Clinical And Ethical Aspects Of Terminally Ill Patients` Care

Ministry of Health of the Republic of Moldova

Public Institution “Nicolae Testemițanu” State University of Medicine and Pharmacy

Faculty of Medicine II

Department of Philosophy and Bioethics

DIPLOMA THESIS

Clinical and ethical aspects of terminally ill patients` care

(Bibliographic study)

Author:

Ahmad Hujeirat

6th year, group no. 1052

Scientific advisor:

Adriana Paladi

PhD, Associate Professor

Chisinau 2016

Content

Introduction

Actuality

The purpose and objectives of the thesis

Theoretical importance and value of the work

Bibliographic analysis of theses

The material and the research methods

Personal results and discussion

Clinical and ethical problems of terminally ill patients` care

Death and pain management in dying patients

Ethical principles and issues at end of life care

Specific problems of end of life care

Euthanasia

Advanced directive

Conclusions

Bibliography

INTRODUCTION

A terminally ill patient with a disease that can not be cured or adequately treated. This term is widely used for progressive diseases such as cancer or advanced heat disease  than for trauma . in other words, it indicates a disease that is followed by death and end of the suffer.

I focus in this subject about Clinical and ethical aspects of terminally ill individuals. With the improvements in modern medicine, people are able to live longer, and the number of elderly people is increasing. As a result, the ethical issues surrounding end of life care continue to gain importance to all members of society. Clinical and ethical aspects of terminally ill patients` care pots a spotlight between clinical, ethical or legal view of this subject.

The purpose of this thesis is to provide a large overview on end of life care.

To reach the above purpose the following objectives have been set:

Study of scientific sources with regard to the medical and bioethical aspects related to end of life care.

To analyze clinical aspects of dealing with dying patients.

To identify the most fervent ethical issues of end of life care.

To desplay the specific ethical and clinical aspects of end of life care.

Theoretical importance and value of the work

The thesis can be useful for students, for medical professionals who deal with dying patients and authorities in shaping the legislative framework of the palliative care.

BIBLIOGRAPHIC ANALYSIS OF THESES

The findings and conclusions of the thesis resulted from the analysis of the various literatures sources: general medical literature about infectious diseases and tuberculosis, bioethical manuals, articles on the topic and study cases.

Analyze here some relevant sources !!!!

THE MATERIAL AND THE RESEARCH METHODS

The material used in the thesis was compiled based on the systematically reviewed specialized literature (articles, monographs, volumes of international conferences, statistical data and sociological studies, study cases, ethical and bioethical codes) recently published on ethically relevant issues associated with end of life care. Relevant articles in English and Romanian languages were identified searching PubMed, Google Scholar, Hinari, SpringerLink with a temporal range of 1990 to 2015.

Studies were identified using combinations of the search terms “end of life care”, “bioethics’ principles”, „pain management”, „ paliative care”, „euthanasia”. The selection of articles was based on their relevance to the bioethical discipline and ethical implications to management of the illness. The references of the selected articles were also evaluated to identify additional relevant publications.

PERSONAL RESULTS AND DISCUSSION

CLINICAL AND ETHICAL PROBLEMS OF TERMINALLY ILL PATIENTS` CARE

4.1.1. Death and pain management in dying patients

Death has many reasons, advanced age, disease or injury (trauma). these 3 branches bifurcate into a big net which covers end of life. in the past, death was announced just by stopping the heartbeat or breath, simply, but today we have the Uniform Determination of Death Act

(UDDA), 5 “An individual who has sustained either (1) irreversible cessation

of circulatory and respiratory functions, or (2) irreversible

cessation of all the functions of the entire brain, including the

brain stem, is dead.”

5 Guidelines for the determination of death: report of the medical consultants on the

diagnosis of death to the President's Commission for the Study of Ethical Problems

in Medicine and Biomedical and Behavioral Research

Causes of Death

Death often comes with advanced age or serious illness. Globally, more than 6 million people die every year. The following were the worldwide leading causes of death in 1998:3

1) Heart disease

2) Stroke and blood vessel blockages neonatal deaths

3) Lower respiratory infections 4) HIV / AIDS 5) Chronic, obstructive lung disease

6) Diarrhea

7) Premature births, stillbirths, and

8) Tuberculosis

9) Lung cancer

10) Motor vehicle crashes

3 World Health Organization. Injury: A Leading Cause of the Global Burden of Disease.

Krug E., ed. Online at

http://whqlibdoc.who.int/hq/1999/WHO_HSC_PVI_99.11.pdf.

The top 10 causes of death worldwide:

3 http://www.worldlifeexpectancy.com/world-rankings-total-deaths

A Good Death

Improving the end of life and advocating for a “good death” has become the mission of many dedicated individuals and organizations, and is also a frequent subject of research and focus for policy improvements.13

13 Jennings B. Rundes T. D’Onofrio C. et al. Access to hospice care:expanding boundaries,

overcoming barriers. The Hastings Center Report, 2003; 33(2):S3-4.

Available online at http://www.thehastingscenter.org/pdf/access_hospice_care.pdf.

what is necessary for a “good death” to take place:

• Pain management.

• minimizing the process time.

• Clear communication about decisions by patient, family and physician.

• Prepare properly for death, both patient and loved ones.

• a spiritual (religious) or emotional sense of completion.

• Showing love and support for the patient as a unique and worthy person.

• Social support, and not being lonely.

Pain management:

Symptom control in the home setting may differ from that provided in a more traditional setting such as a hospital or nursing home. In the home setting, the patient or family members provide much or most of the care. The caregivers administer the medications and report changes in the patient’s status to the health care team?. Although the health care team may visit frequently,the patient is dependent on family members for care, which necessitates good communication between the family and the health care team. Pain management must be responsive to the patient’s changing symptoms, and care must be taken to respect the families wishes and limitations. Family members are often reluctant to give injections or administer medicines rectally. Breakthrough medications are often withheld for fear of getting their loved one “addicted” to opioids. Patients may be faced with either financial problems or the lack of an adequate caregiver. For these reasons, the patient’s support system and environment must be evaluated. The members of the health care team must establish good lines of communication and trust with their patients and the patients’ families, and they must recognize the limitations that may be present in each home. In recognizing the need for improved pain management worldwide, the World Health Organization (WHO) instituted a three-step analgesic ladder as a basis for pain management11: Step 1 – Mild Pain: acetaminophen or NSAID +/– ?adjuvant. Step 2 – Mild to Moderate: weaker opioid for mild to moderate pain + acetaminophen or NSAID +/–? adjuvant. Step 3 – Moderate to Severe Pain: stronger opioid for moderate to severe pain + acetaminophen or NSAID +/– adjuvant.

Opioid Use Although the majority of patients with cancer have pain, proper use of opioids and adjuvant drugs can provide adequate relief in most cases. Jacox et al14 found that 75%-?85% of patients received adequate pain control with oral, rectal, and transdermal drugs. Opioid therapy is initiated when a trial of NSAIDs or acetaminophen is no longer effective. Opioids produce analgesia by binding to specific opioid receptors in the brain and spinal cord. Using the WHO guidelines, a weak opioid is initially used and then titrated to a stronger medication. Important elements in successful opioid? use include frequent reassessment of the patient’s pain, attention to the prevention of side effects, and effective communication

Visceral Pain Management

Visceral pain is one type of nociceptive pain. As previously noted, this type of pain may? be caused by a variety? of factors such as direct invasion of a tumor, stretching of the hepatic capsule, or damage caused by radiation or chemotherapy. This type of pain is generally opioid responsive, and opioids are the principal line of therapy. Careful assessment of the patient, initiation of opioid therapy, and titration of the medication are all cornerstones of effective therapy.

Somatic Pain Management

Somatic pain, another type of nociceptive pain, may arise from metastatic disease to the bone in cancer patients. This pain is generally well localized and constant in nature. Somatic pain is responsive to opioids, but using an additional three-step therapeutic approach enhances treatment. Nonsteroidal anti-inflammatory drugs (NSAIDs) are the mainstay of treatment of somatic pain. NSAIDs inhibit cyclooxygenase, which catalyzes the conversion of arachidonic acid to prostaglandins and leukotrienes. NSAIDs do not activate opioid receptors and thus can be safely used with opioids?. The inhibition of prostaglandins is responsible for the properties of this group of medications that reduce inflammation and the release of substance P. NSAIDs are effective in relieving the pain of bony metastasis.22 Major side effects caused by NSAIDs ?include gastrointestinal bleeding, renal toxicity, and hepatic dysfunction. Minor side effects include nausea, vomiting, ?dyspepsia, heartburn, bloating, and constipation.

https://www.moffitt.org/File%20Library/Main%20Nav/Research%20and%20Clinical%20Trials/Cancer%20Control%20Journal/v8n1/15.pdf

Ethical principles and issues at end of life care

Clinical and ethical problems:

Justice in the medical system has been a challenge for eras, between patients that cannot receive hospice or palliative? care to people who refuse treatment or any kind of communication. The place you live in may affect your access to hospice care.

The vast majority of hospice patient care is paid for by Medicare, according to the National Hospice and Palliative Care Organization (on the internet at http://www.nhpco.org).Medicare requires that a patient have a prognosis of six months or less to live before entering hospice care. The patient must also sign a consent form selecting the Medicare Hospice Benefit in lieu of regular Medicare benefits. Medicare then pays? the hospice 22 program a specific amount per day for the patient, regardless of how much or how little it costs to care for the patient. (Four levels of care are available: Routine Home Care, Continuous Home Care, Inpatient Respite Care and General Inpatient Care. In 2004, Medicare paid hospice programs $115 per? day per patient.) The hospice then provides all care for the patient—including prescription drugs and bereavement services for loved ones

after the patient dies. 36

36 National Hospice and Palliative Care Organization on the internet at

http://www.nhpco.org/i4a/pages/index.cfm?pageid=3283&openpage=3283.

Breaking bad news:

Time seems? to freeze when you know that someone you admire is terminally ill. Maybe you instinctively pushed the news away. Or perhaps you cried, or swung into action. No matter what happened that day, time and life go on after the diagnosis is made?— ?regardless of whether you feel ready to cope.

You and your loved one may have? pursued promising treatments and perhaps enjoyed a respite from encroaching? illness. At some point, however, the illness may become terminal, and gradually the end draws closer. Once further treatments are unlikely to be successful, there is a great deal? you can do to muster support for both of you.

Some of the? support you need is emotional. The fears and feelings that surface now are better aired? than ignored. Some? of the support you need concerns practical details. End-of-life care needs to be arranged and funeral plans need to be considered. Legal and financial matters must be addressed now or in the days after the death. This article can? help guide you through some of these steps and suggest additional sources of support for you to draw on.

When someone has a serious illness, there are many losses to grieve long before the person? becomes? terminally ill—for the person who is dying as well as for family and friends. Blows to independence and security, impaired abilities, and truncated visions of? the future are just a few examples of devastating losses.

Just as with grief after a death, family and friends may feel a multitude of different emotions as? they adjust to the new landscape? of their lives. Typical emotions at this time include:

sorrow

anxiety

anger

acceptance

depression

denial

SPECIFIC PROBLEMS OF END OF LIFE CARE

Euthanasia

https://www.health.ny.gov/regulations/task_force/reports_publications/when_death_is_sought/chap5.htm

Passive euthanasia:

Hastening the death of a person by altering some form of support and letting nature take its course is known? as passive euthanasia.  Examples include ?such things as turning off respirators, halting medications, discontinuing food and water so asto allowing a person to dehydrate or starve to death, or failure to resuscitate.

Passive euthanasia? also includes giving a patient large doses of morphine to control pain, in spite of the likelihood that thepainkiller will suppress respiration and cause death earlier than it otherwise would have happened. Such doses of painkillershave a dual effect of relieving pain and hastening death. Administering such medication is regarded as ethical in mostpolitical jurisdictions and by most medical societis.

These procedures are performed on terminally ill, suffering persons so that natural death will occur? sooner. They are alsocommonly performed on persons in a persistent vegetative state; for example, individuals? with massive brain damage or in acoma from which they likely will not regain consciousness. *

Available on-line on: http://legaldictionary.thefreedictionary.com/Euthanasia,+passive

Advanced directive

https://www.nlm.nih.gov/medlineplus/advancedirectives.html