Ethical Issues to Deal With After a Death in the Family

SAGE Open up Med. 2021; nine: 20503121211000918.

Ethical considerations at the cease-of-life intendance

Melahat Akdeniz

¹Department of Family Medicine, Faculty of Medicine, Akdeniz Academy Infirmary, Akdeniz University, Antalya, Turkey

Bülent Yardımcı

ⁱⁱAmerikan Hospital, Şişli/Istanbul, Turkey

Ethem Kavukcu

^threeSection of Sports Medicine, Faculty of Medicine, Akdeniz University Hospital, Akdeniz University, Antalya, Turkey

Received 2021 Jan xviii; Accepted 2021 Feb 12.

Abstruse

The goal of end-of-life care for dying patients is to forbid or salve suffering as much as possible while respecting the patients' desires. However, physicians face up many upstanding challenges in terminate-of-life care. Since the decisions to be made may concern patients' family members and society every bit well every bit the patients, it is important to protect the rights, dignity, and vigor of all parties involved in the clinical ethical decision-making process. Understanding the principles underlying biomedical ethics is important for physicians to solve the problems they confront in end-of-life intendance. The primary situations that create ethical difficulties for healthcare professionals are the decisions regarding resuscitation, mechanical ventilation, artificial diet and hydration, terminal sedation, withholding and withdrawing treatments, euthanasia, and physician-assisted suicide. Five upstanding principles guide healthcare professionals in the management of these situations.

Keywords: End-of-life care, ethics, accelerate directives, ethical dilemmas, decision-making

Introduction

Advances in mod medicine and medical technologies accept both prolonged life expectancies and changed the natural norms of expiry. Although many mod treatments and technologies do non cure chronic diseases, medical interventions such every bit bogus nutrition and respiratory support can prolong the lives of people by providing secondary support.^i,2 Terminate-of-life care has go an increasingly of import topic in modern medical practice. This process starts with the diagnosis of a fatal affliction, and includes the nobility death that the patient desires and the post-death mourning period.² Expiry is an inevitable office of life. Many people at the end of life experience unnecessary difficulty and suffering. Patients' family members, close friends and informal caregivers besides experience a range of problems. They play very important roles in the stop-of-life care of their loved ones before, during, and after death.³

After hearing about a concluding diagnosis, the families of dying patients feel a period of high stress that tin can exist manifested by anger, depression, interpersonal conflict, and psychosomatic bug.^iii,4 Family unit members are also primer caregivers for the dying patient. They may experience hopelessness, anger, guilt, and powerlessness when they cannot salvage the suffering of their terminally sick family fellow member.⁴

From an ethical perspective, the patient rather than the family, proxy or physician makes decisions best near limiting treatment or treatments that practise not provide cures but prolong life for a while. However, if the patient has lost the ability to make decisions, the family unit, the proxy health intendance or the physician must make a decision virtually the care to exist provided to the patient.^four,5 Family members who feel sadness, fear, anxiety, and are stressed out because a loved one is terminally ill volition accept a hard fourth dimension to make decisions. If they do not know their loved one's preferences regarding terminate-of-life intendance, they cannot be certain nearly whether they can give the most appropriate decisions for the patient. This can increase the anxiety and stress of family members. Sometimes family members may have different preferences regarding the care. While some family members clearly and unambivalently desire that "everything" is done to keep their loved one alive, others are unable to decide to limit handling and may desire the medical staff to make these decisions for them. In such a situation, the physicians will be in a difficult situation.^{3–half-dozen}

The goals of intendance for terminally ill patients are the alleviation of suffering, the optimization of quality of life until expiry occurs, and the provision of comfort in death. However, achieving these goals is not always like shooting fish in a barrel. Because physicians, patients, and patients' family members take to make decisions regarding treatment options such every bit whether to prolong a person's life with the support of medical technologies or allow the natural death process to go along, they confront diverse upstanding dilemmas related to end-of-life care.^1–four Understanding the principles underlying biomedical ethics is important for physicians and their patients to solve the bug they face in end-of-life intendance. The ethical principles are autonomy, beneficence, nonmaleficence, allegiance, and justice.^5,6

In this article, considerations regarding the application of upstanding principles during end-of-life intendance are discussed.

Universal ethical principles

The upstanding principles recognized universal are autonomy, beneficence, nonmaleficence, and justice. These "four principles" are common in Eastern and Western cultures, merely their awarding and weight may differ. This article highlights the universally accepted features of these principles. The social and legal aspects that may affect the ethical principles in different cultures can be covered as a dissever article.

Autonomy is considered a patient'southward right to self-determination. Everyone has the right to determine what kind of care they should receive and to accept those decisions respected. Respecting patient autonomy is one of the cardinal principles of medical ideals.^iv,6 This principle emphasizes physicians' protection of their patients' right to cocky-determination, fifty-fifty for patients who have lost the ability to brand decisions. This protection can be achieved by using advance directives (ADs) appropriately.^iv,6

ADs are derived from the upstanding principles of patient autonomy. They are oral and/or written instructions about the hereafter medical care of a patient in the event he or she becomes unable to communicate, and loses the ability to make decisions for any reason. ADs completed past competent person unremarkably include living wills, health intendance proxies, and "do not resuscitate" (DNR) orders.^3,4,7,8 A living will is a written document in which a competent person provides instructions regarding health care preferences, and his or her preferences for medical interventions such as feeding tubes that can be applied to him or her in end-of-life care. A patient'southward living will take effect when the patient loses his or her decision-making abilities. A wellness care proxy (also called health care agent or power of attorney for health care) is the person appointed by the patient to make decisions on the patient'south behalf when he or she loses the ability to brand conclusion. A health care proxy is considered the legal representative of the patient in a state of affairs of severe medical impairment.^4,7,8 The responsibility of the healthcare proxy is to decide what the patient would want, not what the proxy wants.^seven,9

Upward until age 18, the patient'due south parents or legal guardians unremarkably serve as their health care proxy. After the historic period of 18, they can legally appoint their ain wellness care proxy. The proxies may be ane of the family members or friends or another person. The proxies make decision near treatments, procedures, and life support. Even if their ain wishes are different from the patient, the proxies must take into account the patient's possible preferences, not their ain or anyone else, when making decisions on behalf of the patient.^7,8,x

At the end of life, the priority of making decisions belongs to the patient. If the patient has lost the ability to make decisions, decisions are made according to the patient's Advertizing, if any. The proxy health care is second in decision-making on behalf of the patient. If no AD or proxy, the decision-making is upwards to the family members. If family members avoid making decisions, the healthcare squad must make a decision.^7,eight,10

ADs help ensure that patients receive the intendance they want and guide the patients' family members in dealing with the decision-making burden. Another reason for ADs is to limit the use of expensive, invasive, and useless care not requested by patients. Researches show that ADs improve the quality of end-of-life care and reduce the brunt of care without increasing mortality.^vii,11

In many countries, the right of people to cocky-determination is a legal guarantee. Each patient's "right to cocky-determination" requires informed consent in terms of medical intervention and treatment. A patient has both the "right to need the termination of treatment" (e.g. the discontinuation of life support) and the "correct to decline treatment altogether"; the exercise of these rights is strictly dependent on the person.^4,5 Advert tin be updated yearly and/or prior to whatever hospitalization.⁹

In many countries, the correct of competent individuals to limited their treatment preferences autonomously in end-of-life intendance should be met with ethical respect, taking into account the use of advanced treatments and the prognosis of their disease. However, this autonomy has some limitations. The decisions made by a patient should not harm him or her. Information technology is important for healthcare providers to respect the autonomy of their patient and fulfill their duties to benefit their patients without harming them.^one–five,9

Beneficence requires physicians to defend the most useful intervention for a given patient. Oft, patients' wishes about end-of-life intendance are not expressed through ADs, and the patients' health care providers and family members may not be aware of their wishes about end-of-life care.^ii,nine,10 If a patient is not capable of controlling, or if the patient has not previously documented his or her wishes in the upshot he or she becomes terminally ill, the cease-of-life determination is made by the patient's physician equally a result of consultations with the patient or the patient's relatives or the patient'due south wellness care proxy.^3–6 In this situation, the responsibility of the physician in the intendance of the dying patient should be to advocate the approaches that encourage the commitment of the best intendance available to the patient.³

Nonmaleficence is the principle of refraining from causing unnecessary impairment. This principle concerns a basic maxim of proficient medical care: Primum non nocere (i.e. beginning, exercise no harm). Although some of the medical interventions might cause pain or some impairment, nonmaleficence refers to the moral justification behind why the harm is acquired. Damage can exist justified if the benefit of the medical intervention is greater than the harm to the patient and the intervention is not intended to harm the patient.^five–7,12

To comply with these principles of beneficence and nonmaleficence, healthcare professionals need to know their roles and responsibilities in finish-of-life intendance.^4,5

The ethical principle of justice is nearly ensuring a off-white distribution of health resources and requires impartiality in the delivery of health services.^5–7,12 Medical resources are oftentimes express and should, therefore, be distributed adequately and equally. There is already a need to evaluate the allocation of advanced medical therapy to avoid unnecessary utilize of limited resources. Healthcare providers have an ethical obligation to advocate for fair and appropriate treatment of patients at the terminate of life. This tin be achieved through good education and noesis of improved treatment outcomes.^4–7

Fidelity principle requires physicians to be honest with their dying patient virtually the patients' prognosis and possible consequences of patients' disease.^5–7,12 Truth telling is central to respecting autonomy. Most patients want to have full noesis of their illness and its possible consequences, but this desire may decrease as they arroyo the end of their life. Some patients may not want data about their disease.^2,5 Physicians should exist skilled in determining their patients' preferences for information and, honestly yet sensitively, provide their patients with as much accurate information as the patients desire. Having constructive patient-centered communication skills helps physicians learn and meet the demands of their patients.^5,13

Healthcare professionals, especially physicians, should provide all the information about their patients' status when appropriate. They have a duty to provide detailed information to patients and, if necessary, to the patients' decision-makers about advanced medical treatments that tin can exist used during end-of-life intendance.^iv,13 They can perform their duties past providing their patients with detailed information virtually the benefits, limitations, and disadvantages of these treatments. Even if a patient has the autonomy to choose his or her handling, the physician should explain the results of all therapeutic interventions.^two–five If the patient insists on a handling that volition not be beneficial or will or just prolong her or his life, the dr. can withdraw from the patient's care past explaining why the treatment will not do good the patient, the possible impairment the doc may cause to the patient, and how the provision of the treatment volition lead to the unnecessary apply of resources. The doctor also has the duty to protect the patient's life, but this task should not be dislocated with the apply of unnecessary resources, and the patient should not exist injured further past continuing useless or futile medical treatments.^1,4,5 In other cases, the do good to the patients is adamant just on the basis of the patients' subjective judgment of well-being. Medically futile treatments and interventions are those that are highly unlikely to do good the patient.⁹

Medical futility is defined every bit a clinical activeness serving no useful purpose in attaining a specified goal for a given patient.¹⁴ Futile medical intendance is care provided to a patient, although in that location is no hope of whatever benefit to the patient.⁴ As a full general rule, patients should be involved in deciding whether care is futile. In rare cases, information technology may non be favorable for the patients to participate in this discussion.^2,nine Futile and expensive treatments in finish-of-life care increase the toll of healthcare and promote inequality in healthcare. Advanced technologies practise not promise cures. The employ of these technologies can sometimes harm the patient rather than benefit. Therefore, physicians should certainly consider the ethical value of the autonomy of their patients or his or her patients' proxies, but they should also discuss possible damage from treatments, and how the use of unnecessary resources leads to an increase in healthcare costs. Physicians do not accept to use to useless or futile handling to patients.^3,ix,10,14

Decision-making during end-of-life care

In the end-of-life care of a patient, the conclusion to implement practices to prolong the patient's life or to comfort the patient may exist difficult for the medico, patient, family unit members, or health care proxy. The post-obit topics relate to some situations where difficulty in controlling regarding end-of-life care is encountered:⁹

1. Cardiopulmonary resuscitation (CPR);

2. Mechanical ventilation (MV), extracorporeal membrane oxygenation (ECMO), and mechanical circulatory support (MCS);

3. Artificial nutrition and hydration (ANH);

4. Final sedation;

5. Withholding and withdrawing treatment;

6. Euthanasia and doc-assisted suicide (PAS).

Although CPR is valuable in the treatment of heart attacks and trauma, sometimes the use of CPR may not be appropriate for dying patients and may atomic number 82 to complications and worsen the patients' quality of life. For some terminally ill patients, CPR is an undesired intervention. The decision not to perform CPR on a dying patient can be difficult for healthcare personnel. The decision to administer CPR to a patient depends on many factors such as patient preferences, the estimated success rate, the risks of the procedure, and the perceived do good.^4,12,15 A competent patient may not want to undergo CPR in the result of cardiopulmonary arrest. This decision is called the DNR determination. Despite this request, the patient's family members may ask the doc to perform CPR. In this case, if the patient is witting and has the ability to brand decisions, the patient's decision is taken into account. Physicians must acquire the CPR demands of patients at risk of cardiopulmonary abort. DNR decision can be considered for the following patients:^{9,10,fifteen,16}

• Patients who may not benefit from CPR;

• Patients for whom CPR will cause permanent damage or loss of consciousness;

• Patients with poor quality of life who are unlikely to recover after CPR.

Approximately 75% of dying patients feel difficulty breathing or dyspnea. This feeling can be scary for patients and those who witness it. In cease-of-life care, mechanical ventilation is applied not to prolong the lives of patients but to reduce their anxiety and to permit them to sleep ameliorate and eat more comfortably.^iv,nine

MV, ECMO, and MCS are supportive therapies.^17–20 The decisions to deactivate these devices are made in a similar way. The principle of autonomy is pivotal in evaluating the refusal of treatment and the permissibility of life-catastrophe interventions. If MV, ECMO, or MCS support does not provide any benefit to the patient or no longer meets its intended goals, or if the event is not optimal, or the quality of life is non adequate according to the patient's or family'south wishes, support can be terminated. The timing of the device separation should exist chosen by the patient's family members.^17–xx

Nutrition and hydration are essential parts of homo flourishing. ANH involves giving food and water to patients who are unconscious or unable to consume.^9,21,22

Artificial nutrition can be given through enteral feeding by tube or parenteral feeding. Nutrition and hydration decisions are among the most emotionally and ethically challenging decisions in end-of-life care. Many medical associations suggest that feeding and hydration treatments are forms of palliative intendance that run into basic human needs and must be given to patients at the end of life.^9,12,xvi,23 In 1990, the U.s.a. Supreme Court noted that ANH is not unlike from other life-sustaining treatments. Although to practise so speeds upwardly death, competent adults may refuse artificial nutrition and hydration. ANH may improve the survival and quality of life of some patients such every bit farthermost curt bowel syndrome, bulbar amyotrophic lateral sclerosis, and in the acute phase of some affliction such as stroke or caput injury. It may improve the nutritional condition of patients with nutritional problems. Still, the evidence for the benefits of ANH is insufficient. ANH is associated with considerable risks such as the aspiration pneumonia, diarrhea, and gastrointestinal discomfort.^23,24

In patients with avant-garde cancer, dehydration can cause symptoms such every bit fatigue, myoclonus, and delirium that impair quality of life, and sedation or agitation due to aggregating of active metabolites of opioids. Withal, the benefit of parenteral hydration in these patients is controversial. In a randomized controlled report, Bruera et al.²⁵ investigated the effect of parenteral hydration on quality of life and survival in cancer patients receiving hospice care. Information technology was found that hydration at ane L per day did not improve symptoms, quality of life, or survival compared with placebo. Johnston et al. conducted a study to determine factors associated with death after the percutaneous endoscopic gastrostomy (PEG) tube was inserted. In the study, 43% of the patients died inside a week. Of these patients, 70% died considering of respiratory disease. The expert panel considered that PEG tube insertion is futile in only 19% of the patients.²⁶

For these reasons, the benefits and possible harms of the intervention should exist explained to the patient or to the other conclusion-makers in detail before making the ANH decision. If a patient is incompetent, his or her proxy decision-maker tin decline artificial feeding and hydration on behalf of the patient.^9,21–23

Terminal sedation is a medical intervention used in patients at the end of life, commonly as a last endeavor to relieve suffering when decease is inevitable. Sedatives are used for terminal sedation.^five,nine People have some concerns about concluding sedation considering the treatment of an unconscious patient is sensitive and risky. The purpose of concluding sedation is not to cause or advance death simply to alleviate pain that is unresponsive to other means. In that location are 4 criteria for evaluating a patient for terminal sedation.^5,nine According to the Center for Bioethics at the University of Minnesota, iv criteria are required for a patient to be considered for terminal sedation.^5,9

1. The patient has a terminal illness.

2. Severe symptoms are present, the symptoms are not responsive to treatment, and the symptoms are intolerable to the patient.

3. A "do non resuscitate" order is in effect.

4. Death is imminent (hours to days).

Some medical interventions in cease-of-life care can save or prolong a patient's life. All the same, patients and their family members are oftentimes faced with decisions most when and if these treatments should be used or if the treatments should be withdrawn.^2,9 The terms withholding and withdrawing tin be dislocated with each other. Withdrawing is a term used to hateful that a life-sustaining intervention presently being given is stopped. Withholding is a term used to mean that life-sustaining treatment is not initiated or increased.^21,22

The decision to withhold or withdraw interventions or treatment is one of the hard decisions in terminate-of-life intendance that causes ethical dilemmas. If a patient and medico agree that in that location is no do good in continuing an intervention, the right action is withholding or withdrawing the interventions. Still, the doc must be skilled to manage this word sensitively. For this, physicians must take patient-centered and family unit-oriented advice skills. Respect for the autonomy of a patient seeking to continue or initiate treatment should exist questioned when it would lead to enormous harm, the unnecessary or unequal distribution of resources, or activeness requiring the physician to deed illegally.²³ In most countries, the legal opinion is that patients cannot seek treatment that is not in their best involvement and, that physicians should non strive to protect life at all costs. However, if there is doubt, the decision must be in favor of preserving life. All healthcare professionals should be able to define an ethical approach to making decisions about withholding and withdrawing treatment that takes into account the law, authorities guidance, evidentiary base, and available resources.^14,22,23,27

Physicians must be aware of their patients' chapters, beliefs, and preferences, too as their clinical condition.^2,9

For many decades, euthanasia and PAS have been discussed in the context of terminal intendance in mod societies. The ethics and legality of euthanasia and PAS proceed to be controversial.²⁸

Euthanasia is practical in two means as active or passive euthanasia. In active euthanasia, a person (more often than not a physician) administers a medication, such every bit a allaying and neuromuscular relaxant, to intentionally end a patient'due south life at the mentally competent patient'southward explicit request. Passive euthanasia occurs when a patient suffers from an incurable illness and decides not to apply life-prolonging treatments, such as artificial nutrition or hydration. In PAS or doc-assisted death, a physician provides medication or a prescription to a patient at patient'due south explicit request, with the understanding that the patient intends to use the medications to end his or her life.^28–30

From a global perspective, there are countries (or states) where euthanasia and PAS are accepted and legal and others where they are notwithstanding offenses. In countries where euthanasia and PAS are legal, a physician has the correct to refuse a patient'southward request.²⁸

At the present time, active euthanasia is legal in five countries (Belgium, the Netherlands, Luxemburg, Canada, and Colombia), although the laws of these countries differ considerably regarding practices. Passive euthanasia is legal in 12 countries (Belgium, the netherlands, Luxemburg, Switzerland, Germany, Austria, Kingdom of norway, Sweden, Espana, Canada, Colombia; and Mexico, Argentina, and Republic of chile). PAS is legal in seven countries (Belgium, kingdom of the netherlands, Luxemburg, Switzerland, Deutschland, Finland, Canada, and Japan). In the Us, active euthanasia is illegal, but PAS is legal in 10 states (Oregon, Washington, Vermont, California, Colorado, Washington, DC, Hawaii, New Jersey, Maine, and Montana).^30–32 In countries other than Belgium and holland, the right to euthanasia applies to individuals aged 18 and older. There is no age limit for euthanasia requests in Belgium. In holland, people aged 12 and older who run into the necessary conditions can asking euthanasia.^30,31

Ethical controlling in unlike healthcare settings

Unlike difficulties can be experienced when applying ethical principles in dissimilar healthcare settings where end-of-life care is provided.

Emergency departments (EDs) are settings where healthcare services are provided to terminally ill and seriously ill patients, as well as potentially treatable patients. The goal of healthcare services provided in EDs is to refer patients to an advisable service after treating urgent issues and stabilizing the patients. EDs are not suitable environments in which to provide a dignified death process.^33,34 Nevertheless, family unit members of dying patients can bring the patients to an ED when they feel incapable of managing the death process at home.³³

In EDs, decisions frequently need to be made in a short fourth dimension. Emergency physicians face numerous challenges when managing the clinical care of patients at the end of life. The most of import ethical trouble faced by emergency physicians in end-of-life care is making ethical decisions on issues such as whether to perform resuscitation and go along life-sustaining treatment in cases where the patients are non competent to make decisions.^33,34

Emergency physicians aim to support life through all possible means unless an AD requests otherwise. The Royal College of Emergency Medicine published a best-practice guide for end-of-life care for adult patients in EDs. In the aforementioned guidelines, it is stated that "the best treatment option is the one that provides the most full general benefit and is the least restrictive for the patient'due south future choices, and patients and their families should be involved, wherever possible, in cease-of-life care decisions."³⁵

If a patient is unable to make his or her own decisions about wellness intendance and has an Advert or has appointed a health intendance proxy, the decisions are based on these documents. In cases where there is no AD or appointed health care proxy, family members must determine. Physicians and family members or health intendance proxies sometimes may not hold on medical decisions. In these cases, physicians should human activity according to the decision of ethics committees or the laws of the state.^34,35

In pediatric EDs, most terminal patients lack conclusion-making capacity due to their age and medical condition. Decisions for a child should be made in the context of the child's best interests. A conclusion of "best interests" involves weighing the benefits, burdens, and risks of treatment to achieve the all-time possible outcome for the child or adolescent.^36–39

In nigh countries such as the U.s.a., United Kingdom, and Turkey, legal and medical decision-makers are the parents or legal guardians of the children. Mostly, physicians and determination-makers on behalf of the child concur on cease-of-life care decisions. Notwithstanding, sometimes at that place is disharmonize over decisions. If a child'southward physician thinks that the family or legal guardian's determination is not the all-time decision for the child, the physician tin utilise to ideals committees or courts.^36–39

Most dying pediatric patients receive intendance in hospitals, often in pediatric ICUs. Decisions regarding the stop-of-life care of children are made in accordance with ethical principles and the laws of the relevant land.^36,37

Children under the age of xviii years are not legally considered competent to make that determination. However, in some countries such as the Us, pregnant women, married women, children living independently and away from their families, and financially independent children are considered to be able to make their own decisions. It is accepted that children above the age of 6 should be informed about decisions regarding their end-of-life intendance and that their preferences should be taken into business relationship in the decision-making process, fifty-fifty if they cannot make their own care decisions.^35–39

Pediatricians sometimes face ethical dilemmas and difficult decisions in the care of children at the cease of life.^37,forty Often, parents concur with the communication of physicians. However, an upstanding dilemma can arise when there is a disagreement near the care plan. Ethical dilemmas can arise in deciding whether to administer narcotics for the cessation and/or withdrawal of medical interventions and in decisions regarding the accurateness and administration of narcotics for pain and symptom direction. Almost hard situations can be managed with constructive communication inside the medical team or between the squad and the patient/family unit.³⁸ Providing families and children with clearly explained and understandable verbal and written information specific to the children's individual circumstances and their management can enable the families and children to better assess the state of affairs. When hard decisions need to be fabricated about end-of-life care, giving children and their parents or legal guardians sufficient fourth dimension and opportunities for discussions tin can also assist resolve problems.^39–41

Parental decisions are not accented. In circumstances where a parent makes a decision that could potentially harm a kid, the physician can seek assistance from the institution's ideals committee if the physician is concerned that the determination is not in the all-time interests of the child. Going to court can be an pick of last resort when the medical team believes that a family'southward decisions are reaching the bespeak of being harmful to the kid.^15,37,38

Elderly individuals represent the near apace growing segment of the population. Many chronic, life-limiting diseases such equally avant-garde cancer, neurodegenerative diseases, and organ or system failure occur in elderly individuals. In add-on, many elderly people take cognitive impairments such every bit dementia that affect decision-making.^42–44

Several ethical issues arise in the intendance of elderly patients at the cease of life. At that place is much common basis based on the application of the four major principles of medical ethics: nonmaleficence, beneficence, autonomy, and justice. The goal of end-of-life care for elderly people is to improve their quality of life, helping them cope with illness, disability, death, and an honorable death process. These goals should be accomplished by because these ethical principles.^41–44

Physicians who provide care to elderly patients with a final illness should discuss the goals of care with the patients and family unit surrogate decision-makers. This discussion provides valuable information to the physicians and the patients' conclusion-makers about what kind of care the patients desire to receive at the end of life and what kind of death they prefer. Physicians should be encouraged to advance life planning for their elderly patients.^4,41–44

At that place are some features of upstanding determination-making in ICUs. It is important for physicians working in ICUs to distinguish betwixt treatable patients and those in the terminal period. In the care of a dying patient in an ICU, after the emergency situations are resolved, the patient'southward care should be reevaluated. In this planning, decisions are fabricated for the side by side phase of care of the patient. Ideally, this decision-making process is a shared decision-making model in which the doctors and patient or the patient's proxy share information with each other and participate jointly in the controlling procedure.^45–48

Information technology is very of import to empower the family and, if possible, the patient to participate in this conclusion. The patient and his or her family unit members/care proxy should exist assisted in making decisions through explanations of the patient's condition, possible interventions, and the results of those interventions in clear and understandable linguistic communication. The ethical principle of autonomy supports the legal requirement for informed consent.^45–48

Physicians working in ICUs may confront ethical dilemmas in decision-making regarding end-of-life care. They should brand finish-of-life intendance decisions according to the bones ethical principles (autonomy, beneficence, nonmaleficence, and justice).⁴¹ Co-ordinate to the autonomy principle, patients have decision-making priority. However, many critically sick patients in ICUs do non accept the capacity to brand decisions. In such cases, if the patients have an Advertising or health care proxy, decisions are fabricated according to those documents. If at that place are no such documents, the decision-making falls on the patients' family members. When there are disagreements betwixt family members, a family meeting can be helpful.^46–48

Physicians sometimes recall that the decisions made past family unit members are not the most appropriate decisions for the patients. In cases of conflict betwixt intensive care teams and family members, assistance from institutional ethics committees may exist sought.⁴⁸ In a study by Schneiderman et al.,⁴⁹ it was found that ethical consultations help resolve conflicts.

Palliative care and hospice intendance

Most people express a preference for dying at home.^l However, various factors may make it impossible to deliver quality end-of-life intendance in the patient's dwelling. In contempo years, palliative care and hospice programs that provide intendance for terminal patients accept gradually improved.

The World Health Organization (WHO) defines palliative care as an arroyo that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early on identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.⁵¹

Palliative care is given by an interdisciplinary team. In its written report "Dying in America," the American Medical Institute (Plant of Medicine (IOM)) emphasizes that all physicians in disciplines and specialties that care for people with terminal disease should be competent in basic palliative care skills, such as person-centered and family-oriented advice skills, professional cooperation, and symptom direction.⁵²

Palliative care, including hospice, equally an established approach providing the best possible quality of life for people of all ages who have an advanced serious disease or are likely approaching expiry. The main goal is to prevent and salvage suffering, to improve quality of life for both the patient and the family.^43,52 Control of symptoms such as pain, shortness of breath, nausea, constipation, anorexia, insomnia, anxiety, depression, and defoliation should exist addressed with the patient and family.^53,54

Considering psychological, spiritual, and social factors may all affect the perception of symptoms, psychosocial distress, spiritual issues, and practical needs should be handled appropriately according to the preferences of patients and their families.⁵⁵ In palliative care, the care plan is determined co-ordinate to the goals of the patient and family with the guidance of the multidisciplinary health care team, and is regularly reviewed.^53,55

Hospice is an essential approach to address the palliative intendance needs of patients with limited life expectancy and their families. Hospices are an important component of palliative care. Hospice intendance focuses primarily on symptom command and psychologic and spiritual support for dying patients and their families.^43,52 Hospice teams' goal is to make the patient as comfortable as possible in the end of life. Hospice can be provided in any setting, including patients' homes, nursing homes, hospitals, and a separate hospice facility.^55,56 In add-on to patient intendance, the interdisciplinary team provides support to the principal caregiver or family unit fellow member who is responsible for the majority of the patient care.^55,57 Hospice team may provide emotional and spiritual support, social services, nutrition counseling, and grief counseling for the patients and their families.

Studies have shown that palliative care results in improved quality of life with less acute health care use and in moderately lower symptom burden compared to routine care.⁵⁸ A meta-analysis on hospice care take likewise shown that hospice care increases the quality of life and life expectancy for terminal ill patients.⁵⁹ Therefore, health care providers who will treat concluding patients must take primary palliative intendance skills. In add-on, for all patients to benefit, hospice care must be covered past health insurance in all countries.

All ethical principles should too exist taken into account in palliative care commitment. Nevertheless, the near considered ethical principles are beneficence and nonmaleficence. Beneficence emphasizes on relieving the symptoms that impair the quality of life of a dying person. Nonmaleficence emphasizes on relieving the symptoms that can actually impairment the patient.⁵⁶

In palliative care setting, the end-of-life decision mentioned above (CPR, MV, ANH, terminal sedation, withholding and withdrawing handling) may need to be taken. The application of the ethical principles in palliative conclusion-making is required to achieve a comfortable end-of-life period for patients.^53,56

Conclusion

The goal of end-of-life care is to prevent or salvage suffering as much as possible while respecting the desires of dying patients. However, physicians face up many ethical challenges in stop-of-life care. Since the decisions to be fabricated may concern patients' family members and society as well as the patients, it is important to protect the rights, dignity, and vigor of all parties involved in the clinical ethical decision-making procedure. Open communication and shared decision-making among health intendance providers, patients, and families would avert many of the upstanding dilemmas at end-of-life care.

Limitations

At that place are unlike beliefs, traditions, and legal regulations that touch on the application of ethical principles in different societies. This article discusses universal upstanding principles accepted in terminate-of-life intendance; all the same, the application of ethical principles in different societies is not mentioned. In addition, the role of unlike healthcare professionals in end-of-life care has non been discussed.

Footnotes

Declaration of conflicting interests: The author(southward) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The writer(s) received no financial support for the research, authorship, and/or publication of this commodity.

ORCID iD: Melahat Akdeniz https://orcid.org/0000-0003-0792-8701

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7958189/