Ethical issues in palliative care
- Erik K Fromme, MD
Erik K Fromme, MD
- Associate Professor of Medicine, Radiation Medicine, and Nursing
- Oregon Health & Science University
- Mary Denise Smith, RN, CNS
Mary Denise Smith, RN, CNS
- Instructor of Medicine and Nursing
- Oregon Health & Science University
- Section Editors
- Robert M Arnold, MD
Robert M Arnold, MD
- Editor-in-Chief — Palliative Care
- Section Editor — General Principles of Palliative Care
- Chief, Section of Palliative Care and Medical Ethics
- University of Pittsburgh School of Medicine
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
Ethical issues in palliative care often arise because of concerns about how much and what kind of care make sense for someone with a limited life expectancy. There is often conflict between clinicians, nurses, other healthcare team members, patients, and family members about what constitutes appropriate care, particularly as patients approach death.
This topic will discuss ethical issues in palliative care. Other issues regarding the legal aspects of end of life care, advance care planning, how to approach requests for potentially inappropriate and futile therapies, and discussing goals of care are discussed separately. In addition, issues related to specific symptoms for the patient in palliative care and/or at the end of life are discussed separately.
- President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: The legal and ethical implications of informed consent in the patient-practitioner relationship. United States Government Printing Office; Washington, DC 1982.
- Lorenzl S. End of one's life--Decision making between autonomy and uncertainty. Geriatric Mental Health Care 2013; 1:63.
- Roeland E, Cain J, Onderdonk C, et al. When open-ended questions don't work: the role of palliative paternalism in difficult medical decisions. J Palliat Med 2014; 17:415.
- Billings JA, Churchill LR. Monolithic moral frameworks: how are the ethics of palliative sedation discussed in the clinical literature? J Palliat Med 2012; 15:709.
- Beauchamp TL, Childress JF. Principles of Biometical Ethics, 6th ed, Oxford University Press, 2009. p.336.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed, Oxford University Press, 2009. p.344.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed, Oxford University Press, 2009. p.356.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed, Oxford University Press, 2009. p.162.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed, Oxford University Press, 2009. p.353.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed, Oxford University Press, 2009. p.36.
- Beauchamp TL, Childress JF. Principles of Biomedical Ethics, 6th ed, Oxford University Press, 2009. p.46.
- Giblin MJ. Beyond principles: virtue ethics in hospice and palliative care. Am J Hosp Palliat Care 2002; 19:235.
- Cerminara KL. The law and its interaction with medical ethics in end-of-life decision making. Chest 2011; 140:775.
- IOM, Report Brief September 2014. http://www.iom.edu/~/media/Files/Report%20Files/2014/EOL/Report%20Brief.pdf.
- Shalowitz DI, Garrett-Mayer E, Wendler D. The accuracy of surrogate decision makers: a systematic review. Arch Intern Med 2006; 166:493.
- Kim SY, Kim HM, Ryan KA, et al. How important is 'accuracy' of surrogate decision-making for research participation? PLoS One 2013; 8:e54790.
- Sharma RK, Hughes MT, Nolan MT, et al. Family understanding of seriously-ill patient preferences for family involvement in healthcare decision making. J Gen Intern Med 2011; 26:881.
- Torke AM, Moloney R, Siegler M, et al. Physicians' views on the importance of patient preferences in surrogate decision-making. J Am Geriatr Soc 2010; 58:533.
- Wagner GJ, Riopelle D, Steckart J, et al. Provider communication and patient understanding of life-limiting illness and their relationship to patient communication of treatment preferences. J Pain Symptom Manage 2010; 39:527.
- Kelly B, Rid A, Wendler D. Systematic review: Individuals' goals for surrogate decision-making. J Am Geriatr Soc 2012; 60:884.
- Pope TM. Legal fundamentals of surrogate decision making. Chest 2012; 141:1074.
- Scheunemann LP, Arnold RM, White DB. The facilitated values history: helping surrogates make authentic decisions for incapacitated patients with advanced illness. Am J Respir Crit Care Med 2012; 186:480.
- Pochard F, Azoulay E, Chevret S, et al. Symptoms of anxiety and depression in family members of intensive care unit patients: ethical hypothesis regarding decision-making capacity. Crit Care Med 2001; 29:1893.
- Wendler D, Rid A. Systematic review: the effect on surrogates of making treatment decisions for others. Ann Intern Med 2011; 154:336.
- Braun UK, Beyth RJ, Ford ME, McCullough LB. Voices of African American, Caucasian, and Hispanic surrogates on the burdens of end-of-life decision making. J Gen Intern Med 2008; 23:267.
- Schenker Y, Crowley-Matoka M, Dohan D, et al. I don't want to be the one saying 'we should just let him die': intrapersonal tensions experienced by surrogate decision makers in the ICU. J Gen Intern Med 2012; 27:1657.
- Swetz KM, Burkle CM, Berge KH, Lanier WL. Ten common questions (and their answers) on medical futility. Mayo Clin Proc 2014; 89:943.
- Hebert R, Argo Ben Itzhak N. A Potential Downside to Promoting the Economic Benefits of Palliative Medicine. J Palliat Med 2015; 18:738.
- The Hastings Center. Guidelines on the termination of life-sustaining treatment and the care of the dying, The Hastings Center, Briancliff Manor, NY 1987. p.32.
- Wicclair MR. Conscientious objection in medicine. Bioethics 2000; 14:205.
- 2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Part 2: Ethical issues. Circulation 2005; 112:IV.
- President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forgo life-sustaining treatment. US Government Printing Office; Washington, DC 1983.
- Ditto PH, Jacobson JA, Smucker WD, et al. Context changes choices: a prospective study of the effects of hospitalization on life-sustaining treatment preferences. Med Decis Making 2006; 26:313.
- Weissman DE. Consultation in palliative medicine. Arch Intern Med 1997; 157:733.
- Quill TE, Holloway R. Time-limited trials near the end of life. JAMA 2011; 306:1483.
- Chaitin E, Rosielle DA. Responding to requests for nondisclosure of medical information, #219. J Palliat Med 2013; 16:320.
- McCabe MS, Wood WA, Goldberg RM. When the family requests withholding the diagnosis: who owns the truth? J Oncol Pract 2010; 6:94.
- Ulysse FG, Balicas M, Xu Y. Ethical dilemma: Therapeutic nondisclosure. Clinical Scholars Review 2011; 4:115.
- Hallenbeck J, Arnold R. A request for nondisclosure: don't tell mother. J Clin Oncol 2007; 25:5030.
- Pope TM, West A. Legal briefing: voluntarily stopping eating and drinking. J Clin Ethics 2014; 25:68.
- Leeuwenburgh-Pronk WG, Miller-Smith L, Forman V, et al. Are we allowed to discontinue medical treatment in this child? Pediatrics 2015; 135:545.
- O'Connor J, concurring. Glucksberg v. Washington. 521 U.S. 702, 737, 1997.
- Goldstein NE, Cohen LM, Arnold RM, et al. Prevalence of formal accusations of murder and euthanasia against physicians. J Palliat Med 2012; 15:334.
- FRAMEWORK FOR ETHICAL REASONING
- Applying principlism in palliative care
- - Palliative paternalism
- Alternative moral frameworks
- APPLYING ETHICS IN CLINICAL SETTINGS
- Decision making
- - Determining best interest
- - Working with surrogates
- - Impact of acting as a surrogate
- Conflicts of value
- SPECIFIC SCENARIOS
- Application of Do Not Resuscitate orders
- Advance care planning
- Withdrawing versus withholding treatment
- Time-limited trial
- Pain management at the end of life
- Requests from the family to withhold information
- Requests to discontinue life sustaining treatment
- Palliative sedation
- - Proportionate palliative sedation
- - Palliative sedation to unconsciousness
- Physician-assisted dying