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When stakes are high and emotions run strong Ethical dilemmas at the
End of Life
October 27 2015
Andi Chatburn DO MA
Palliative Care Physician
Medical Director for Ethics Providence Health Care
wwwprovidenceorgethics
Objectives
bull Introduce the scope of Palliative Care and Hospice Care and ways they intersect
bull Discuss the common ldquoevery day ethicsrdquo that arise in caring for patients and families at the end of life
bull Examine the end-of-life experience from patient and family perspectives discussing implications for physicians
bull Analyze cases where ethical principles and values conflict in serious illness and at the end of life
bull Note how humanities and self-reflection are important tools in educating whole-person physicians
Reminder regarding Cases
bull Cases are based on actual clinical experiences Please respect the privacy and confidentiality of the actual patients and families behind the de-identified cases
bull The cases presented may not include all the information you may want in order to make your recommendation
Nothing to disclose
When itrsquos personal all bets are off
Sam Caplet ldquoDonrsquot Let Gordquo
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
wwwprovidenceorgethics
Objectives
bull Introduce the scope of Palliative Care and Hospice Care and ways they intersect
bull Discuss the common ldquoevery day ethicsrdquo that arise in caring for patients and families at the end of life
bull Examine the end-of-life experience from patient and family perspectives discussing implications for physicians
bull Analyze cases where ethical principles and values conflict in serious illness and at the end of life
bull Note how humanities and self-reflection are important tools in educating whole-person physicians
Reminder regarding Cases
bull Cases are based on actual clinical experiences Please respect the privacy and confidentiality of the actual patients and families behind the de-identified cases
bull The cases presented may not include all the information you may want in order to make your recommendation
Nothing to disclose
When itrsquos personal all bets are off
Sam Caplet ldquoDonrsquot Let Gordquo
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Objectives
bull Introduce the scope of Palliative Care and Hospice Care and ways they intersect
bull Discuss the common ldquoevery day ethicsrdquo that arise in caring for patients and families at the end of life
bull Examine the end-of-life experience from patient and family perspectives discussing implications for physicians
bull Analyze cases where ethical principles and values conflict in serious illness and at the end of life
bull Note how humanities and self-reflection are important tools in educating whole-person physicians
Reminder regarding Cases
bull Cases are based on actual clinical experiences Please respect the privacy and confidentiality of the actual patients and families behind the de-identified cases
bull The cases presented may not include all the information you may want in order to make your recommendation
Nothing to disclose
When itrsquos personal all bets are off
Sam Caplet ldquoDonrsquot Let Gordquo
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Reminder regarding Cases
bull Cases are based on actual clinical experiences Please respect the privacy and confidentiality of the actual patients and families behind the de-identified cases
bull The cases presented may not include all the information you may want in order to make your recommendation
Nothing to disclose
When itrsquos personal all bets are off
Sam Caplet ldquoDonrsquot Let Gordquo
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Nothing to disclose
When itrsquos personal all bets are off
Sam Caplet ldquoDonrsquot Let Gordquo
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
When itrsquos personal all bets are off
Sam Caplet ldquoDonrsquot Let Gordquo
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
US Army
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Grayerbaby
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Cagle
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Common Ethical Dilemmas at the End of Life
bull Withholding and Withdrawing medical interventionsndash Code Status and Unilateral DNAR
ndash Artificial Hydration amp Nutrition
ndash Turning off ICD or much less commonly pacemaker
ndash When to stop chemoXRT
ndash Mechanical Ventilation
bull Surrogate Decision Makers
bull Disagreement between patientfamily amp medical teams
bull Unique religious preferences at end of life
bull Non-Beneficial or Futile medical interventions
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Providence Model for Ethics
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
The Providence Model
Promote
bull Honesty in representing right professional practices and delivery of health care
bull Dependability in delivering care that benefits patients medically
bull Fairness to patients in their contexts
bull Accountability to the legitimate interests of others in light of justice
Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making copy2014 ndashNicholas J Kockler
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ethical Decision-Making Model
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical IntegrityBeneficence
AutonomyJustice amp
Nonmaleficence
Therapeutic relationship between patient and provider
amp
Narrative
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical Context
Acute Rescue Fix Chronic Maintain Manage Palliative Alleviate Enhance QOL Life-Sustaining Prolongation of
biological life Futile Non-Beneficial
or harmful
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ms C
bull 88 year old woman
bull Admitted to hospital for combativeness not eating
bull Advanced Dementia lt7 words
bull Not eating losing weight
bull Maximally Cachectic 87 lb
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical Integrity-My relationship with my profession
bull How do we make a care plan when we are still uncertain about the diagnosis or prognosis but need to act now
bull What care options should be offered
bull What should we do when the patientrsquos or familyrsquos goals seem inconsistent with traditionally recognized goals of care
bull How do I resolve professional issues such as truth-telling coercion or conflicts of interest
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ms C
bull 88 year old woman
bull Ms P is lifelong devout Catholic
bull 3 daughters 2 sons
bull Widowed
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
How does Ms C Express her Autonomy
bull Patient Self Determination Act 1991
bull Advance Directives
ndash Durable Power of Attorney for Health Care
ndash Living Will
ndash Conversations with family
ndash POLST TPOPP
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ms C
bull Has an advance directive
bull Named 3 of her 5 children as joint DPOA-HC
bull Section on Artificial Hydration and Nutrition (AHN) has 2 boxes to be checked
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ms C
ndash I would want Artificial Hydration and Nutrition
ndash I would not want Artificial Hydration and Nutrition
bull Neither box is checked
bull Default in fine print at bottom of form states that if neither box is checked default is to give Artificial Hydration amp Nutrition
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ms C
bull 5 children
bull Oldest Daughter in Maryland
bull 2 sons live within 1 hour
bull Youngest daughter is caregiver
bull Children are split on what to do
bull 3 of the 5 are listed as joint DPOAs
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Autonomy-My relationship with the patient
bull Does the patient understand whatrsquos wrongbull What does my patient think is a good outcomebull What is my patientrsquos cultural religious or ethnic
point of viewbull Can my patient make decsionsbull Can my patient participate in a complex care plan
or follow-up planbull Will my patient engage in the care planbull What are my patientrsquos goals and aspirationsbull WhatWho are my patientrsquos support system
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Beneficence-My relationship with the outcomes
bull Am I fixing whatrsquos wrong
bull Am I effectively managing a disease process
bull Am I appropriately managing my patientrsquos last days
bull Am I simply delaying the inevitable
bull Am I causing harm to my patient Or am I worried Irsquom causing more harm than good
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
wwwchoosingwiselyorg
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Youlsquore sick Itrsquos serious
httpwwwgeripalorg201102youre-sick-its-serioushtml
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Palliative Care
Palliare (Latin) to cloak comfort
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Palliative Care
bull Who
ndash Anyone with a serious illness
bull What
ndash Pain and symptom relief
ndash Psychosocial support
bull Goal
ndash Find out what matters most
ndash Improve Quality of Life
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
The Disease Spectrum
httpwwwmedumichedugeriatricspatientpalliative-faqhtm
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Hospice v Palliative Care
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Clinical Integrity Beneficence
AutonomyJustice amp
Non-Maleficence
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Justice amp Nonmaleficence-My relationship with others
bull Do I owe my patientrsquos family somethingbull Do I owe my colleagues somethingbull Is my patient at risk for being hurt and if so do I
have an obligation to prevent harmbull Can I explain the protections in place or the lack of
protectionbull Are there conflicts of interest that could harm my
patient or someone elsebull Am I being a good steward of resourcesbull Do I owe society or the community somethingbull Do I owe my employer or its sponsors something
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Access to Primary Palliative Care
Communication about treatment options amp pain and symptom management that happens between a patient and their
regular doctor
Conversation should be built in to regular visits for any patient with serious illness
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Changing medical attitudes about death
bull Death is NOT a failure of the physician
bull Death as a natural part of life
bull Goals of Medicine prevent an untimely death
bull Responsible medical spending and social justice
ndash Bankruptcy is not infrequent in families of patients that have extended hospital stays in the last 3 months of life
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Choosing Wisely Campaign- AAHPM
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Support for Palliative Care via Choosing Wisely Social Justice
bull American College of Emergency Physiciansndash Donrsquot delay engaging available hospice and palliative care
services in the emergency department for patients likely to benefit
bull Society of Gynecologic Oncologyndash Donrsquot delay basic level palliative care for women with advanced
or relapsed gynecologic cancer and when appropriate refer to specialty level palliative medicine
bull American Society of Clinical Oncologyndash Donrsquot use cancer-directed therapy for solid tumor patients with
hellip low performance status no benefit from prior evidence-based interventionshellip and no strong evidence supporting the clinical value of further anti-cancer treatment
bull AMDA amp American Geriatrics Societyndash Donrsquot insert PEG tubes in individuals with Advanced Dementia
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Common Reasons for Specialty Palliative Care Consult
Symptoms
bull Uncontrolled pain
bull Nausea
bull Constipation
bull Dyspnea
bull Fatigue
bull Loss of appetite
bull Depression
bull AgitationDelirium
Goals of Care
bull Family communication
bull Guidance with complex treatment choicesndash Feeding Tube
ndash Code Status
ndash Surgical Intervention
ndash When to stop dialysis
bull Emotional and Spiritual Support
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Back to Ms C
Sam Caplet ldquoDonrsquot Let Gordquo
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Should a Feeding Tube be Placed
bull Would this be Ms Prsquos most likely desire
bull Who decides
bull Would Tube Feeds be clinically appropriate
bull What would the family see as a good outcome
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ms C- symptom managment
bull Increasing agitation
bull Grimacingmoaning
bull Daughter at bedside states ldquono pain medicinerdquo
bull Already on antipsychotic medication for agitation to avoid physical restraints in the hospital
bull Familyrsquos story 5th daughter that no one mentions
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Ethics of Pain Control
bull Stigma of addiction v pseudo addiction
bull Side effect of somnolence
bull Potential for high dose opiates at end of life
bull High risk
ndash Potential for diversion of medications
bull Doctrine of Double Effect
ndash Shortens life span Does it matter
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Principle of Double Effect
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Responding to Intractable Terminal Suffering
Quill and Byock
bull Terminal (Palliative) Sedation and voluntary refusal of hydration and nutrition ought to be more commonly considered options
bull Ought to be considered for all types of suffering not only physical pain and symptoms
bull Physicians should make sure the request is not coming from pt having undiagnosed depression or symptoms that can be treated with palliative measures
Letter to the editor Sulmasy et al
bull Mistaken and dangerous impression that there is consensus among experts
bull Agree that could be appropriate therapy when performed in carefully selected cases by palliative care specialist
bull Disagree that there is a wider range of indications for terminal sedation
bull Unclear what sorts of suffering might be an indication for terminal sedation
Quill TE Byock IR Responding to intractable terminal suffering the role of terminal sedation and voluntary refusal of food and fluids Ann Intern Med 2000 132 408-414
Sulmasy Ury Ahronheim Siegler Kass Lantos Burt Foley Payne Gomez Krizek Pellegrino Portenoy Letters to the editor responding to Quill and Byock Ann Intern Med 2000 133(7) 560-562
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Quill and Byock
ldquoMedicine cannot sanitize dying or provide perfect solutions for all clinical dilemmas
When unacceptable suffering persists despite standard palliative measures
terminal sedation and voluntary refusal of food and fluids are imperfect but useful last-resort options that can be openly
pursuedrdquo
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Controversy at End of Life
bull Physician Aid in Dying ndash Oregon 1998
ndash Washington 2008
ndash Vermont May 2013
ndash Montana- 2009 (Baxter v Montana)bull Physician right to challenge charge if prosecuted for
prescribing a medication intended for physician aid in dying
ndash California 2015
bull Euthanasiandash Netherlands Switzerland
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Self Care
When you do the physically and emotionally hard work of doctoring
no matter which specialty
it is important to find something that nourishes your soul
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
Referenceo Beauchamp TL amp Childress JF (2008) Principles of biomedical ethics (6th ed) New York Oxford University
Press
o Charon R (2006) Narrative medicine Honoring the stories of illness New York Oxford University Press
o Charon R amp Montello M (Eds) (2002) Stories matter The role of narrative in medical ethics New York Rutledge
o a AR et al (2006) Clinical Ethics A Practical Approach to Ethical Decisions in Clinical Medicine (6th ed) New
York McGraw-Hill
o Jonson AR amp Toulmin S (1990) The abuse of causistry A history of moral reasoning Berkely CA University of
California Press
o Kockler N Seeing Ethics Consultaitons for the First Time Disclosure Models Analytic Design and Ehtical Decision-Making
copy2014 ndashNicholas J Kockler
o Montello M(Ed) (2014) Narrative Ethics The Role of Stories in Bioethics The Hastings Center Report Special
Reports
o McGee G (2003) Pragmatic bioethics (2nd ed) Cambridge AM MIT Press
o Pellegrino ED (1995) Toward a virtue-based normative ethics for heath professions Kennedy Institute of Ethics
Journal 5(3) 253-277
o Pellegrino ED amp Thomasma DC (1993) Virtues in medical practice New York Oxford University Press
o Sulmasey D and L Snyder Substituted Interests and Best Judgments JAMA 304 17 2010
o Sulmasy DP amp Sugarman J (2001) The many methods of medical ethics (or thirteen ways of looking at a
blackbird) Pp 3-18 Washington DC Georgetown University Press
o Tong R (1997) Feminist approaches to bioethics Boulder CO Westview Press
o Wiggins OP amp Schwartz MA (2005) Richard Zanerrsquos Phenomenology of the Clinical Encounter Theoretical
Medicine 26(1) 73-87
o Zaner RM (1996) Listening or telling Thoughts on responsibility in ethics consultation Theoretical Medicine
17(3) 255-277
bull Zaner RM (2004) Conversations on the edge Narratives of ethics and illness Washington DC Georgetown
University Press
