End of Life Issues

Objectives: After study and discussion of this module, the student should be able to:
▪ Understand the use of advance directives
▪ Understand conditions of withholding / withdrawing artificial life support;
including Artificial Nutrition and Hydration
▪ Appreciate ethico-legal issues relating to Do Not Resuscitate (DNR) orders
▪ Understand the definition and related ethical issues of:
- Physician-Assisted Suicide
- Euthanasia
- Terminal Sedation (the law of double effect)
- Futile Treatments (Palliative vs Curative)
Advanced ▪ An advance directive is the method by which a patient communicates his wishes for
Directives his health care in advance of becoming unable to make decisions for himself.
‫التوجيهات المسبقة‬ ▪ It is a part of a concept of autonomy.
▪ It includes statements such as refusal to be admitted to an intensive-care unit, or
refusal of resuscitation or limited to palliative care.
▪ Types of Advanced directives:
1. The Living Will:
- A written form of advance directive
- Should be clear & specific, the “living will” is most valid and usable when specific
tests and treatments are outlined.
2. Health Care Proxy “medical power of attorney”
- The health-care proxy is a person chosen specifically by the patient to make
health-care decisions for her in the event that she cannot make decisions for
herself.
- These decisions are limited to health care, not finance.
- The proxy outweighs all other potential decision makers, including the family.
- The proxy makes decisions based on two parameters:
a. The patient’s directly expressed health-care wishes (written or verbal
expression)
b. What the patient would have wanted if he/she had capacity.
Here is a list of the various kinds of consent, with the most desirable listed first:
▪ Direct patient wishes verbalized by the patient
▪ Formal advance directive (a proxy or a living will)
▪ Oral advance directive
▪ Surrogate decision-makers: (United group of family in end of life issues; if Family
members disagreement→
▪ Ethics committee
▪ Courts
Terminology and concepts
Terminal illness, also called (maradh al maut) is an illness from which recovery is not expected. Death is
expected within 6 months.
Palliation consists of measures taken to make the remaining life of a terminal patient as comfortable as
possible; it includes pain relief, support (psychological, social, and spiritual), nutrition, hydration, etc.
Palliative care starts when the hope for cure of the disease disappears.

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 End of Life Issues
Withholding/ ▪ Withholding of life support: is not instituting futile artificial life support measures
Withdrawal in a terminal or critically ill patient.
of life support ▪ Withdrawal of life support: is terminating futile artificial life support measures in
a terminally or critically ill patient, or in some cases in patients who are clinically or
brain-dead, but still on life support.
▪ There is no ethical or legal distinction between withholding and withdrawal of
medical treatment.
The artificial fluids and nutrition (AFN):
▪ “Artificial nutrition” basically refers to any form of nutrition other than eating.
- Feedings or fluids administered by nasogastric, gastric, or jejunostomy tube.
- Intravenously administered nutrition such as total parenteral nutrition (TPN),
also referred to as hyperalimentation.
▪ Competent adult:
- The artificial administration of fluids and nutrition is a medical procedure and
treatment that can be accepted or refused by a competent adult in exactly the
same manner as any other treatment.
- Competent adult with the Capacity to Understand his own medical problems has
the right to determine what treatments he does or does not wish to receive.
- Forced Feeding is considered the same as assault and battery.
▪ Adult Who Has Lost the Capacity to Understand: Unless there are advance
directives or a family agreement to withhold / withdraw; we can never withhold
ordinary nutrition like food to eat and water to drink, we should continue in the basis
of the patient’s best interest.
(DNR) order ▪ A “Do Not Resuscitate” (DNR) order means if the patient has cardiopulmonary
arrest, the doctor does not perform a cardiopulmonary resuscitation (CPR) i.e.:
- Don’t perform chest compressions
- Don’t attempt electrical cardioversion
- Don’t administer IV anti-arrhythmic medications.
▪ DNR does not mean patients should receive less of care or less of anything except
cardiopulmonary resuscitation.
▪ DNR does not mean it is okay just to let the patient die, or that the doctor does not
have to be as careful, DNR should get all other aspects of routine good care such as
surgery, biopsies, or dialysis.
▪ Although controversial, a patient can still be intubated and maintained on a ventilator
if s/he is DNR.
▪ A Do Not Treat (DNT) order is an advance medical decision to withhold futile
therapeutic intervention from a terminally ill patient, such as cancer; however,
palliative and symptomatic treatments can continue.
▪ Resuscitation should be carried out for cases of reversible cardio-respiratory arrest,
(Don’t misunderstood DNT order as DNR order).
Physician- ▪ In physician-assisted suicide, the physician provides the patient with the means of
Assisted ending his own life.
Suicide ▪ Physician-assisted suicide is always considered incorrect and ethically
unacceptable.

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Euthanasia Euthanasia, also called mercy killing, (qatl al rahmah):
▪ Painless killing of a terminal patient suffering from painful incurable disease or in
irreversible coma.
▪ The intension is to relief the patient suffering.
Classifications:
▪ According to Procedure:
- Active euthanasia: acts of commission deliberately bring about death e.g. lethal
injection
- Passive euthanasia: acts of omission lead to death e.g. withdraw of life support.
▪ According to Consent:
- Voluntary (with patient consent)→ Legal in some countries
- Non-voluntary (without patient consent)→ Illegal
- Involuntary (against the patient wish)→ Murder

Terminal ▪ There is an enormous difference between administering a lethal injection and giving
Sedation (the pain medications that might inadvertently shorten a patient’s life. The issue is one
law of double of intent.
▪ If the intent is to end life, it is wrong. If the intent is to relieve suffering and
effect)
accidentally - as an unintended effect - the patient’s life is shortened, then the
treatment is acceptable.
Futile Care ▪ The physician is not under an obligation to give treatment or perform tests that will
not benefit the patient. This is true even if the patient or the family is demanding it.
▪ The major problem in withholding or withdrawing therapy on the basis of it being
futile is being sure that there will be no benefit. It is hard always to be certain if the
treatment will not help.
▪ If it is clear that there will be no benefit then you should not give it.
Advanced ▪ DETERMINATION OF DEATH AND BRAIN DEATH
Topics ▪ POSTMORTEM “AUTOPSY” (ethico-legal issues)

Review 1. Define / Compare the following concepts:

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