Chapter 58
Ethics and the End of Life
Copyright © 2021 Elsevier, Inc. All Rights Reserved.
Learning Objectives (1 of 4)
Describe the elements of the “goals-of-care
framework” and state the advantages of its
use in contributing to the care of seriously ill
patients approaching the end of life
Describe the ethical and legal significance of
the “right to refuse life-sustaining treatment”
and how it is applied in the care of seriously ill
patients at the end of life
Copyright © 2021 Elsevier, Inc. All Rights Reserved.
Learning Objectives (2 of 4)
Articulate the importance and contribution to
care of clinicians taking the time to know the
patient as person rather than only as a patient
Discuss the legal and ethical approaches to
end-of-life care,
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Learning Objectives (3 of 4)
Discuss the legal and ethical approaches to
end-of-life care, including the merits of the
concepts of euthanasia, physician-assisted
suicide, withdrawing and withholding life-
sustaining treatment, and palliative sedation
while also considering the distinctions
between these concepts
Describe an ethically defensible approach to
the management of pain and other symptoms
at the end of life in the setting of withdrawing
life-sustaining treatment
Copyright © 2021 Elsevier, Inc. All Rights Reserved.
Learning Objectives (4 of 4)
Describe and apply the rule of double effect
to a clinical case
Describe the role of the respiratory therapist
as a contributing professional on an
interdisciplinary team
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Introduction
Whenever a patient is seriously ill, “airway
and respiration” are of prime concern
The RT plays a key role in the patient’s care
Ø Plays his or her professional role by responding
with competence, compassion, and knowledge of
ethical practice
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“Goals of Care” as an Essential
Organizing Framework (1 of 2)
Developing goals of care requires:
Ø Physician leadership
Ø Input from medical and surgical physician
consultants
Ø RTs, nurses and allied health professionals
When a patient’s breathing is compromised,
his or her perception of this difficulty and its
physiologic impact can cause immense
distress and anxiety
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“Goals of Care” as an Essential
Organizing Framework (2 of 2)
The goals-of-care framework has three
components:
Ø The patient’s medical and rehabilitative prognosis
Ø The patient’s values, beliefs, and preferences
Ø Ethically and legally permissible care options
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Medical Prognosis and
Rehabilitative Prognosis
What is medically possible for the patient?
Can the opinions of medical and surgical consultants
be brought to bear on the “whole”?
What is the rehabilitation potential for the patient?
Are LSTs effective or likely to be effective in restoring
the patient’s functional status or at least restoring the
patient to a reduced yet acceptable functional status
and quality of life?
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Values, Beliefs, and Preferences
(1 of 3)
Ethics of care
Ø One approach that can guide ethical decision
making
In a goals-of-care framework
Ø An ethic of care is made tangible by considering
particulars, context, and relationships
Particulars
Ø “Who is this person (and family)?”
Ø What is important to her/him/them?
Ø What would a “good day” look like
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Values, Beliefs, and Preferences
(2 of 3)
Particulars
Ø What would “intolerable days” be like for the
patient?
Ø Quality of life—can it be projected for the patient?
Ø What religious, spiritual, and cultural beliefs
influence end- of-life decision making?
Context
Ø Where does this patient find herself or himself at
this time—what is immediately confronting the
patient in terms of utmost concern?
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Values, Beliefs, and Preferences
(3 of 3)
Relationships
Ø Almost all persons, particularly when ill and at the
end of life, look to the relation- ships that are
important in their lives
Ø RT should recognize that significant family and
friends may be in conflict with the patient but are
still important to him or her
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Ethical and Legal Parameters
(1 of 2)
Refusal of life sustaining treatment
Ø Critical for RTs to know what is ethically and
legally permissible in the state they practice
Ø RT must be aware of the ethical and legal
appropriateness of a physician’s orders in general
as well as in terms of the specific patient case.
Ø Ethically and professionally bound to question any
orders that are not congruent with acceptable
ethical and legal practices as well as hospital
policy
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Ethical and Legal Parameters
(2 of 2)
Refusal of life sustaining treatment
Ø Advanced directives
Ø Durable power of attorney for health care
decisions
Ø Withholding and withdrawing LSTs are rendered
as ethically and legally equivalent
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Management of Pain and Other
Symptoms (1 of 4)
Provision of palliative and comfort-oriented
care ought to be provided to patients in their
end-of-life time when goals of care define
such a pathway
Ø An ethically and legally defensible position is quite
relevant for the RT
When such LSTs are withdrawn, medications
are rightfully ordered to ensure the patient’s
comfort
Ø Understanding definitions is important
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Management of Pain and Other
Symptoms (2 of 4)
Definitions of end-of-life concepts
Ø Euthanasia
• The act of putting to death someone suffering from a
painful or prolonged illness or injury. Someone other than
the patient commits the action to end the patient’s life,
usually by the injection of medicine
Ø Assisted suicide
• The means to end a patient’s life is provided to the
patient with knowledge of the patient’s intention to use it.
Physician-assisted suicide connotes that a physician will
provide such means
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Management of Pain and Other
Symptoms (3 of 4)
Definitions of end-of-life concepts
Ø Palliative sedation
• The controlled and monitored use of nonopioid
medications intended to lower the patient’s level of
consciousness to the extend necessary for relief of
awareness of refractory and unendurable symptoms
Ø Withholding, withdrawing, and refusal of life-
sustaining treatment
• Life-sustaining treatments include but are not limited to
mechanical ventilation, cardiopulmonary resuscitation,
chemotherapy, dialysis, antibiotics, medically supplied
nutrition, and hydration
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Management of Pain and Other
Symptoms (4 of 4)
Definitions of end-of-life concepts
Ø Palliative care
• An approach that improves the quality of life of patients
and their families facing the problems associated with life-
threatening illness through the prevention and relief of
suffering by means of the early identification and careful
assessment and treatment of pain and other problems,
physical, psychosocial, and spiritual
Ø Hospice care
• Care of patients and families at the end of life and during
the last few weeks or months of life that builds on the
palliative care model to minimize suffering by providing
appropriate symptom management and emotional support
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Doctrine or Rule of Double Effect
(1 of 2)
The ethical approach to pain and symptom
management at the end of life is best guided by the
rule of double effect
Ø Derived from the ethical principle of nonmaleficence
Ø Recognizes that an act can have both a good and bad
effect, and that to achieve the good effect, the bad
effect must be tolerated
Ø Provides an ethical guideline to care well for the patient
while also avoiding harms
Ø Provides support for the ethical administration of pain
and symptom management
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Doctrine or Rule of Double Effect
(2 of 2)
The rule of double effect has four conditions
Ø The “nature of the act” must be good, or at least
morally neutral—the act of medicating a patient at the
end of life is not immoral
Ø “Intention of the health professional” in the clinical
situation; The goal is to “intend the good effect” while
foreseeing the potential “bad effect,” which must be
tolerated
Ø The distinction between means and effects
Ø Consideration of “proportionality between good and
bad effect”
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Special Situations
Status epilepticus
Ø Ethical dilemma of stopping seizure suppressive
medicines to give the patient an opportunity for
respiratory effort versus continuing seizure
suppressive medications, realizing that respiratory
effort will be subdued
Those with intractable pain and symptoms in
need of palliative sedation
Patient receiving paralytics
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Ethical Conflict at the End of Life
For the vast majority, a consensus can be
reached without issue or disagreement
Ø Most families and patients concur with the
physician’s recommendation
Ø Conflict can be present within families, within the
health care team, or between families and the
health care team
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RT as Ethical Practitioner
RT should not make assumptions about a
patient’s or family’s wish or preferences and
how their unique cultural backgrounds may
shape how they arrive at certain decisions
RTs can comfort patients and families
RTs are key members of the interdisciplinary
health care team with expertise that is not
duplicated by other professional disciplines
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