Moral and Ethical DilemmasMoral and Ethical Dilemmas in End of Life Care and in End of Life Care and

DementiaDementia

Ethical DilemmasEthical Dilemmas• Truth Telling• Consent• Confidentiality• Hydration• Feeding• Justice• Euthanasia• Symptom Management

Ethical FrameworksEthical FrameworksPrinciples basedDuties basedConsequentialistNon-consequentialistUtilitarian

Ethics – not universalEthics – not universalTimePlaceSocietyCultureReligion

Principle Based Approach to Principle Based Approach to BioethicsBioethics

BeneficenceNon-malficenceRespect for autonomyJustice

BeneficenceBeneficence

Non-malficenceNon-malficence

AutonomyAutonomyRespect for the autonomy of others

in so far as such respect is compatible with respect for the autonomy of others

Make decisions based on deliberation and values

AutonomyAutonomyCapacity – situation specificAffected by cognitive (and

communication) deficits

Bodily AutonomyBodily AutonomyResistive behaviour to care

JusticeJusticeFairness

JusticeJusticeDistributitive justiceRights based justiceLegal justice

JusticeJusticeTreat equals equallyTreat unequals unequally

Ethical Aspects of Symptom Ethical Aspects of Symptom Management in DementiaManagement in Dementia

Patient report essentialLimited evidence baseNo effective symptom-

assessment tools? Under management

Artificial Feeding in Advanced Artificial Feeding in Advanced DementiaDementia

No evidence of reduction in pressure sores, infection, improved function, comfort, survival

Finucane, Christmas, TravisJAMA, 1999: 282(14), 1365-70

Percutaneous endoscopic gastrostomy does not prolong survival in patients with dementia

Murphy and LipmanArch Int Med 2003, 163; 1351-3

Artificial HydrationArtificial HydrationWhat is the purposeBenefits - prolong life

- relieve symptomsBurdens

IV access Subcutaneous inflammation Hospitalisation Fluid overload

Artificial HydrationArtificial Hydration

A blanket policy is ethically indefensible

Towards death a person’s desire for food and drink lessens

Evidence suggest Artificial Hydration in imminently dying patients influences neither survival or symptom control

An Bord Altranais An Bord Altranais

‘So long as there is a means of nutrition and hydration it is the duty of the nurse to provide nutrition and hydration’

Medical Council of IrelandMedical Council of Ireland

‘The Council reiterates its view that access to nutrition and hydration remain one of the basic needs of human beings and all reasonable and practical efforts should be made to maintain both of them’

Advance Directive / Care Advance Directive / Care PlanPlan

Ethical to respect if current situation reflects envisaged situation

May be formally writtenMay be informal – patient’s

wishes

Advance Directive/ Care Advance Directive/ Care PlanPlan

The role of family/social networkSubstituted decisionNot ’legal’ but likely to be

recognised by courts

Confidentiality Confidentiality An ethical obligationMay need to be breached if a

patient is not able to make decisions about care

Views of family about what patient would have wanted

Truth TellingTruth Telling

What is the ethical obligation? Consequentialist Nonconsequentialist

‘Negotiated’ truth telling

Moral and Ethical Dilemmas Moral and Ethical Dilemmas at the End of Life and at the End of Life and

DementiaDementia

Do the right thingThe patient’s voiceForward planning Framework for decision making

informed by professional code and an ‘ethical guide’