Palliative Care and Ethics

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Major evolution and developments in medical ethics were made since 20 th century. The betrayal of scientific medicine's ideals during the Second World War by Nazi doctors, in carrying out inhuman medical practices amounting to torture and killing of innocent prisoners, lead to the Nuremberg trial in The Nuremberg code was issued and this is considered the basis of modern medical ethics. These laws and policies are provided by Declaration of Geneva , last modified in and further incorporated in Declaration of Helsinki , last modified in October The foundation of medical ethics is supported by four pillars, namely;.

Added to the above four, are two more aspects which form the cornerstones of medical practice:. Dignity - the patient and the persons treating the patient have the right to dignity. The lady with ovarian cancer, narrated at the beginning who had earlier been treated by chemotherapy could be offered second-line of aggressive chemotherapy. Is this the only option?

Medical Ethics and Palliative Care

This exemplifies the need for patient's autonomy, beneficence vs. It is known that timely institution of palliative care alleviates the distressing symptoms in terminal stages of diseases, avoids toxicities of questionable anti-cancer therapy, and improves the quality of remaining life. The treating palliative care team may face conflicts in terms of patient's family carer refusing to stop the toxic anti-cancer therapy.

Hence effective communication and explanation of the disease process is the key to ethical palliative care.

Clinical and Ethical Issues in Palliative Care and Dementia – An Overview

The team should be knowledgeable to give proactive care, understand the patient's preferences and forgive conflicts. The process of truth telling in advanced cancer or any other terminal illness can be a difficult task. Whenever a patient is too moribund and not in a suitable mental stage, the family carers are required to give informed consent. The doctor and nurse in the palliative care team have to build the communication with a responsible family carer so that confidentiality and dignity for patient's last stage are maintained.

The lady with progressive ovarian cancer has fluid in abdomen and chest, and may not get a regular appetite. The husband could feel distressed that she is going to die in hunger.

This needs a good explanation to alleviate the conflict regarding forced feeding in a terminal stage of cancer. Effective and compassionate communications are the integral components of ethics are in palliative care. Pain relief is successfully achieved by the scientific and holistic principles of analgesic ladder in palliative care. Lack of knowledge and skill in pain assessment, improper medication, unavailability of morphine, unfounded myths about opioid addiction and sedation are some of the complex hurdles. It is now recognized in most countries that relief from pain is a legal right and availability of morphine is a societal responsibility.

For ethical reasons, the correct step would be to view pain as a public health crisis, and take the necessary steps to remove all hurdles. The public fear that drugs such as sedatives and opioids prescribed in the terminal stage of a patient hasten the death process.

Keele University - Medical Ethics and Palliative Care

It is ethical to prescribe narcotics and sedatives for intractable pain, even when there is the possibility of terminal sedation. Morphine calmed him down; he felt relieved, could sleep soundly, and passed away peacefully after two weeks. End-of-life care is both a medical and an ethical challenge. In the last part of life, with multiple distressing symptoms, infection, anorexia-cachexia, fatigue, mental confusion etc, deciding the right place of care is the first priority.

Whenever possible, a good death is when it comes at the patient's home, surrounded by family members and relatives. Hence, advance care planning should be recorded. In India, home care will be less expensive and a more practical approach to offer palliative care at the door-step. There can crop up certain contentious issues like use of antibiotics, supportive drugs, blood transfusion, naso-gastric tube, parenteral nutrition, intensive care etc.

Wherever possible, the patient's preferences should be balanced with palliative care principles. Advance directives in the form of recording the patient's or family's consent should be routinely practiced. This will avoid the terminal palliative care patient being subjected to unnecessary tests, hospitalization, intensive monitoring, and resuscitation procedure. In many countries of the world, do-not-resuscitate DNR policy is well founded in end-of-life care. Of course, this is not yet a routine in India. Legal aspects and human rights give the fundamental protections that allow equal participation and individual justice in a society.

In the 20 th century, the right to healthcare is well-established, encompassing not only the delivery of basic clinical services but also an environment that allows good health to flourish.

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However, euthanasia poses an ethical dilemma in palliative care. It is interesting to note that the spread of palliative care, use of analgesics, and effective prescription of terminal sedation even in the face of double effect have reduced the need for euthanasia, in a recent Dutch study.

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Can one be given oral morphine and the other fentanyl skin patch for two weeks to assess pain and symptom relief? Good medical practice requires evidence of effectiveness to address deficits in care. There are substantial opportunities to improve palliative care. However, a treating physician can face dilemmas, because research that involves patients near the end of life creates numerous ethical challenges. Risks and benefits of palliative care research are difficult to assess.

In practice, the dying of an incurable patient is medically recognized as a natural process. The patient can experience dynamic changes in physical and psychosocial symptoms. Palliative care physicians and nurses should address existing deficits. Balancing the ethical principles in terms protecting the vulnerable patient from harm and at the same time carrying out scientifically designed studies should be possible. Palliative care is mandated in advanced stage incurable cancer and other terminal chronic illnesses. The different aspects of palliative care such as pain and symptom control, psychosocial care, and end-of-life issues should be managed in an ethical manner.

The cardinal ethical principles to be followed are-autonomy, beneficence, non-maleficence and justice. The palliative care experts and team members should carry out their responsibilities with honesty and dignity. Henk ten Have : "The importance of humility".


Invited presentation in Symposium in honor of Dr Edmund D. Edmund Pellegrino and the Ethics of Health Care. Henk ten Have : "Palliative sedation and ethics. Duquesne University, Pittsburgh, May 17, This website is best viewed in a modern browser with Javascript enabled.

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When the Beginning is the End: Ethical and Practical Issues in Neonatal End-of-Life Care

Palliative Care Ethics Dr. Henk ten Have The debate on end-of-life care continues to be an important area of research in bioethics. Publications Henk ten Have : Palliative care. Presentations Henk ten Have : "Cultural views of death and dying".