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Palliative Care - Ethical Issues - Fast Facts | NEJM Resident 360

Medical Ethics Framework

A standard approach to biomedical ethics, developed by Thomas Beauchamp and James Childress in Principles of Biomedical Ethics (first published in 1985), evaluates ethical dilemmas based on the balance of four ethical principles:

• Autonomy: Each patient has the right to make choices regarding treatment and goals of care without coercion or coaxing.

• Justice: The risks and benefits of any choice must be distributed equally among all people.

• Beneficence: Care must be provided with the intent of doing good for the patient.

• Nonmaleficence: Care should not harm the patient or others.

Key Ethical Issues and Definitions in Palliative Care:

• Opioid use and the prin****ciple of double effect: The principle of double effect is often used in palliative care to justify use of opioid medications to alleviate symptoms such as pain or breathlessness at the end of life. The following four criteria must be met if the action is to be morally permissible:

Principle of Double Effect

The action must be either morally good or neutral.
The bad effect must not be the means by which the good effect is achieved.
The only intention must be achievement of the good effect, and the bad effect must be only an unintended side effect.
The good effect must be at least equivalent in importance to the bad effect.

(Adapted from: A 44-Year-Old Woman with Intractable Pain Due to Metastatic Lung Cancer. N Engl J Med 2015.)

When prescribed proportionately, the risk is low for respiratory depression and hastened death from opioid therapy. In the rare case that death is hastened by proportional opioid treatment, we invoke the principle of double effect, as the intention of the action (administering opioid medication) is to relieve pain and not to cause death.

• Advance directives: These legal documents used in advance care planning allow patients to document goals and wishes regarding their care. Examples include a living will, durable power of attorney for health care, medical power of attorney, and health care proxy. Advance directives are not medical orders and therefore cannot be followed by first responders in a crisis. On the other hand, Portable Orders for Life-Sustaining Treatment (POLST) serve as medical orders and can be followed across all care settings.

• Surrogate decision-makers: We always look to the patient first to clarify goals and values. However, sometimes patients are unable to make health care decisions. In this case, we look to a surrogate appointed by the patient (durable power of attorney for health care, medical power of attorney, health care proxy agent) to provide guidance. Surrogate decision-makers are asked to make decisions based on the concept of substituted judgement — what they think the patient would want based on their understanding of the patient’s goals and values. If the patient is unable to make decisions and did not appoint a surrogate decision-maker, many states have statutory priority lists that rank-order who the decision-maker should be. These lists vary by state, and in some states, the best decision-maker is based on who has the best understanding of the patient’s values.

• **Advance care planning:**Advance care planning is a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care. The goal is to ensure that people receive medical care that is consistent with their values, goals, and preferences. (See Goals of Care in this rotation guide for a detailed approach to such discussions.)

• Voluntary stopping of eating and drinking (VSED): VSED refers to voluntary refusal of all food and liquids with the understanding that doing so will hasten death. It is utilized by patients with terminal illness who do not want their dying process prolonged. VSED is a legal and legitimate approach to limiting suffering at the end of life for patients with a terminal disease.

• Physician aid in dying (or physician-assisted death [PAD]or medical aid in dying [MAID]): PAD or MAID refer to when a medical clinician prescribes a lethal dose of medication to a competent, terminally ill patient at the patient’s request. Once prescribed, the patient may or may not choose to use the medication to end his or her life. The legality of PAD varies by state, and is currently legal in California, Colorado, Hawaii, Maine, Montana, New Jersey, Oregon, Vermont, Washington, and the District of Columbia. The American Academy of Hospice and Palliative Medicine has taken a position of “studied neutrality” on the question of whether PAD should be legally permitted.

• Euthanasia: Euthanasia is the act of administering a lethal dose of medication to a person with the intention of ending the person’s life for the purpose of relieving pain and suffering. Euthanasia is not legal and not supported by palliative care practice.

Read a summary of legal landmark cases in palliative care here.

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