8.

End of life decisions

 End of life decision
 Advances in medicine have greatly improved possibilities to
treat seriously ill patients and to prolong life
 However, there is increasing recognition that extension of life
might not always be an appropriate goal of medicine and other
goals have to guide medical decision-making at the end of life,
 such as improvement of quality of life of patients and their
families by prevention and relief of suffering.
 end-of-life issues range from attempts to prolong the lives of
dying patients through highly experimental technologies, to
terminate life prematurely through euthanasia and medically
assisted suicide

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 End of life decision…
Medical end-of-life decisions, in principle, include:
1. whether to withhold or withdraw potentially life-prolonging
treatment- e.g. mechanical ventilation, tube-feeding, and
dialysis;
2. whether to consider euthanasia or doctor assisted suicide,
which can be defined as the administration, prescription, or
supply of drugs to end life at the patient’s explicit request;
and
3. whether to relieve pain and manage other symptoms
effectively with, for example, opioids, in doses large enough
to hasten death as a possible or certain side effect

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 End of life decision…
 Euthanasia driven from the Greek for “good death”
 knowingly and intentionally performing an act that is clearly
intended to end another person’s life to keep a person with
incurable disease from suffering
 Euthanasia includes the following elements:
 the subject is a competent, informed person with an incurable

illness who has voluntarily asked for his or her life to be

ended;
 the agent knows about the person’s condition and desire to

die, and commits the act with the primary intention of ending
the life of that person; and
 the act is undertaken with compassion and without personal

gain
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Euthanasia - active vs. passive
 Active euthanasia “killing” and “letting die”
 occurs in those instances in which someone takes active

means, such as a lethal injection, to bring about death;

 Passive euthanasia
 the deliberate omission of an act that, under normal and

expected circumstances prolong life

 the withholding or withdrawing of interventions necessary to

keep the patient alive

 “letting nature take its course” - the disease, not the doctor, has

killed the patient

 Example

 refrain from resuscitating someone who we think could

 stop supplying fluids and nutrition

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Euthanasia…
 Typical case for active euthanasia
 there is no doubt that the patient will die soon
 the option of passive euthanasia causes significantly more pain for
the patient (and often the family as well) than active euthanasia and
does nothing to enhance the remaining life of the patient, and
 passive measures will not bring about the death of patient
 Voluntary vs. involuntary euthanasia
 Direct voluntary euthanasia: the patient make the choices
 Indirect voluntary euthanasia: responsible surrogates make the
choices
 Involuntary euthanasia: the physician, without consultation with
patient or legitimate decision-maker, acts by himself???

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Assistance in suicide
 Assistance in suicide means knowingly and intentionally
providing a person with the knowledge or means required to
commit suicide, including counselling about lethal doses of
drugs, prescribing such lethal doses or supplying the drugs
 Euthanasia and assisted suicide are often regarded as morally
equivalent, although there is a clear practical distinction
 it is physician-assisted suicide when the physician provides a
client with a lethal dose of medication so that the client can self-
administer the medication - the agent of death is the patient
 it is active euthanasia when a physician administers a lethal dose
to the client - the agent of death is the clinician

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 Assisted suicide and euthanasia
 In case of either physician assisted death or euthanasia, the
physician is active and involved; however, in both cases the client
decides whether to ask for the medication
 The client or close relatives make the choices in dying
 In physician-assisted death, the client acts last, whereas in active
euthanasia, the physician acts last
 requests for euthanasia or assistance in suicide arise as a result of
pain or suffering that is considered by the patient to be intolerable
 they would rather die than continue to live in such circumstances
 furthermore, many patients consider that they have a right to die
if they so choose, and even a right to assistance in dying

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 Assisted suicide and euthanasia…
 physicians are regarded as the most appropriate instruments of
death since they have the medical knowledge and access to the
appropriate drugs for ensuring a quick and painless death
 physicians are understandably reluctant to implement requests
for euthanasia or assistance in suicide because these acts are
illegal in most countries and are prohibited in most medical
codes of ethics
 the rejection of euthanasia and assisted suicide does not mean
that physicians can do nothing for the patient with a life-
threatening illness that is at an advanced stage and for which
curative measures are not appropriate

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 Assisted suicide and euthanasia…
 In recent years there are great advances in palliative care treatments
for relieving pain and suffering and improving quality of life
 Palliative care can be appropriate for patients of all ages, from a
child with cancer to a senior nearing the end of life
 Aggressive palliation have two possible effects, one positive (e.g.,
pain relief and one negative (e.g., depression of respirations),
 when the intent is palliation, the action is considered medically,
ethically, and legally justified under the doctrine of double effect
 physicians should not abandon dying patients but should continue to
provide compassionate care even when cure is no longer possible

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 Assisted suicide and euthanasia…
 the possibility of prolonging life through recourse to drugs,
resuscitative interventions, radiological procedures and intensive
care requires decisions about when to initiate these treatments
and when to withdraw them if they are not working
 medical decision-making for patients with life threatening
diseases increasingly entails a balanced consideration of medical,
ethical, psychosocial, and societal aspects
 arguments supporting or opposing assisted suicide are generally
made from several frames of reference
 these include ethical and moral arguments, legal arguments, and
medical arguments

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Arguments in support of assisted suicide
 Ethical and moral arguments
 competent patients have the right to refuse any medical treatment,
even if the refusal results in their death
 principle of autonomy states that persons should have the right to
make their own decisions about the course of their own lives
 they should also have the right to determine the course of their
own dying as much as possible
 When the burdens of life outweigh the benefits because of
uncontrollable pain, severe psychological suffering, loss of
dignity, or loss of quality of life as judged by the patient,
 if there is appropriate evaluation of decisional capacity

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 Arguments in support of …

 Legal arguments state that it would be in the best interest

of dying patients to be able to regulate practices that are
currently being used covertly for assisted suicide

 Medical arguments contend that competent terminally

ill patients wishing to choose assisted suicide may feel
abandoned by physicians who refuse to assist

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 Arguments in opposition to assisted suicide
 Ethical and moral arguments
 the principle of protection of the socially and economically
disadvantaged
 persons whose autonomy and well-being are compromised by
poverty or by membership in a stigmatized social group, will be
coerced into assisted suicide
 the pressure to choose suicide may not be explicit and personal
 many seriously ill persons may not have the resources necessary
for implementation of the choice to live
 the principle of respect for human life and the related beliefs
that killing is wrong, even if a person consents to it

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 Arguments in opposition to…

 Legal arguments against assisted suicide include

concerns about civil suits resulting from premature or
unnecessary termination of life following a diagnostic
error or incorrect prognosis

 There are also concerns about enforcement of legal

procedures devised to prevent against misuse, abuse, and
improper application or coercion in assisted suicide

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 Arguments in opposition to…
 Medical arguments against assisted suicide
 the possibility of misdiagnosis, the potential availability of
new treatments, and the probability of incorrect prognosis,
because medicine is fallible and research is ongoing
 requests for assisted suicide may indicate that improved
palliative care, aggressive pain management, and better
psychosocial support are needed
 it poses serious societal risks, such as ill persons' feeling
abandoned or losing trust in the health care system if
providers participate in this practice

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 Arguments in opposition to…
 Arguments regarding slippery slope
 once assisted suicide is accepted as an available option for
competent terminally ill adults, it may be permitted for ever
-larger groups of persons, including the non terminally ill
 those whose quality of life is perceived to be diminished by
a physical disability, persons whose pain is emotional
instead of physical, and so forth
 critics point to the fact that permitting euthanasia and assisted
suicide, as is done in the Netherlands, does not prevent
violation of procedures (e.g., failure to report) or abuse (e.g.
involuntary euthanasia)

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 Arguments in opposition to…

 Assisted suicide and euthanasia in Netherlands 1990,

 130,000 deaths
 2300 (1.8%) were the result of euthanasia.
 400 (0.3%) were assisted suicides
 1,000 deaths (0.8%) caused by euthanasia in which the patient
was not concurrently competent, a clear violation of the
guidelines
 About a quarter of the physicians admitted causing death
without an explicit request

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