisJAMA, 1999: 282(14), 1365-70
Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia
Murphy and LipmanArch Int Med 2003, 163; 1351-3
Artificial HydrationArtificial HydrationWhat is the purposeBenefits - prolong life
- relieve symptomsBurdens
IV access Subcutaneous inflammation Hospitalisation Fluid overload
Artificial HydrationArtificial Hydration
A blanket policy is ethically indefensible
Towards death a person’s desire for food and drink lessens
Evidence suggest Artificial Hydration in imminently dying patients influences neither survival or symptom control
An Bord Altranais An Bord Altranais
‘So long as there is a means of nutrition and hydration it is the duty of the nurse to provide nutrition and hydration’
Medical Council of IrelandMedical Council of Ireland
‘The Council reiterates its view that access to nutrition and hydration remain one of the basic needs of human beings and all reasonable and practical efforts should be made to maintain both of them’
Advance Directive / Care Advance Directive / Care PlanPlan
Ethical to respect if current situation reflects envisaged situation
May be formally writtenMay be informal – patient’s
wishes
Advance Directive/ Care Advance Directive/ Care PlanPlan
The role of family/social networkSubstituted decisionNot ’legal’ but likely to be
recognised by courts
Confidentiality Confidentiality An ethical obligationMay need to be breached if a
patient is not able to make decisions about care
Views of family about what patient would have wanted
Truth TellingTruth Telling
What is the ethical obligation? Consequentialist Nonconsequentialist
‘Negotiated’ truth telling
Moral and Ethical Dilemmas Moral and Ethical Dilemmas at the End of Life and at the End of Life and
DementiaDementia
Do the right thingThe patient’s voiceForward planning Framework for decision making
informed by professional code and an ‘ethical guide’