扬州大学：《医学伦理学》课程教学课件（PPT讲稿）Chapter 7 End-of-Life Issue

CHAPTER7END-OF-LFE ISSUE

CHAPTER 7 END-OF-LIFE ISSUE

2Would you ever consider haltinglife-sustaining therapybecauseoffamilydemands,evenifyoufelt that it was premature?Yes-16.3%No-54.5%Itdepends-29.2%

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"l do not participate in active withdrawal of suchintrinsic life-sustaining needs. The family couldfind another physician if they feel so strongly'"lt depends on what you mean by 'premature' Iwould feel differently if death is imminent andthere's no hope, and the quality of life is poorrather than if there's no hope but some quality, or ifthere is some hope but the quality of life is lousy.I'd always try to think, what would the patientwant.""Not if the family insisted, but if the patient insistedon it, I would.""This is why hospitals have ethics boards. I wouldrefer cases like these toexperts

• "I do not participate in active withdrawal of such intrinsic life-sustaining needs. The family could find another physician if they feel so strongly." • "It depends on what you mean by 'premature.' I would feel differently if death is imminent and there's no hope, and the quality of life is poor rather than if there's no hope but some quality, or if there is some hope but the quality of life is lousy. I'd always try to think, what would the patient want." • "Not if the family insisted, but if the patient insisted on it, I would." • "This is why hospitals have ethics boards. I would refer cases like these to experts

Wouldyoueverrecommend orgivelife-sustainingtherapywhenyoujudged thatitwas futile?Yes-23.6%No-37.0%Itdepends-39.4%

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"l once had a terminal patient who wanted to see hisgranddaughter before he died, so I prolonged hisintravenous therapy for 3 days until'she arrived. He diedthe same night.""Some families have completely unrealistic expectations,despite my educational efforts. I would give continuedcare, but not happily."l do not have the right to determine futile unless thepatient is brain dead. Futility is a matter of opinion. Weall will die eventually."I would not recommend it if I thought it was futile, but Iwould give it if that is what the patient or the familywanted.""Why waste money and time when results are nil?""l would do this if I felt it would give the family time toaccept the inevitability of death

• "I once had a terminal patient who wanted to see his granddaughter before he died, so I prolonged his intravenous therapy for 3 days until she arrived. He died the same night." • "Some families have completely unrealistic expectations, despite my educational efforts. I would give continued care, but not happily." • "I do not have the right to determine futile unless the patient is brain dead. Futility is a matter of opinion. We all will die eventually." • "I would not recommend it if I thought it was futile, but I would give it if that is what the patient or the family wanted." • "Why waste money and time when results are nil?" • "I would do this if I felt it would give the family time to accept the inevitability of death

MEDICALFUTILITYPhysiologic futility: The treatment will notachieve a physiologic goal.Qualitative futility: the treatment will notachieve a certain quality of life that isacceptable to the patient.Imminent-Demise futility: in spite ofintervention the patient will die in thenearfuture

MEDICAL FUTILITY Physiologic futility: The treatment will not achieve a physiologic goal. Qualitative futility: the treatment will not achieve a certain quality of life that is acceptable to the patient. Imminent-Demise futility: in spite of intervention the patient will die in the near future

WITHDRAWAL OFMEDICALTREATMENTDiscontinuation of life-sustainingtreatmentDifferent from never starting or offeringtreatmentWithdrawal of treatment is not the sameas withdrawal of care

WITHDRAWAL OF MEDICAL TREATMENT - Discontinuation of life-sustaining treatment - Different from never starting or offering treatment - Withdrawal of treatment is not the same as withdrawal of care

WITHDRAWAL OFMEDICALTREATMENTDecision-making hierarchyPatientAdvancedirectivePower of attorneyNext of kin spouse, children..Physician and court order

WITHDRAWAL OF MEDICAL TREATMENT Decision-making hierarchy • Patient • Advance directive • Power of attorney • Next of kin —— spouse, children. • Physician and court order

WITHHOLDING AND WITHDRAWALOFMEDICALTREATMENT PASSIVEEUTHANASIA)The withholding, or withdrawing, of treatmentis widely accepted as morally right in manycircumstances. And it is protected by law inEngland, the US, Canada, and many othercountries. There are two grounds on which itis accepted:(1) that it is in the patient's best interests; and(2) that it is in accord with the patient's wishes

WITHHOLDING AND WITHDRAWAL OF MEDICAL TREATMENT (PASSIVE EUTHANASIA) The withholding, or withdrawing, of treatment is widely accepted as morally right in many circumstances. And it is protected by law in England, the US, Canada, and many other countries. There are two grounds on which it is accepted: (1) that it is in the patient’s best interests; and (2) that it is in accord with the patient’s wishes

For example, a 60-year-old man with diabetesand hypertension develops renalinsufficiency to the point of needingdialysis. He is equivocal about spendingthe rest of his life on dialysis, but he agreesto start. The patient is not depressed and isfully alert. Six months after startingdialysis, he comes to realize very clearlythat he absolutely does not wish tocontinue. You have no doubt that thepatient has full capacity to understand theimplications of this decision. What shouldyou do?

For example, a 60-year-old man with diabetes and hypertension develops renal insufficiency to the point of needing dialysis. He is equivocal about spending the rest of his life on dialysis, but he agrees to start. The patient is not depressed and is fully alert. Six months after starting dialysis, he comes to realize very clearly that he absolutely does not wish to continue. You have no doubt that the patient has full capacity to understand the implications of this decision. What should you do?