Journal watch: EthicsMarch 2013

Hannah Zacharias

Objectives

Journals from last 3/12

Not specific to medical ethics journals

Summary of interesting articles from:

JPSM

European Journal of Palliative Care

BMC Medical Ethics

BMC Palliative Care

Artificial feeding in terminally ill cancer patients with bowel obstruction.

Herodotou N. European Journal of Palliative Care, 2012; 19(5)

3 case reports of use of PEG/TPN/venting gastrostomy

Patients aged 38, 32, 44yrs

All estimated to be in last couple of months of life.

Reasons:

Hunger, lethargy – PEG used as feed and VG

Prolongation of life to see child born (TPN)

Intractable vomiting – VG during day and PEG feed O/N

Discussion re. the 4 ethical principles

Very few studies evaluating benefits of feeding these patients in last weeks of life

Cochrane review: insufficient evidence to recommend

For: enhancing QOL, providing hope, using PEG as venting device

Against: futility, health economics and risk of harm.

Brooksbank et al 2002: VG for N/V in advanced cancer. 92% relief of symptoms. Median survival 17 days

Organization position statements and the stance of “studied neutrality” in Euthanasia in Palliative Care

Johnstone M-J, JPSM Dec 2012. 44(6)

Careful or premeditated practice of being neutral in a dispute.

Intended to foster a respectful culture among people of diverse views and to guide action that does not afford material advantage to a partisan group on the euthanasia issue.

Neither opponents nor proponents happy.

Proponents: official indecision and disrespect of patient’s decision to chose death when life unbearable.

Oponents: ‘going soft’ and weakening political resistance

The ethical decisions UK doctors make regarding advanced cancer patients at the end of life – the perceived (in) appropriateness of anticoagulation for VTE: A qualitative study.

Sheard L et al. BMC Medical Ethics 2012, 13:22

In depth interview with 45 doctors from Oncology, Palliative medicine and GP. Framework analysis.

Cancer patients high risk, esp advanced disease

Decisions placed on a shifting continuum.

Is the action ‘appropriate’. Prognosis and patient wishes key features. Opinion can be polarised even of doctors of same grade and specialty

‘nice way to go’ – not supported by evidence and not always fatal

Treatment for VTE intrinsically bound to the doctors own moral and ethical framework

Can physicians’ judgements of futility be accepted by patients?: A comparative survey of Japanese physicians and lay people.

Kadooka Y, BMC Medical Ethics 2012, 13:7

Vignettes used for physicians to assess whether they would offer potentially futile treatments to patients at EoL

Physicians: medical info, QOL

Lay people: treatment wishes of the family and psych impact of treatment on pt

Wide variety in threshold of judging futility in both groups

88% physicians had provided futile treatment due to communication difficulties with pt and lack of systems regarding futility or foregoing treatment.

Lay people more supportive of providing futile treatments than physicians, explained by importance of medical info, family’s influence to decision making and QOL

Threshold of futility is arbitary

40% physicians provided futile treatment several times a year

Reasons for providing treatment judged to be futile:

66% request by the patient

38% to satisfy patient

32% request from pt’s family

21% pt’s lack of understanding about the futility of Rx

End of life medical decisions in France: a death certificate follow-up survey 5 yrs after the 2005 act of parliament on patients’ rights and end of life

Pennec S, BMC Palliative Care 2012, 11:25

Nationwide retrospective study of a random sample of adult patients who died in Dec 2009. Questionnaires were mailed to the physicians who certified the deaths.

47% of all deaths followed at least one decision that may certainly or probably hasten death

End of life decisions are common in France, most in compliance with 2005 law. Some decisions made where not all legal obligations met and some where the decision was totally illegal.

Medical decision to withold treatment increases steadily with age and implementation of LPT decreases.

70% cases when an EoL decision was made, the persons when competent were involved in the decision. The greater likelihood that the decision would hasten death, the more frequently it was discussed with the patient, if competent.

Discussed with family / MDT etc in vast majority of cases

3% given medicine with intention of hastening death. Only 1 in 5 of these cases had the patient explicitly requested this.