Eckerdal-WMA EoL Presentation Vatican-Nov2017

11/23/17
1
Treatment limitations vs.
euthanasia. End stage decisions
about medication, feeding and
terminal sedation
Gunnar Eckerdal, sweden
Doctor, tell me……
• Patients want from the physician:
• Excellence
• Normal physiology
• Pathophysiology
• Symptom control
• Normal psychological responses to
stress
• Structure
• Advance care planning
• Continuity
• Compassion
• To be a fellow human being. No more,
no less.
Palliative medicine is not different
• Treatment without clinical
indication should be stopped.
• Treatment that is not going to
give effect should not be
started.
• In palliative care every
treatment must be re-evaluated
regularly.
• It is a question of balance –
are the benefits greater than
the risks?
Palliative medicine is not different
• This balancing must be
done in dialogue with the
patient.
• Symptom control seldom
shortens life
• The physician always
recommends treatment that
reduces suffering.
• The physician never
recommends treatment that
deliberately shortens life.
WMA DECLARATION OF VENICE ON TERMINAL
ILLNESS 13TH OCTOBER 2006
The duty of physicians is to heal, where possible,
to relieve suffering and to protect the best
interests of their patients. There shall be no
exception to this principle even in the case of
incurable disease.
listen to the patient!
• Sometimes the patient wants the physician to stop important life-
supporting treatment.
• Dialysis
• Nutrition
• Life-supporting medication and medication for symptom control
• Blood transfusion
• The dialogue must be shared with other health professionals. The
patient’s decision capacity must be evaluated, and depression
must be assessed. Dialogue with relatives is often necessary.
• After that the treatment often can be stopped. It is not euthanasia.
It is recognizing the patient’s right to have power over his own
body.
11/23/17
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WMA DECLARATION OF VENICE ON TERMINAL
ILLNESS 13TH OCTOBER 2006
……The patient’s right to autonomy in decision-making
must be respected with regard to decisions in the
terminal phase of life. This includes the right to refuse
treatment and to request palliative measures to relieve
suffering but which may have the additional effect of
accelerating the dying process. However, physicians are
ethically prohibited from actively assisting patients in
suicide. This includes administering any treatments
whose palliative benefits, in the opinion of the physician,
do not justify the additional effects……
Nutrition
• In palliative care the goal is to nourish
as much as the metabolism needs.
• If the patient is artificially nourished,
there is a risk that too much nutrients
will not be used by the patient’s
metabolism – they do not reach the
cell metabolism, but degrade in the
body into products that cause nausea
and in some cases confusion.
• In the palliative care team this calls for
assessment every day.
• Nutrition by mouth is always
preferable – very low risk of
overfeeding.
Terminal sedation Palliative sedation in sweden
• The indication is always symptom control.
• The treatment is most commonly used intermittently.
• Continuous sedation with doses that makes the patient
permanently unconscious is very rare. It is only used when
all other treatment has failed.
• Severe delirium is the most common indication.
• It is not an alternative to euthanasia.
• Eckerdal G, Birr A, Lundström S. Palliativ sedering är ovanlig inom specialiserad palliativ vård i
Sverige. Läkartidningen. 2009 106:1086-8
What about prognosis?
Days between writing prescription and death, Oregon DWDA patients,
1998-2015
Frequency Percent
Valid
Percent
Cumulative
Percent
Less than 183 days 1380 92 92,1 92,1
183 days or more 119 7,9 7,9 100
Unknown 1 0,1
1500 100
In Oregon >7,9 % of the estimates of time to death was wrong.
Ref: OREGON DEATH WITH DIGNITY ACT: 2015 DATA SUMMARY
How about decision-making
capacity?
11/23/17
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suicide – cancer
”Cancer patients carry an increased risk of suicide.
However, this risk peaks with the month following
diagnosis. Clinicians should be aware of this
increased risk and include assessments of mood
state and suicidality at the time of initial diagnosis
of the malignancy and be prepared to provide
referral to mental health treatment providers.”
Johnson TV, Garlow SJ, Brawley OW, Master VA. Peak window of suicides occurs within
the first month of diagnosis: implications for clinical oncology. Psychooncology. 2012
Apr;21(4):351-6
Can suicide be a rational act?
Depression can be treated in
palliative care!
WHO (2014):
11/23/17
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Security and efficacy
• PAS/euthanasia is not secure
• Wrong diagnosis
• Wrong prognosis
• Underdiagnosed and undertreated depression
• PAS/euthanasia is not efficient
• The patient´s condition is better addressed with
treatment that does not shorten life
Conclusion
• In the palliative team we listen
to each patient.
• We practice evidensbased
medicine as in other specialities.
• A ”No” to some of the patient´s
wishes is necessary….
• …to protect other patients from
harm.
• Together we in almost every
situation come to an acceptable
agreement.
conclusion
• My guess is that 20% of
all PAS/euthanasia-
actions are made after
wrong assessments.
• Can we accept that
patients with help from
their doctors commit
suicide on wrong
grounds?
• PAS/euthanasia is not
safe!