For A - M -- Advance Directives -- Medical Futility
Palliative Care
Associated with care delivered to persons with terminal disease. To palliate means to relieve symptoms without curing them. In this regard, palliative treatment refers to that given, usually to patients who are incurably ill, with the aim of relieving their suffering and controlling their symptoms in the most effective way. The World Health Organization definition is:
"The active, total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families." (WHO, 1990).
Palliative Care/Hospice. Medical care designed to provide comfort and dignity when curative therapy is no longer appropriate. It offers control of pain and other symptoms as well as emotional and spiritual support. This approach has been comprehensively developed within the hospice movement which provides specialised medical, nursing and support services for terminally ill patients and their families. .
(South Australian Voluntary Euthanasia Society - SAVES)
See:
Hospice Definition
Definition & History of Hospice & Palliative Care Fact Sheet
Hospice Definition (Adopted from: South Australian VES -- SAVES)
Persistent vegetative state - PVS
The diagnosis of a permanent vegetative state is made when a patient is found to be unaware of himself or herself and the environment and there is no prospect of any change in this state by any means. Although the clinical characteristics and diagnosis of the condition have been established, the clinical diagnosis is not easy as there is a spectrum from the vegetative state to full awareness. The border between these two states is referred to as the low awareness state. No absolute definition exists for low awareness state. Generally, however, the patient behaves in a way that implies that at times he or she may be able to extract meaning from a stimulus and may be able to respond in a goal directed way. Usually the state is intermittent, with only vegetative responses being present at other times. Rarely, it may be possible to establish some form of rudimentary communication. We do not know if patients have any day-to-day memory or appreciation of their situation or whether they can experience somatic or emotional pain or pleasure.
Diagnosis of permanent vegetative state
The patient shows no behavioural evidence of awareness of self or environment
There is brain damage, usually of known cause, consistent with the diagnosis
There are no reversible causes present and
At least six (and usually 12) months have passed since onset
See Ethical Issues in Diagnosis and Management of Patients in the Permanent Vegetative State
British Medical Journal February 1, 2001
Physician-assisted dying
A term used in varying ways to describe the involvement of a physician in the death of a patient upon that patients request. Some use the term to describe anything from the involvement of a physician in the act of terminating treatment of a patient that results in his or her death to a physician who knowingly and willingly prescribes a lethal medication for a patient to use in ending his or her own life, which is legal in the State of Oregon. In this regard, there are many who believe that the term "physician-assisted dying" is preferable to the term "physician-assisted suicide." This is because the dying who request and receive physician assistance are not committing suicide, because their death is inevitable and often imminent, and the act is lessening the period of their suffering.
In these cases, physician assisted dying allows patients to escape what the patient defines as meaningless suffering prior to their death, especially when death is the only way to relieve their suffering.
Adopted from: Death and Dignity, Marking Choices and Taking Charge by Timothy E. Quill, M.D.
Physician-assisted suicide
The ending of one's own life by taking a medication knowingly provided by a physician for that purpose. A physician knowingly supplies the means, which usually involves a prescription for a lethal dose of barbiturates (sleeping pills). Some physicians provide other, less-effective, medications, because they feel hesitant to be linked to any prescription that is rigorously controlled in most jurisdications around the world.
See
American Medical Association Physician-assisted suicide
Assisted Suicide Q & A (From S. Jamison: Final Acts of Love)
Assisted Suicide Questions & Answers
Principles of Bioethics
Refers to the rules and principles generally accepted as relevant in the moral analysis of ethical issues in medicine. In health care it is difficult to hold absolute rules or principles because of the many variables that exist in the context of clinical and the fact that different principles may seem to be applicable in a given situation. These serve as powerful action guides in clinical medicine. The commonly accepted principles of health care ethics include:
- the principle of respect for autonomy,
- the principle of nonmaleficence,
- the principle of beneficence, and
- the principle of justice.
For an in-depth explanation of these four principles see the University of Washington, School of Medicine, Clinical Ethics, Ethical Principles
Also see, American Medical Association Principles of Medical Ethics
Right to Die
This phrase suggests that dying is a matter of choice rather than part of the human condition. The issue that came before the Supreme Court in 1997 was whether terminally ill, mentally competent adults have the right to request aid-in-dying from physicians to avoid intolerable suffering, and whether physicians have the legal right to provide a person with a prescription and consultation if doing so is consistent with their values.
Sanctity of Life
A religious concept that holds that life is a gift from God and so can only be ended by God.
Slippery Slope
An argument frequently used against changing the law, which states that it is impossible to set secure limits. Under this argument, it is claimed that voluntary euthanasia would eventually and inevitably lead to non-voluntary or even involuntary euthanasia.
Substituted Judgment
If an advance directive is not available, then any statements made by the patient prior to becoming incompetent, or other relevant evidence, can be used to determine the patient’s intent concerning receiving or withholding medical treatment. Often referred to as the doctrine of "substituted judgment", courts applying this principle seek to discover the patient’s values and treatment preferences to determine what the patient would have done under the circumstances, if the patient were not incapacitated. Other courts decide such cases based on what is in the patient’s "best interests". Under this approach, the court evaluates factors relevant to the patient’s particular situation to determine what course of action is in the patient’s best interests.
Suicide
The intentional taking of one's own life. In the medical literature, suicide is viewed as an act of despair and connotes an often desperate, violent, secretive act resulting from severe depression or mental instability. By this definition, suicide is something to be actively prevented, and is fundamentally different from aid-in-dying. Suicide ends the process of living in a life that can go on; physician-aid-in-dying ends the process of dying. Suicide in the context of severe end-of-life suffering can have a different meaning and under such circumstances can be rational.
Terminal Sedation
Terminal sedation usually refers to when a consenting patient is sedated to the point of unconsciousness to relieve otherwise untreatable pain and suffering, and is then allowed to die of dehydration or other intervening complications. The goal of administering the sedative, to relieve otherwise unrelievable suffering, is good. Whether death is intended or merely foreseen is less clear, and the practice is sometimes referred to as "slow euthanasia". Unlike the use of high-dose opioids to relieve pain, with death as a possible but undesired side effect, terminal sedation inevitably causes death, which in many cases is what the patient desires. Although the overall goal of terminal sedation is to relieve otherwise uncontrollable suffering, life-prolonging therapies are withdrawn. As a result, it is often termed "slow euthanasia" if nutrition and hydration are withheld, because under such circumstances the intent of hastening death is obvious.
See
Terminal sedation Fact Sheet
Patient Refusal of Nutrition and Hydration. Ira R. Byock, American Journal Hospice & Palliative Care, March/April 1995.
Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids. Ira Byock and Timothy Quill, Annals of Internal Medicine. 2000.
Termination of Treatment
Hastening the death of a person by ceasing or altering some form of support, which otherwise would help the patient to live longer, and allowing the patient to die from the underlying physical condition. These can include such actions as:
The removal of life support equipment (e.g. ventilator or respirator);
Termination or withholding of medical procedures (e.g., medications, antibiotics, blood products, etc.);
Cessation or withholding of nutrition (food) and hydration (water), and allowing the person to starve to death or dehydrate.
Withholding of CPR (cardio-pulmonary resuscitation), defibrillation, etc., and allowing a person, whose heart has stopped, to die.
See
Termination of Treatment Questions & Answers
Also see American Medical Association Policy on Withholding & Withdrawing Treatment
Patient Refusal of Nutrition and Hydration. Ira R. Byock, American Journal Hospice & Palliative Care, March/April 1995.
Responding to Intractable Terminal Suffering: The Role of Terminal Sedation and Voluntary Refusal of Food and Fluids. Ira Byock and Timothy Quill, Annals of Internal Medicine. 2000.
Ventilator
A machine that helps a patient breathe. Sometimes it is used temporarily until a person can breathe on his or her own; other times it is a permanent breathing aide. In the latter case, a tube is often placed directly into a patient's windpipe via a procedure called a tracheotom
Withholding or Withdrawing Treatment
The primary goal of medical treatment is to benefit the patient by restoring or maintaining the patient's health as far as possible, maximising benefit and minimising harm. However, if treatment fails, or ceases, to give a net benefit to the patient (or if the patient has competently refused the treatment), the primary goal of medical treatment cannot be realised and the justification for providing the treatment is removed. Unless some other justification can be demonstrated, treatment that does not provide net benefit to the patient may, ethically and legally, be withheld or withdrawn and the goal of medicine should shift to the palliation of symptoms.
Most ethicists argue that withholding and withdrawing treatment are equally ethical and justifiable. In countries such as the USA and Great Britain they also are are legally equal.
Treatment should never be withheld, when there is a possibility that it will benefit the patient, simply because withholding is considered to be easier than withdrawing treatment. Although emotionally it may be easier to withhold treatment than to withdraw that which has been started, there are no legal, or necessary morally relevant, differences between the two actions.
Treatments should not be withheld because of the mistaken fear that if they are started, they cannot be withdrawn. This practice would deny patients potentially beneficial therapies. Instead, a time-limited trial of therapy could be used to clarify the patient's prognosis. At the end of the trial, a conference to review and revise the treatment plan should be held. Some health care workers or family members may be reluctant to withdraw treatments even when they believe that the patient would not have wanted them continued. The physician should prevent or resolve these situations by addressing with families feelings of guilt, fears, and concerns that patients may suffer as life support is withdrawn.
Adapted from:
Withholding and Withdrawing Life-prolonging Medical Treatment: guidance for decision making, British Medical Association
Position Paper -- American College of Physicians -- Ethics Manual, Fourth Edition, Annals of Internal Medicine, American College of Physicians.
Spanish Translation Manual de ƒtica Cuarta Edici—n ACP
Patient Refusal of Nutrition and Hydration. Ira R. Byock, American Journal Hospice & Palliative Care, March/April 1995.