Ethical decision making with end-of-life care
In a review article published in an issue of Mayo Clinic Proceedings, Mayo Clinic physicians differentiate the ethical and legal permissibility of withholding or withdrawing life-sustaining treatments and accepted comfort measures, specifically palliative sedation, from that of physician-assisted suicide or euthanasia
Physician reviewers find that palliative sedation has an important place on the continuum of appropriate palliative care.
“At the end of life, patient goals often shift to comfort, and removal of burdens and relief of suffering become paramount,” says lead author, Dr Paul Mueller, General Internal Medicine, Mayo Clinic.
“Many physicians are uncomfortable removing life-sustaining therapy or providing comfort-directed medication because of confusion about the ethical soundness of such treatments. In contrast to physician-assisted suicide or euthanasia, withdrawal of or withholding life-sustaining treatment and administering palliative sedation are ethically sound options.”
Palliative sedation is appropriate therapy for refractory and unacceptably severe suffering.
“As with any other therapy, the patient or surrogate should be informed of potential adverse effects, including loss of social interaction and potential for life-threatening aspiration or respiratory depression. Palliative medicine teams should be involved, if possible, in any case in which palliative sedation is considered,” says Dr Mueller.
“We hope that by increasing familiarity with the ethical basis for these practices we will encourage their appropriate application,” he said.
In another part of the world, NHS National Services Scotland (NSS) has announced it will develop a Key Information Summary that will be fully integrated with its Emergency Palliative Care Summary (EPCS) record.
Speaking at the BCS Health Scotland conference, Jonathan Cameron, programme manager of the National Information Systems Group for NHS NSS, said that the new summary would build on the success of the EPCS but would add considerably more information to the record.
“The Key Information Summary (KIS) aims to replace paper notes being faxed from GP practices to NHS24, provide support for electronic anticipatory care plans, long term conditions and mental health by utilising the existing EPCS infrastructure,” he said.
The summary will include four new sections. Special Notes will give GPs the ability to add free text to records and any additional information that care providers may need to know. Current Situation will give an overview of the patients’ main diagnosis and current illness.
Care and Support will provide information on home care support, guardianship and power of attorney. And Information and Action for A&E and out-of-hours will provide information on areas such as resuscitation requests.
Earlier this year, NHS NSS began rolling out the palliative care summary within the Emergency Care Summary, which is now provided to more than 25% of the population.
“We’re still going to keep the palliative element, that’s very important for OOH and NHS 24 in particular, but we’re going to have a system that provides more of the right information [without being] the entire patient record,” said Mr Cameron.
“Users of the ECS and KIS will include NHS24, all OOH, A&E acute receiving units, and now the Scottish Ambulance units as well.”
