End of Life Decisions - Research Paper Example

End of life decisions and End of life decisions Introduction Human beings have limited or totally no input or control on their births, but they have the opportunity (in most cases) to anticipate their deaths and their last days on earth. To some extent, they may help and contribute to the nature and kind of healthcare that they may want (or may not want) given to them by their children, spouses and relatives. Since the inception of advanced care services, frenzied debates have continued to go on, and to the present day, there are still many varying issues expressed by clinicians, doctors and palliative care givers concerning the end of life decisions (Baylis, 2011). The Canadians are a society that places much emphasis and importance on issues to do with health, and health needs for those approaching their end of life are not ignored. The ministry concerned ensures the universal access of apposite and quality healthcare to all the citizens regardless of race, age, color, gender, religious beliefs or social class. To ensure that no one is discriminated, the Canadian Hospice and Palliative Care was established and is an organization bringing together researchers, clinicians, doctors and substitute decision makers. It was formed with an objective of reaching out to the Canadians and raising their awareness concerning issues, aspects and importance of engaging in advance care planning, and how to get involved. The Health Care Consent Act was also founded with an intention of educating people about advanced care planning, and informing them of their rights as substitute decision makers and those of their patients. Another body that is in Canada that is concerned with issues to do with advance care planning is the Consent and Capacity board (Robert and Michael, 2013). The Consent and Capacity Board, as Robert and Michael (2013) collectively note was established to give timely, dignified and fair hearings in a bid to get an equilibrium state between medical and legal matters. This work shall discuss the ethical, legal and professional issues that arise in making such decisions (end of life decisions). To begin with, imperative statistics about the health situation in Canada shall be presented, examples of major life decisions shall be discussed and then a case study shall be provided. From this case study; the ethical, professional and legal issues shall be discussed in that order. Thereafter, a conclusion focusing on end of life decisions shall be drawn. Important Statistics A research conducted in 2006 showed that between 2005 and 2036, it was projected that the number of aged people (who in this case are aged 65 and above) would increase by 25%, and the deaths would also increase by 65% (E-laws, 2011). This means that the number of the aged people in Canada would increase from 4.2 million (2005) to 9.8 million (2036) (E-laws, 2011). This forecast is likely to hold considering the increasing number of the aging population in Canada, and the equally increasing costs in health care. Presently, 2014, the costs of healthcare have undoubtedly increased from what they were in the past, and this can be depicted from the increased costs of healthcare in Ontario in the period 1994-2004. Figure 1: Increase in health related costs in Ontario from1994-2004. This is just but a representation of the constantly increasing health related costs in Canada. If this was the increase ten years ago, then the costs must have risen to considerably higher amounts today. It is important to note that in these costs, there is a significant proportion that is as a result of age related illnesses. Today, ten years since the above statistics of Ontario were provided, there are many changes. The population for the aging is very high as compared to the earlier days. In addition, patients are currently living longer as compared to then, and the demand for medical related services in Canada has escalated. The end of life services that are currently required are unmatched to what they were then (Baylis, 2011). To illustrate this, the following diagram shows the health care expenses in Canada by 2006. Figure 2: Cost of healthcare in 2006. Evidently, the costs are highest in the 65 and above age bracket. Research shows that most of the people at this category require advance care planning, and at the end of their lives, decisions sometimes have to be made for them. In2012, a research was carried out among the elderly people in a hospital. They were asked about their end of life plans, decisions or wishes. Of the total, 70 % confidently said that they would prefer palliative care with comfort, rest and reduced pain rather than the aggressive plan treatment and technologically supported death commonly applied (Schuklenk et al, 2011). 70% of Canadians, as research shows usually get their advanced care in hospitals. 10-15 % of the patients are usually confined in the I.C.U, and their life is supported by powered machines (Smith, 2012). At the same, of the 70%, 54% end up getting admitted at the hospital’s intensive care unit during their last days (Smith, 2012). Another research which sought to establish the various views on some crucial end of life decisions and choices was carried out in a town in Canada in 2011. The results are as depicted in the diagram below. F Figure 3: End of life decision choices. With such a representation, it is evident that different views continue to be held concerning end of life decisions. Examples of controversial major end of life decisions There are times a person will get too sick to a point that they cannot speak, and when important decisions about their lives have to be made, many issues can be arise. Some of the major treatment decisions include CPR (Cardiopulmonary Resuscitation), use of feeding tubes, sedation practices and intravenous (IV) hydration. CPR raises countless issues even within the care givers themselves. CPR refers to emergency treatments that are procedurally applied to preserve the functioning ability of the brain when a person’s heart stops beating, chiefly due to a cardiac arrest. The treatment is considered very important for aging patients since they are most likely to suffer from such conditions. However, those who do not support it argue that there are high chances of this treatment inflicting pain on the patient and also subjecting them to traumatic experiences (Smith, 2012). Secondly, they argue that instead of helping the patient, it might leave them in a condition worse than they were before the treatment. The scholars against CPR also say that for the people who are able to make end of life decisions for themselves, many do not prefer or advocate for this kind of treatment. For them, a DND (do not resuscitate) order is issued so that this treatment is not given to them once their breathing stops. Others however argue that the patients deserve to be given any treatment available since there are slight chances that if they were able to communicate for themselves, that is what they would have wished for (Dossetor, 2005; Smith, 2012). When a person has difficulties swallowing food or drinking, tube feeding is usually adopted. However, the argument against the use of this feeding module is the fact that there is no proven evidence that this feeding improves the patient’s quality of life. In addition, some doctors and clinicians say that this feeding can lead to internal infections and thus end up compromising the patient’s health (Baylis, 2011). It is also argued that insertion of the tubes is very painful, and thus the patient should be left to peacefully succumb to their illnesses if there aren’t better treatment options. However, some scholars and clinicians argue that life is God-given, and the human being therefore has no right to deny the patient their right to life by withdrawing or withholding tube feeding. Sedation practices continue to raise a lot of different opinions in different healthcare institutions. This is because some people say that these practices are an indirect form of euthanasia, and euthanasia is widely unacceptable to many people. Other people say that one should not play a hand or assist in the patient’s death, and that euthanasia at all costs should be avoided (Smith, 2012). Towards a person’s dying days (those who have been sick for a long time), it is common that they have insufficient amounts of water in their bodies. Intravenous (IV) hydration is the administration of a liquid through a needle in the human vein that is intended to rehydrate the patient. This process has an advantage of slowing the death process, and this is where people take this as an aspect of prolonging life. The goal of advanced or palliative care should be to provide care and quality life for a person at their last days, and some scholars argue that the practices discussed above do not make the patient’s life anything close to comfortable. That is why it is very important that if any of the above life decisions are taken, it should be applied with an ultimate goal and for a specified period so as to determine whether it is worth it or not. Discussion of ethical, professional and legal issues related with end of life decisions Case study Petch and Laupacis (2013) give the case study of Hassan Rasoulli. Hassan had been unconscious for over three years and was in the Intensive Care Unit at a hospital in Sunnybrook, where his life was supported by a mechanical ventilator. After much observation, treatment and monitoring, the doctors concluded that all attempts were futile and Hassan had limited chances (if any) of ever recovering the function of his brain. They therefore suggested the withdrawal of the machine. Hassan’s wife (Parichehr Salasels) vehemently opposed to the doctor’s ideas. She argued that if her husband was in a position to make a decision, he would prefer to be kept alive under the machine support. She especially based the could-have-been decision of the husband on their religious beliefs (Petch and Laupacis, 2013). Rasullli’s end of life decision case was forwarded to the Ontario Superior court where the court was to decide what the doctors were to do, and if they could only withdraw this life support with the consent of the substitute decision maker (the wife). On 18th October 2013, the court ruled that the doctors could not withdraw the life support machines from Hassan, unless the wife provided them with consent. This particular case raised a lot of heated debate and will also be applied here, especially in the legal issues section. Ethical and professional issues relating to end of life decisions The society directs a greater percentage of many of the things we do and some that we say. It is like a mirror and has codes and conducts that guides us, and distinguishes one group of people from another. In Canada, the right to quality health is among one of the many key areas that the government continuously focuses on. Ethical and professional issues shall both be discussed in this section as they are greatly intertwined and interrelated. Doctors have a responsibility to provide patients at their end of life period with quality health and comfort (Dossetor, 2005; E-laws, 2011). However, some of the decisions that they are forced to make raise heated debates. Taking an example of Hassan from the case study above, people question the ethicality of the doctor’s suggestions and the professionalism in it. Before making such a suggestion, however, the doctors usually weigh up all the available options. They usually monitor any improvement and progress regarding the patient’s condition, and when there are no changes recorded for a significant length of time, they forward their suggestions. Ethically, there is an un-debatable agreement that no man has a right to end the life of another, not even a doctor. The Health Care Consent Act clearly provides that the doctors cannot withdraw life support or administer (IV) hydration without the consent of the patient or the substitute decision maker (E-laws, 2011; Schuklenk et al, 2011). The doctors therefore do whatever they can to make the last days of the patient as comfortable as they can. Arguments however arise as they did in the case study above over what to do when the doctors realize that the efforts are futile and give their suggestions, only for the substitute decision maker to reject it. On the other hand, some doctors really find it hard when the patients on their end of life days has an order of a DND, or an order barring the doctors from administering any other form of advance care. Some feel that this care should be administered to the patients until when it shall be futile to administer them. Such doctors feel that it is not upon them to cut short the life of any man and they should do all that they can to ensure that the patient lives as long as possible. Another issue is the application of euthanasia as an end of life decision. Take also a case of a person suffering from dementia (Smith, 2012). The curve below illustrates the scenario predeceasing the end days of such a person. In such a case, the person may be able to communicate during the first days, even though the speech might not be coherent. If the person does not express their wishes, doctors usually have a hard time deciding on what to do, especially if there is no substitute decision maker. During the last days, activities, speech and even the ability to eat or carry out other activities might be very low. If one has been a doctor to such a person since they started manifesting the signs, yet they did not make their wishes concerning their last days, it becomes hard for the doctor to decide on what best to do. Figure 4: Curve for a dementia patient This is why doctors, researchers, clinicians and other elites in Canada are teaming up to advise and create awareness to people on the importance of making end of life decisions as this not only makes the work of the doctors simpler but also the last days of the patient (Robert and Michael, 2013). If Hassan had made a wish before he got into such a condition, the court battle would have been avoided. According to Robert and Michael (2013), a research conducted in 2013 in a hospital where elderly patients had been hospitalized showed that the programs and awareness campaigns on advance care have made significant changes. Of the interviewed patients, 76 % of them had given a thought to end of life care, each having different wishes. Of the 76%, only about 12% wished to be given life prolonging services, using any available means. 48% of them had already applied and completed end life and advance care plans, with 73% of them having already named a substitute decision maker (Robert and Michael, 2013). Legal issues related with end of life decisions Physician assisted suicide, or euthanasia as it is commonly called is considered illegal in Canada. The laws strongly prohibit this kind of end of life decisions. The problem arises when it is a patient’s request to have this treatment. Some doctors feel that by assisting a patient in such an activity, they are breaking the law. They therefore find it very hard to consent with such a patient’s demand, yet the Health Care Consent Act provides that the patient’s wishes should be respected. On the other hand, some doctors argue that there are some cases where there are no chances of the patient ever recovering. At such a point, they feel that assisted euthanasia would be a wise choice, but again the Health Care Consent Act and the governing laws prohibit the doctor from being involved in involuntary attempted suicide (Petch and Laupacis, 2013). Other issues regarding the end of life decisions are seen with regards to the Consent and Capacity board. Initially, the board was formed to deal with cases of patients resisting psychiatric treatment. The board was established to protect the rights and responsibilities of patients and their substitute decision makers and at the same time promote safety in the community.Petch and Laupacis (2013) note that concerns have been forwarded over the board’s lack of expertise, with scholars suggesting that since most of the board members have never worked in the hospital, (especially in a department dealing with people with advance care needs), they (board members) cannot understand the sensitivity of the details and decisions involved. It is argued that a qualified doctor with vast experience in several fields should sit at the board as the board members fail to understand the doctors. Guidance of the board by precedent would definitely make it better. It is argued that in some of the past cases, the decisions reached at by the board were based more on the patient’s religious views, and this directly conflicts with the provisions of the Health Consent Care Act (Petch and Laupacis, 2013; Baylis, 2013). The Health Consent Care Act values patients’ beliefs and their values, but these are not given preference over their well being. Lastly, other clinicians and care givers argue that the time taken by the board and even the courts to reach to an amicable decision is usually much, yet decisions in the I.C.U. are made within hours and minutes, not the lengthy weeks, years or months usually taken as seen from the above case study. The case of Hassan is a perfect example as it was presented to the Superior Court in 2011, only for the decision and ruling to be arrived at in 2013 (Petch and Laupacis, 2013). Another issue arises when the end time decision regards a child. In many of the cases, the children are unable to make any end time decisions and wishes, especially when the child is a minor. Here, the parent has the responsibility of making the end of life decisions for the child. The parent, usually directed by the parent-child love and instinct might end up making choices that are unwise, and when the doctors realize that there are no chances of recovery and they suggest withdrawal of life support, the parent might not concur (Smith, 2012). At other times, the child is old enough to make sound decisions on what they would like done to them when they have lost their ability to express themselves. The parent however, may take it that the child did not make the right decision and attempt to seek legal support for the decision to be changed. In both cases, the law has to be involved to decide who will have the final word. Personal opinion We all have differing views and opinions on different life issues. End of life decisions and advanced care plans is one such area. I feel that doctors are sometimes placed between a rock and a hard place. They are expected to obey the law, observe cultural norms and society conduct, yet on the other hand they are expected to obey the wishes of the patient. But I agree with the ideas represented in the Heath Consent Care Act, and all doctors should definitely respect the wishes of any patient, especially those at their end of life periods. Such decisions aid in deciding how comfortable one will be at their end of life periods. If a patient had expressly directed a DND, the substitute decision maker should not try to direct the doctors to do otherwise. On the board issues, I feel that the doctors are put in a difficult position by the decisions usually reached. The board should be changed to accommodate one or two doctors and thus the decisions made will have a precedent ground, fair for the patients and nursing staff. Conclusion The Canadian healthcare ministry should work even harder to create awareness to people regarding the importance of making end of life decisions as early as when they are healthy. The issues surrounding this area will definitely reduce. This is made more important by the indirect rationing practiced by the Canadian government due to the rapidly increasing demand yet the resources are scarce. This awareness helps to promote the well being of the patient and also makes the doctor’s decisions simpler. The choice to not apply extreme measures and programs to keep the patient alive does not translate to withdrawal of all treatments, but the treatments should be aimed to a specific goal and for a specified period as Robert and Michael (2013) and Schuklenk et al (2011) collectively agree. End of life decisions are one of the major issues in Canada, and though the relevant ministry has put a lot of effort, the number of these cases are rising with every passing day. People should know that these decisions are paramount for the safety of the community and the overall development of the nation. As doctors play their part, the patients and their substitute decision makers should make their decisions while they are still healthy, when communication has not totally broken down. References Baylis, F. (2011). Health Care ethics in Canada. New York: Cengage Learning. Dossetor, J. ( 2005). Beyond the Hippocratic Oath: A memoir on the rise of modern medical ethics. Edmonton: University of Alberta. E-laws.gov. (2011). Health Care Consent Act, 1996. Retrieved from http://www.e-laws.gov.on.ca/html/statutes/english/elaws_statutes_96h02_e.htm> Petch, J., and Laupacis, A. (2013). Conflict at the end of life: What happens when doctors and families disagree? Retrieved from Robert, F., and Michael, H. (2013). End of life care in Canada. Clin Invest Med, 36(3), 127-132. Schuklenk, U., Delden, J., Downie, J., Mclean, S., Upshur, R., and Weinstock, D. (2011): End of life decision making. Retrieved from Smith, S. (2012). End of life decisions in medical care. : Principles and policies for regulating the dying process. Cambridge: Cambridge University Press. Read More