Ethical Care at the End of Life
Frederic Koning
Director, Ethics Services
April 1st, 2009
A CANADIAN VISION FOR END OF LIFE CARE
Quality end-of-life care must become an entrenched
core value of Canada’s health care system. Each
person is entitled to die in relative comfort, as free as
possible from physical, emotional, psychosocial, and
spiritual distress. Each Canadian is entitled to access
skilled, compassionate, and respectful care at the end
of life. This subcommittee sees care for the dying as
an entitlement for all.
Subcommittee to Update "Of Life and Death" of the Standing
Senate Committee on Social Affairs, Science and Technology (2000).
Quality end-of-life care: The right of every Canadian. Ottawa: Authors.
VALUES
Seniors are important, integral and vital participants
of Canadian society. Health care and social service
providers need to assure seniors that their enormous
value is uppermost when their care is undertaken.
The legacy of strength, experience and wisdom that
resides in this population is important and the ethical
issues that surround the care of seniors must always
be taken into consideration, especially when dealing
with the difficult issues that surround the end of life.
National Advisory Committee (2000).
A guide to end-of-life care for seniors.
Ottawa: Health Canada.
CURRENT CHALLENGES
Calls for a more compassionate and comprehensive
approach to end-of-life seem to be assigned a low
priority in the existing health care system. Thus, in
spite of statistical evidence indicating an increase in
the numbers of total deaths and acknowledged
changes in demographics, disease patterns, and
health care institutions, there has not yet been the
required shift of resources to end-of-life care.
Subcommittee to Update "Of Life and Death" of the Standing
Senate Committee on Social Affairs, Science and Technology (2000).
Quality end-of-life care: The right of every Canadian. Ottawa: Authors.
CLINICAL CONSIDERATIONS:
AN ETHICAL ANALYSIS
What do clinicians experience as their
challenges to providing quality end of
life care that reflects the expressed
values of this Senate Subcommittee?
QUESTIONS OF PROGNOSIS AND RELATIVE
MERITS OF TREATMENT OPTIONS
 Questions of competence
 Interpreting advance directives
 Morally expendable
 Medical futility
ETHICAL ANALYSIS
An ethical analysis begins by identifying the
morally relevant factors period. For any
medical case the most important feature is
the patient’s prognosis.
Ruth Macklin (1987, p. 52).
Mortal Choices: Bioethics in Today’s World.
Pantheon Books.
MENTAL COMPETENCE:
A CONTINUUM
A single core meaning of the word competence applies in all
contexts. That meaning is “the ability to perform a task”. By
contrast to this core meaning, the criteria of particular
competencies vary from context to context because the criteria
are relative to specific tasks. The criteria for someone’s
competence to stand trial, to raise daschunds, to write checks,
or to lecture to medical students are radically different. The
competence to decide is therefore relative to the particular
decision to be made. Rarely should we judge a person
incompetent with respect to every sphere of life.
Beauchamp, T. L. & Childress, J. F. (2008, p. 112).
Principles of Biomedical Ethics, 6th Edition.
New York: Oxford University Press.
MENTAL COMPETENCE:
A CONTINUUM
We usually need to consider only some type of competence,
such as the competence to decide about treatment or about
participation in research. The judgements of competence and
incompetence affect only a limited range of decision making.
For example, a person who is incompetent to decide about
financial affairs may be competent to decide to participate in
medical research, or able to handle simple tasks easily while
faltering before complex ones.
Beauchamp, T. L. & Childress, J. F. (2008, p. 112).
Principles of Biomedical Ethics, 6th Edition.
New York: Oxford University Press.
UNDERSTANDING
DECISION-MAKING COMPETENCY
A “conversation” to determine
the competence of the moment.
Dr. Romayne Gallagher
TYPES OF DIRECTIVES
Proxy Directives: instructions naming person(s)
to be contacted to make health care decisions in
the event of incapacity
Instructional Directives: specific or general
directions to aid in decision–making, documented
and distributed to family and potential health care
providers
RATIONALE FOR ADVANCE DIRECTIVES
Based on the principle of respect for autonomy
Respect for autonomy is, in turn, based on an
ethic of “respect for persons”
Directives seek to ensure that this respect
continues even when the person (patient,
resident, client) is unable to participate in his/her
own care
“TREATMENT” TERMINOLOGY
“Ordinary” and “extraordinary”
are confusing and should be replaced by
“appropriate” and “inappropriate.”
R. Veatch (2003)
The Basics of Bioethics, 2nd Edition
Upper Saddle River, NJ: Pearson
MEDICAL FUTILITY
There are two criteria:
 Physiological uselessness
 Does not postpone death in a dying patient
even for a very short time
D. Kelly (2007).
Medical Care at the End of Life: A Catholic Perspective
Washington, DC: Georgetown University Press.
CRITERIA FOR CLASSIFYING TREATMENTS
THAT ARE MORALLY EXPENDABLE
 Uselessness
 Grave burden
 Proportionality (benefit/harm ratio)
R. Veatch (2003)
The Basics of Bioethics, 2nd Edition
Upper Saddle River, NJ: Pearson
When a man is attacked by a disease more
powerful than the instruments of medicine,
it must not be expected that medicine
should prove victorious.
Science of Medicine
Hippocratic Writings
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