Ethical decision-making in surgical ICU end-of-life care

Ethical Decisions in a Patient's Right to Die

DYING AS AN OPTION

Ethical Decisions in a Patient's Right to Die

Studies showed that 29% of terminally ill and severely suffering patients make end-of-life decisions and 21% of them actually die afterwards. The rest of them seek termination of treatment, DNR or the withdrawal or withholding of life support. Age, a diagnosis of sepsis or cirrhosis, seriousness of illness and transfer from another hospital constitute common factors in the decisions. The rule of double effect enhances pain management but must develop from moral integrity. If the patient's family or guardian feels it is in the patient's best interest to withdraw or withhold life-sustaining treatment, the witness of the attending physician and the management of the health facility must be obtained and given due course.

Review of Literature

Epidemiology

A large study showed that 29% of patients who die in surgical intensive care units make end-of-life decisions in some form (Meissner et al., 2010). About 21% of deaths occurred after the decisions are made, 16 times more in cases of severe sepsis and/or septic shock than any other cases. Of the total, 2.7% made end-of-life decisions, 1.6% reached a DNR order, and 1.1% withdrew life support. Age, a diagnosis of sepsis or cirrhosis, seriousness of illness, and admission from another hospital were determining factors. The study surveyed 14,720 patients at the surgical intensive care units at the Friedrich Schiller University Hospital in Germany between September 2002 and July

2006 (Meissner et al.).

The study sought to identify the possible factors associated with end-of-life decisions in surgical ICUs in view of the increasing incidence of these decisions in these settings (Meissner et al., 2010). It has been observed that deaths follow in 60-80% of cases when life support is withdrawn. DNR or do-not-resuscitate orders are also resorted to in critical care settings prior to end-of-life care. Only 20% of patients who die in the ICU undergo cardiopulmonary resuscitation. The main findings were the prevalence of end-of-life decisions among surgical ICU patients; only 3.5% who made such decisions were eventually discharged; the decisions correlated with the severity of sepsis and/or septic shock at 51%; and older age, admission from another hospital, and a diagnosis of cirrhosis, sepsis and severe sepsis or septic shock (Meissner et al.).

Case Study: the Portuguese Intensive Care Society

Probability of survival and the patient's wishes were the chief criteria, which influence end-of-life decisions and decisions to withhold or withdraw treatment (Cardoso et al. 2003). This was the finding of a survey conducted with 175 Portuguese intensive care physicians belonging to the Portuguese Intensive Care Society. DNR orders were used in their ICUs along with 98.3% to withhold treatment and 95.4% to withdraw treatment. These decisions were made only by the medical groups in most of the respondent ICUs. Many respondents, however, hoped they could be more involved in the undertaking. The gender, experience and religious beliefs were also influencing factors.

Fewer than 15% of the respondents said they involved nurses, 9% patients and less than 11% patients' relatives in making end-of-life decisions. Those with more than 10 years experience involved nurses in these decisions. Agnostic or atheist doctors involved patients' relatives in deciding to withhold or withdraw treatment (Cardoso et al.).

Terminal Sedation

This is treatment resorted to when other palliative treatments fail to be adequate

(Bimbacher 2007). It is meant to keep a severely pained patient unconscious while approaching death. It is indicated for agitation, fear of suffocating, vomiting, sleeplessness and severe pain states. The term sedation refers only to a temporal incidence of sedation and does not link sedation to subsequent death. It only helps the patient make his last moments easier without casually contributing to death. It helps in dying, but not helping to die. It is when combined with non-palliative medical treatment that it creates ethical problems, such as by being a form of euthanasia. Terminal sedation is used in combination with withdrawing or withholding life sustaining treatment or nutrition and hydration in addition to withdrawing or withholding life sustaining treatment (Bimbacher).

The interest of society in these matters lies in applying euthanasia to address terminal suffering and in preventing abuse and misuse of this treatment (Bimbacher 2007). It is much preferable to assisted suicide in terminating terminal suffering. Terminal sedation does not require the patient's capacity to move his limbs or to swallow, the availability of appropriate substances or outside assistance to provide them. The physician is much more involved and contributory in assisted suicide than in terminal sedation. It has been generally held that termination of treatment is morally acceptable when further treatment proves ineffective in improving his condition or allowing him to live with a quality of life he deems acceptable. Termination of treatment is generally permissible but not obligatory in most cases. When permitted, the physician is still bound by duty to relieve symptoms proceeding from the termination of treatment. It is, however, obligatory when treatment is clearly detrimental to the patient or when he refuses treatment. Termination of treatment under terminal sedation becomes unjustified when not primarily attuned to the patient's well-being but at that of relatives or caregivers. It is also objectionable when better alternatives exist about which the patient has not been informed. Finally, termination of treatment under terminal sedation can be resorted to if the patient himself objects to being sedated but prefers to live through the experience (Bimbacher).

Refusing Treatment

The patient's basic right to control the course of medical treatment is largely unchallenged and recognized for hundreds of years (King 2007). This is the substance of documents like The Living Will, Advance Directives and Health Care Proxy. The law provides that a competent adult has the absolute right to determine what should be done to his own body. The decision-making standard for his best interest derives from his wishes, including his personal beliefs. It clearly and explicitly recognizes his personal dignity and uniqueness in making choices for the preservation of his life, relieving his suffering and the use of palliative care and pain management. The guardian's responsibility is to make an informed decision in providing for healthcare. But in withholding or withdrawing life-sustaining treatment, the attending physician must attest to the patient's lack of capacity to make the decision. This is then entered as a medical record. That record must state that the patient's medical condition is terminal, irreversible and indefinite, involves permanent unconsciousness and that life-sustaining treatment would create tremendous or extraordinary burden on the patient. The guardian's decision to withdraw or withhold life-sustaining treatment must be filed with 2 witnesses, one of whom is the attending physician. The guardian may be a parent, adult sibling, healthcare provider, the CEO of the health facility or the commissioner of an agency in charge of mentally retarded who are terminally ill. Healthcare practitioners need to understand the state and local laws governing the delivery system. They should also reach out to the guardian who may be unaware of these laws. If refusing medical care is not allowed by these laws, guardians should resort to active lobbying (King).

Nurses' Values and Managing Pain and Ethics

Unprecedented medical advances view death as a disease that must be treated rather than as a natural event in life (Zomorodo and Lynn 2010). Sophisticated technological interventions enable Americans to live through chronic conditions for an average of 17 years. In the critical care unit especially, this view of death has separated the patient and family from the natural dying experience. As a result, they are rendered unaware of approaching death and unable to prepare for it. Death has come to be viewed as a medical failure. Healthcare professionals see the patient as a disease or condition instead of an individual with personal values and desires. He and his family are deprived of the patient-centered care they need precisely at the moment. Nurses, therefore, must include them in the decision-making process and help them through the technology used. Nurses need to provide that patient-centered care in order to improve the patient's quality of dying and raise the level of satisfaction on all sides (Zomorodo & Lynn). (Kirk 2007)

Home hospice nurses are not always able to fully meet their ethical obligations to patients (Kirk 2007). Often, the most these nurses can accomplish is incorporate the select family members into delivering the best palliative care possible. The use of evidence-based strategies does not guarantee that ensuing death will be free of symptoms and family members' full participation in the care. This is particularly the case when family members do not adequately palliate the patient and otherwise-treatable symptoms produce distress during the dying process. These failures often produce moral distress and a sense of failure in nurses (Kirk).

Point-of-View

When life no longer possesses the quality, which in the patient's estimation, makes it no longer worth living, the fundamental and ultimate right to die becomes entirely his. Terminal sedation becomes the preferable option to assisted suicide. It is not obligatory for physicians and facilities manager to assist a severely and terminally suffering patient in actively committing suicide. Yet good reasons exist that those managing his care are obliged to administer terminal sedation with the intention of saving him from symptoms, which accompany the termination of treatment. Simply stated, the patient has the right to demand terminal sedation in this case. This right is grounded in his strong interest in being relieved from severe and terminal suffering in his last moments and in expectation and pursuit of a peaceful death.