Ethical Issues in End-of-Life Decision Making

1. The Four Core Bioethical Principles

2. Informed Consent and Decision-Making Capacity

• A patient with decision-making capacity has the right to consent to or refuse any treatment, including life-sustaining therapy - this is firmly established in common law.
• Capacity requires: ability to understand information, appreciate consequences, reason, and communicate a choice.
• If capacity is lost (e.g., sedated ICU patient, obtunded, comatose), a surrogate decision maker steps in.
• Surrogates apply two standards:
  • Substituted judgment - "What would the patient have wanted?" (guided by advance directives)
  • Best interests standard - used when patient's prior wishes are unknown

3. Advance Directives

• Legal documents that express patient wishes before incapacity develops.
• Types:
  • Living Will - specifies desired/undesired treatments (e.g., no mechanical ventilation)
  • Durable Power of Attorney for Healthcare (DPAHC) - designates a specific surrogate decision maker
  • POLST/MOLST - Physician/Medical Orders for Life-Sustaining Treatment
• The Patient Self-Determination Act (USA, 1990) mandates asking all admitted patients if they have advance directives.
• Advance directives must be reviewed and honoured in the perioperative period.

4. DNR (Do Not Resuscitate) Orders - Specific Anesthesia Issue

• Automatic suspension of DNR in the OR is ethically problematic - the ASA opposes routine suspension.
• The ASA Ethical Guidelines require required reconsideration of DNR orders before surgery, not automatic suspension.
• Three approaches in the perioperative period:
  1. Full suspension - DNR suspended for entire perioperative period (patient/family consents)
  2. Procedure-directed - specific resuscitation procedures limited (e.g., no chest compressions, but vasopressors allowed)
  3. Goal-directed - resuscitation based on clinical context and patient's stated goals
• Anesthesia itself alters physiology in ways that may mimic cardiopulmonary arrest; many perioperative events (e.g., laryngospasm, drug-induced hypotension) are rapidly reversible - this justifies selective resuscitation rather than blanket DNR enforcement.

5. Withholding vs. Withdrawal of Life-Sustaining Therapy

• Ethically and legally, withholding (not starting) and withdrawing (stopping) life support are considered equivalent.
• Both are ethically justified when:
  • Treatment is medically futile
  • Patient or surrogate refuses treatment
  • Burdens outweigh benefits
• Commonly withheld/withdrawn: mechanical ventilation, vasopressors, renal replacement therapy, artificial nutrition and hydration.
• The landmark Quinlan case (1976) established that surrogates can refuse mechanical ventilation for a vegetative patient.

6. Medical Futility

• Treatment is futile when it cannot achieve the patient's goals or provides no meaningful benefit.
• Quantitative futility: an intervention has < 1% chance of achieving its goal based on evidence.
• Qualitative futility: the quality of life achievable is unacceptably poor.
• Physicians are not obligated to provide futile treatment, even when demanded by families.
• Disagreements about futility should be resolved through ethics committee review.

7. Principle of Double Effect

• Applicable when giving adequate opioids/sedatives for pain and dyspnea in dying patients may secondarily hasten death.
• Ethically permissible if:
  1. The primary intention is to relieve suffering (not to cause death)
  2. The dose is proportionate to the symptom
  3. Death is a foreseen but unintended consequence
• This is the ethical justification for palliative/terminal sedation.

8. Palliative Sedation to Unconsciousness

• Used for refractory suffering near death (uncontrolled pain, dyspnea, agitation).
• Ethically distinct from euthanasia - intent is relief of suffering, not death.
• AMA Code of Medical Ethics Opinion 5.6 addresses sedation in end-of-life care.

9. Euthanasia and Physician-Assisted Death

• India's Supreme Court in Common Cause vs. Union of India (2018) recognised passive euthanasia and the right to die with dignity, and gave legal validity to advance medical directives.

10. Shared Decision Making (SDM)

• The ATS/SCCM 2016 joint statement defines SDM as collaboration between patients, surrogates, and clinicians using best evidence + patient values.
• Requires: information exchange, deliberation, and a treatment decision.
• ICU family conferences are the primary forum - but evidence shows they are frequently suboptimal (clinicians often fail to elicit patient values or discuss purely palliative options).
• Good communication reduces family decisional conflict and post-traumatic stress.

Quick Summary for 5-Mark Answer (Exam Template)

1. Four bioethical principles (beneficence, non-maleficence, autonomy, justice)
2. Decision-making capacity and surrogate decision makers
3. Advance directives (living will, DPAHC)
4. DNR in perioperative period - ASA guidelines (required reconsideration, not automatic suspension)
5. Withholding vs withdrawal - ethically equivalent
6. Medical futility
7. Double effect principle / palliative sedation
8. Euthanasia - passive vs active (Indian legal context)