Ethical Issues in End of Life Care
Providing proper end of life care has become a fundamental requirement for healthcare professionals. Every decision that a medical practitioner makes needs to be ethical particularly with matters such as assisted suicide or euthanasia emerging in end of life care. Although medical knowledge and technology has increased rapidly, medical practitioners face a dilemma in choosing the best options to ease the pain before the patient takes his/her last breath. Forgetting the aspect of spirituality in patient care before death makes it difficult to offer holistic care to patients. Through ethics, healthcare professionals have become careful of how they exploit current technology in handling dying patients. Thus, ethics contribute significantly to clinical decision-making, particularly with dying patients, since it increases expectations and moral worthiness of healthcare professionals.
Ethical Dilemmas in Palliative Care
Ethical issues are problems or situations that necessitate individuals or organizations to decide on various alternatives that can be either morally right or wrong. For instance, it is morally unacceptable for healthcare professionals to remove patients from life-support equipment without approval from family members. Sometimes ethics go beyond legal provisions, as the law does not coerce health professionals to act contrary to their personal consciences. In such circumstances, questions may be raised as to whether the actions taken are ethical or unethical. According to Jeffrey (2006), ethical issues that touch on patient care should be identified and frameworks established to help healthcare professionals, as well as patients, in making difficult or controversial decisions.
End-of-life care has its own dilemmas, often captured by the media, as families seek orders from courts to withdraw life-sustaining apparatus from dying family members once medical experts declare that the patients have no hope for recovery. The end of life involves the time when patients approach the end of their mortal lives and disengage from human relationships with other people while reconciling with undesirable past events and seeking spiritual peace (Dunlop, 2007). Even though medical professionals have continued inventing new methods of treatment to evade death or delay the end of life, most individuals have persisted in questioning the ethics of medical care. Advanced medical care therefore, does not necessarily assure patients of prepared death, but rather prolongs the time that they spend with their loved ones.
Death is one of the essential aspects of human life that individuals cannot live without thinking about. Although there has been a dramatic development in medical knowledge and technology in recent years, sudden deaths are still common in healthcare facilities. Nowadays, it has become rare for patients to die without raising the issue of limited care. While the facts concerning death are unavoidable, the timing of death is in the hands of humans and God. Gradual deaths seem to raise more ethical challenges than sudden deaths due to the rise in life-sustaining technologies (Dunlop, 2007).
The deployment of life-sustaining technology has created a conflict between patients’ interests and the interests of individuals who are likely to gain when the patient dies. The rights of families to request intervention in terms of terminal care deserve respect, as some patients may have already lost the ability to decide what is best for them. Patient’s interests pose a dilemma to healthcare professionals who may be of the opinion that a life-sustaining method does not benefit the patient, but the patient insists on having it anyway.
There is a big gap between killing and allowing an individual to die depending on the situation. Euthanasia has raised several ethical issues, as healthcare professionals have to explain the circumstances that may lead to ending the life of a chronically ill patient without interfering with his/her rights. Both proponents and opponents of euthanasia can argue that the practice can be performed by either action or omission (Watt, 2000). For people who argue that patients lack human status or valuable life, carrying out euthanasia may appear ethical as long as other people are unaffected. On the contrary, those who believe that patients possess human status and that life has an intrinsic value, carrying out euthanasia could harm patients, as well as the individuals conducting it.
Critics argue that allowing patients to decide on matters of medical care to shorten their lives may undermine the motivation of healthcare professionals in their commitment to offer the highest care to all patients. However, doctors should not decline requests for euthanasia as long as they respect patient’s autonomy. It may be hard for the healthcare professionals to abide by a patient’s decision, particularly when the patient’s mind is sound. However, such decision must stand, as the work of palliative care is to support determinations made by patients in all situations. Patient autonomy is the main defense for euthanasia and healthcare professionals have to evaluate the patient’s request in an ethical manner (Watt, 2000).
Society may perceive denial of life sustaining resources as ethical if such resources offer no benefit to the terminally ill patient. Society also has an interest in the allocation of scarce resources, and if the cost of sustaining an ailing patient rest entirely on society, a patient’s desire may be overruled by the need to serve other patients who could benefit from these resources. Healthcare professionals should therefore evaluate the costs and benefits involved before making judgments on matters concerning life.
Patients should always be allowed to contribute to decisions concerning their medical care. Life-sustaining treatments should offer benefits that respect a patient’s preference. Once established, the withdrawal of life-sustaining treatment can be regarded as ethical when the patient makes the request. Thus, healthcare professionals should seek approval from patients before prescribing any form of treatment. Patients can decline treatment even when they are quite sure that such refusal may lead to death. However, patient’s request for euthanasia may not be considered as an obligation or ethical if life is worthless (Watt, 2000). Ethical dilemma emerges when non-autonomous patients are denied euthanasia when death seems to be a benefit to them.
A Good Death
Healthcare professionals face a moral dilemma on whether it is right or wrong to terminate the life of a patient who has been in severe pain and has no hope of survival. It is normal for human beings to hope for life, but they must also focus on having a good death. For many people who believe in Christianity, it is almost impossible to think about having a good death without incorporating spirituality. Spirituality involves seeking the meaning of life and connection to a greater power through reflection, belief and ethics. Christians believe that a good death is the natural course of commitment to faith that an individual made earlier in life (Dunlop, 2007).
Society is considered civilized if it treats people ethically before their lives end. Every individual merits a good death and this should be communicated early before death. Experiences of fear, family issues and feelings of guilt may emerge as patients approach death. Thus, healthcare professionals should strive to offer psychosocial care as relief from suffering. Palliative care is an appropriate course to a good death because it enhances the quality of life among patients who have encountered life-threatening illnesses. Palliative care ensures that a patient’s needs are identified and appropriate treatments are administered to ease suffering.
A good death can be assured through proper communication between the patient, the caregiver and the family members. In palliative care, patients are permitted to express their needs openly so that they can receive appropriate assistance from their caregivers. However, Patients who seek their own versions of good death often face challenges while making end of life choices, since they require assistance from other autonomous individuals. Consequently, the level of care directed to the patient may be far beyond what they really wanted. When such patients die, they leave their families with questions as to why they had to die, considering that amily members had made the appropriate choices.
Terminally ill patients command respect and an assurance of better treatment even when they are almost sure they would not survive for long. Considering the scenario offered by Dunlop (2007) concerning a 97 years old grandmother, the doctor allowed a surgery, hoping that she would recover, but she ended up in the ICU with no hope of recovery. Telling family members that she would not recover would have been a shock after undergoing successful surgery. Reconciling with people who have wronged the patient and letting go of life-sustaining treatment are some of the assurances of a good death. For Christians, death does not end life; it only offers a new beginning of eternal life after living a godly life.
Spiritual Care in End of Life
Patients experience physical, emotional, psychological and spiritual distress as they approach their time of death. However, matters of spirituality are often overlooked during patient care despite this being a main concern for many people before death occurs. The application of spiritual care is extremely vital for the end of life, because it focuses on matters of contentment and security. Abbas and Panjwani (2008) defined spirituality as something that offers humans a transcendent meaning in their lives. This implies that spirituality is not something tangible, but a religious belief that connects individuals with their families as well as their communities. Spirituality is more powerful than religiousness as it relates to people’s perception of the ultimate meaning of life. Through spirituality, healthcare professionals can liberate dying patients from hopelessness and guilt.
Failure to take cognizance of appropriate spiritual care may consequently result in failure of the overall patient care. This is because spirituality enables patients to feel divine power, understand the meaning and purpose of life, apply ethics to their deeds and appreciate the beauty of nature. Apart from physical, social and psychological pain, patients also experience spiritual pain, which makes them question their relationship with their God, or other supreme being/s (Abbas & Panjwani, 2008). Thus, healthcare professionals have a responsibility to listen to patients struggling with illnesses before their death. If terminally ill patients are left wallowing in despair and insecurity, they tend to suffer more. Christians believe that individuals can attain spiritual growth and develop a closer relationship with God by being ethical in their actions.
All forms of suffering, including illnesses, make individuals evaluate themselves through soul-searching. Patients may feel guilty of something, or feel vulnerable as they go through pain and distress, since they tend to feel that they are no longer the same person they were before the suffering started. Thus, palliative care is useful in assisting patients to understand their spirituality before they die. According to Abrahamic faith, God is the provider of life and all kinds of thinking and awareness emanate from him (Abbas & Panjwani, 2008).
The most essential aspect in palliative care is to give hope and comfort to the dying patient so that they can be relieved of their inner fears. During the early stages in palliative care, patients develop the hope that they would recover from their sickness. Later on, when a cure seem impossible, hope wanes and patients may hope that time would allow them to make peace with their families and with God, in order to experience a peaceful death. Turning to spiritual care enables healthcare professionals to understand the kind of distress that affects patients mostly and they can then devise ways of approaching these issues without annoying the patients. Spirituality has also been helpful to caregivers who often turn to spiritual discussions whenever they feel burned out in their busy schedules. The problem with spirituality in healthcare is that it lacks clarity since it focuses on individual nuances, affecting how healthcare professionals approach patients.
Healthcare professionals need to be ethical when handling terminally ill patients during their last moments of life because such moments allow for evaluation of their earlier life both emotionally and spiritually. They should understand intangible needs among patients in order to relieve the fears and insecurities that develop as end of life approaches. Technological advancement in end of life care has made most patients fear how they would die rather than fear death itself. This has made medical professionals abide by patient’s requests even when they are convinced that such requests are unnecessary. Dying is one of the most undesirable experiences that an individual can look forward to and healthcare professionals should ensure that they respect the last wishes or requests of their patients.
Abbas, S. Q. & Panjwani, S. (2008). The Necessity of Spiritual Care Towards the End of Life. Ethics & Medicine, 24(2): 113-118.
Dunlop, J. (2007). A Good Death. Ethics & Medicine, 23(2): 69-75.
Jeffrey, D. (2006). Patient-centred ethics and communication at the end of life. Abingdon: Radcliffe.
Watt, H. (2000). Life and death in health care ethics: A short introduction. London: Routledge.