Ethical Challenges in End of Life Care for the Elderly. David A. Fleming, M.D., MA, FACP Professor of Medicine Chairman, Department of Medicine Director, MU Center for Health Ethics University of Missouri School of Medicine 573-882-2738 [email protected]
Ethical Challenges in End of Life Care for the Elderly
David A. Fleming, M.D., MA, FACP
Professor of Medicine
Chairman, Department of Medicine
Director, MU Center for Health Ethics
University of Missouri School of Medicine
I have no significant financial relationships with commercial entities producing healthcare-related products and/or services.
…due to lack of clarity
…due to moral discomfort
…due to fear of reprisal—professional, legal
Delay in actions may prematurely lead to deathor
Unwanted or harmful treatment may be given
When is enough enough?
I’m afraid there’s really very little I can do…
How Does the Current U.S. Health Care System Do in Caring for Dying People?
Could not answer7%
National survey of 1,002 adults conducted by
Lake-Snell-Perry Associates for Last Acts, 2002
Integration of Palliative and Disease-oriented Treatment
in the Trajectory of Death
Abrahm, J. Update in Palliative Medicine and End of Life Care
Ann. Rev. Med. 2003;54:53-72
Joanne Lynn, M.D. Rand Corporation
“Death is not an instantaneous,
momentary phenomenon, but a
very protracted process.”
Frederick Engels, 1880
Christakis N and Lamont E. BMJ. 2000;320:469-472
Block, JAMA. 2001
Dowdy, Crit Care Med. 1998
Kemper P, Murtaugh CM. Lifetime use of nursing home care.
NEJM. 1991; 324:595-600
Ersek M and Wilson S. The Challenges and Opportunities in
Providing End-of-Life Care in Nursing Homes
J Pal Med. 2003, Vol. 6, No. 1: 45-57
Zedlewski SR, Barnes RO, Burt MK, McBride TD, Meyer J.
The Needs of the Elderly in the 21st Century.
Washington, DC: The Urban Institute; 1989.
Doty PJ. The oldest old and the use of institutional long-term
care from an international perspective.
In: Suzman R, Willis DP, Manton KG, eds.
The Oldest Old. New York: Oxford University Press;
at 85 = 5 years
Ouslander J, Osterweil D, Morley J.
Medical Care in the Nursing Home. McGraw-Hill.1997.
Rovner BW, German PS, Brant LJ et al.
Depression and mortality in nursing homes.
Zerzan J , Stearns S, Hanson L. Access to
Palliative Care and Hospice in Nursing Homes
Fagerlin, Hastings Ctr Report. 2004;34(2):30-41
Survival rate on television = 66%
Actual in-hospital survival rates:
-All hospital patients 15%-18%
-Frail elderly <5% -Pt. with advanced chronic illness <1%
[12% survived CPR]
deVoss, R et al. Quality of Survival After Cardiopulmonary Resuscitation.
Arch Intern Med. 1999;159:249-254
Survived CodeSurvived to D/C
Witnessed In Hosp. 48% 22%
Un-witnessed In Hosp. 21% 1%
Bystander 40% 6%
Ambulance CPR 15% 2%
Defib. w/in 5 Min 74% 30%
(18.5% versus 13.6%).
Schneider A and Nelson D. In-hospital cardiopulmonary
resuscitation: a 30-year review. J Am Board Fam Prac.
How it’s presented:
Murphy D et al. NEJM. 1994 ;330(8) 330:545-549
(Desired or intended outcome highly unlikely)
FEffectiveness + Benefits
(Not a mathematical equation)
A measurable changes in natural history of disease or symptoms can be reasonably expected.
(…reasonable medical certainty of intended outcome)
Patient and Physician determine “Benefit” together
Patient determines “Burden”: cost of treatment
Obligation to treat
There are legitimate moral limits to what physicians “must do”… physician autonomy.
Morally valid if by the patient
The competent patient
The incompetent patient
Valid anticipatory declaration (HCD)
Morally valid surrogate
Morally invalid if by anyone else not primarily representing the patient
Incompetent patients without valid surrogate
Morally variable (fairness of rationing)
Chronology vs. Physiology
Chronology vs. Effectiveness of Treatment
Relevant as it pertains to impacting the prognosis of underlying and acute conditions.
Danger of Ageism (discrimination)
young/old value conflicts
economic and fiscal pressures
What is a “normal” lifespan?
Action itself must be “good”
The agent must intend a good effect
The “bad” effect is foreseen, not intended
The good and bad effects must follow immediately from the same action
Proportionality between the two should favor the “good” effect
One act, two effects
One effect is good, the other bad
One intends to do good
The unintended bad effect is not the cause of the intended good
All things considered, the good that results far outweighs the bad that is likely to occur
82yo man in NH with dementia, mild CHF and Cr=2.2 now with pneumonia; DPOA suggests he would not want “aggressive treatment” should he deteriorate.
75yo man in NH following a CVA has pneumonia and is willing to accept a feeding tube and perhaps short term vent support if there is hope of recovery but does not want CPR. This is consistent with his HCD; speech deficit but has capacity and is capable of communicating.
65yo female with PVS, recurrent aspiration pneumonia, renal failure, sepsis, and SBE is deteriorating. The family insists that CPR be attempted and refuses to allow LOT or DNAR.
Define “futility” Together
Exchange values and beliefs
Set medical and non-medical goals
Set Time Limits (re-evaluate)
Prepare and Discuss Meaning of Advance Directives 9written and verbal)
Early use of Ethics Consultants
If no compromise the provider can withdraw or the family can discharge provider or transfer care