ETHICS, PALLIATIVE CARE

IN THE END OF LIFE

Problems: surgeons are confronted with clinical or
interpersonal situations:
• Incomplete information
• Uncertain outcomes
• Complex personal and familial relationships

BIOMEDICAL ETHICS
Guiding to “good practice” of surgery
with 4 principles:
 autonomy
 beneficence
 nonmaleficence
 justice
• Autonomy: respects the capacity and the right of
individuals to make choices about their medical
care and physician have to permit it

• Beneficence: any action of physician aims at and

achieve something good

• Maleficence: aims at avoiding concrete harm:

primum non nocere

• Justice: fairness where both the benefits and

burdens of a particular action are distributed
equitably
 Solving ethical dillemas:
• clarify the relevant principles (e.g., autonomy,
beneficence, nonmaleficence, and justice) and values
at stake (e.g., self-determination, quality of life, etc.).
• patients and surgeons together choose the best course
of action

PRACTICAL WISDOM

Practical Wisdom (Greek:phronesis) : Capacity to choose

the best option from among several imperfect
alternatives
(Aristotle)
 ISSUES IN SURGICAL ETHICS

1. Informed Consent

2. The Boundaries of Autonomy: Advanced Directives

and Powers of Attorney

3. Withdrawing and Withholding Life-Sustaining

Therapies
Informed Consent

Adequate informed consent entails at least four basic

elements:
1. The physician documents that the patient or surrogate
has the capacity to make a medical decision
2. The surgeon discloses to the patient details regarding the
diagnosis and treatment options sufficiently for the
patient to make an informed choice
3. The patient demonstrates understanding of the disclosed
information before
4. Authorizing freely a specific treatment plan without
undue influence
Challenge In Informed Consent:

• Emergency Surgery
• Decisions are often made with incomplete
information  limits patient autonomy
• Surgeon consider possibility of life saving and if and if
successful, what kind of disability might be
anticipated
• Initial Resuscitation of injured patient
• Consent in pediatric population
• Consent in certain religious practices or beliefs
• Consent for Organ donation
• Limitation of patients capacity to assimilate information
in the context of their illness  misinterpretation
The Boundaries of Autonomy

• Ethical dillema to determined the best option for medical

care for patient with severe illness and impending deaths.
Living willness of patient (formal document)
Vs
privileges of surrogate / family

• Patients should be encouraged to clearly identify their

surrogates, both formally and informally, early in the course
of treatment, and before any major elective operation

• Misinterpretation of DNR
Reluctance around physician-patient agreement about DNR may
reflect patient and family anxiety that DNR orders equate to “do not
treat
Withdrawing and Withholding Life-Sustaining Therapies

Under the principle of

double effect, a physician
may withhold or withdraw a
life-sustaining therapy if the
surgeon’s intent is to relieve
suffering, not to hasten
death  beneficence, non-
maleficence
 PALLIATIVE CARE

• Palliative care is a coordinated, interdisciplinary effort

that aims to relieve suffering and improve quality of life
for patients and their families in the context of serious
illness.

• The standard of palliative treatment :

Physycian-patient agreement that the expected
outcome is relief from distressing symptoms, lessening of
pain, and improvement of quality of life.
Pain : An unpleasant sensory and emotional
experience associated with actual or potential
tissue damage, or described in terms of such
damage.

Total Pain is the sum total of four principal

domains of pain: physical, psychologic, social or
socioeconomic, and spiritual.

The relief of pain has been the clinical foundation

for hospice and palliative care.
 Fundamental elements of palliative
care:
• Pain and nonpain symptom
management
• Communication among
patients, their families, and care
providers
• Continuity of care across health
systems and through the
trajectory of illness.
• Spiritual and psychosocial
support for patients, their
families, and care providers,
• Bereavement support.

Effective Communication is needed in giving bad news: to change the goals

of care from cure to palliation near the end of life.

Some tools provide prognostic rate to help communicate bad news:

APACHE, MODS, performance status in cancer patient (Karnofsky or ECOG)
 PROFESSIONAL ETHICS
Requirement for surgical and clinical research to be ethically sound:

a. Value— enhancement of health or knowledge must be derived from the

research
b. Scientific Validity—the research must be methodologically rigorous
c. Fair Subject Selection—scientific objectives, not vulnerability or privilege, and the
potential for and distribution of risks and benefits, should determine communities
selected as study sites and the inclusion criteria for individual subjects
d. Favorable Risk-benefit Ratio—within the context of standard clinical practice and
the research protocol, risks must be minimized, potential benefits enhanced, and
the potential benefits to individuals and knowledge gained for society must
outweigh the risks
e. Independent Review—unaffiliated individuals must review the research and
approve, amend, or terminate it
f. Informed Consent—individuals should be informed about the research and
provide their voluntary consent
g. Respect For Enrolled Subjects—subjects should have their privacy protected, the
opportunity to withdraw, and their well-being monitored