Druml-WMA EoL Presentation Vatican-Nov2017

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CD 2017
Right to live, right to die ?
The medicalisation of the end of life
Christiane Druml
christiane.druml@meduniwien.ac.at CD 2017
“O Lord, grant death to each in one’s own way.
Grant that one may pass away from a life
that was filled with love, meaning, and desire.
For we are only hull and leaf.
The large death, which each carries within,
is the fruit around which all it spins.”
Rainer Maria Rilke, Das Stundenbuch, Von der Armut und dem Tode
O Herr, gib jedem seinen eignen Tod.
Das Sterben, das aus jenem Leben geht,
darin er Liebe hatte, Sinn und Not.
CD 2017
Yesterday
CD 2017
It could be your mother, sister, friend…
Maria K.; age 82, academic, physically active, socially engaged,
• Heavy smoker, COPD, since 4 years suffering from lung cancer
• Decision with her family physician for only symptomatic treatment,
• Advanced directive notarized against any invasive therapy, artifical
ventilation
• Lately increasingly problems of breathing (COPD)
• One evening in February admission at (her usual) private hospital –
where the advance directive is known – because of pneumonia
• During the night cardiac arrest, resuscitated by physician on night shift
(with broken ribs and sternum), sedated and intubated in ICU
• Next day, tubes are removed, palliative care provided
• Maria K. dies within 24 hours
CD 2017
Today
Medicalisation of the end of life
Disproportionate treatment
versus
„Salus aegroti ultima lex“
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CD 2017
Place of death
persons over 65 years
Where do people die? An international comparison of the percentage
of deaths occurring in hospital and residential aged care settings.
Broad JB et al; Int J Public health, 2013
CD 2017
Perceived process issues leading to inappropriate life-
prolonging
treatment.
Perceived responsible parties for inappropriate
life-prolonging
treatment.
A prospective determination of the incidence of
perceived inappropriate care in critically ill patients
Singal RK. et al. Can Respir J 2014;21(3):165-170.
CD 2017
“It is a clear and undisputed principle that treatments
which are
• not (or no longer) indicated or
• treatments which the patient refuses must not be
performed.
There are still cases where disproportionate treatment is
initiated.
This results in diagnostic, therapeutic or care-related
interventions whose benefit for the individual patient is highly
questionable and which may expose the patient to a stressful
situation that becomes problematic.”
Disproportionate treatment
CD 2017
• Therapeutic ambition
• Justified and unjustified fear of legal consequences
• Service invoicing logistics at the hospital
• Lack of communication within the healthcare team
• Lack of communication between healthcare team and
patient
• Relatives request therapy
• Patient requests therapy
Causes for disproportionate treatment
Disproportionate treatment is incompatible with two ethical
principles, the principle of non-maleficence and the principle of
justice.
CD 2017
Austrian Bioethics Commission
www.bka.gv.at/bioethik
2011 2015
CD 2017
Prevention of disproportionate medical interventions
• Medical interventions which provide no benefit for the
patient or which are more burdensome than potentially
beneficial to the patient, and which may lead to a
prolongation of the dying process in end-of-life situations,
are ethically and medically unjustified because they
come at a disproportionate burden.
• The legal conditions for complex end-of-life
decisions should take due account of this fact to allow
for carefully weighed decisions without fear of criminal
prosecution.
Recommendations I
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CD 2017
The two following aspects are of crucial importance:
• The outdated and imprecise terms “active and passive
euthanasia” need to be revised in accordance with the
“Recommendations for the terminology of medical
decisions in end-of-life situations” released by the Bioethics
Commission.
• This shall be taken into particular account in the education
and training programs for the legal and medical
professions.
Recommendations II
The terminology
CD 2017
Trust and legal certainty in cases of limitation or discontinuation of
medical measures which are no longer justified has to be established
and to be exempted from legal punishment, when
• The therapeutic decision is based on a comprehensible, substantiated
and to the individual situation corresponding decision-making process.
• ethical standards and guidelines by professional associations; academic
ethical institutions or supranational institutions are followed.
• Adherence to decision-making process is guaranteed.
Compliance with clear guidelines should lead to the presumption of trust
and to legal certainty for the treating physician.
Recommendations III
CD 2017
Advance planning of medical end-of-life decisions shall be
promoted through the following initiatives:
• reducing the formal and financial hurdles to the
establishment of legally binding living wills and powers
of attorney
• defining and checking quality standards and
qualifications to assure proper information of healthcare
and legal professionals
• raising public awareness through a national program
Planning for end-of-life care decisions
(living will, power of attorney, guardianship, …)
CD 2017
Wallner J,
Finding the right words for
medical decisions at life’s
end
Wien klin Wochenschr 2008
Confusion of terminology in
German language
CD 2017
Terminology of end of life decisions
NAZI-EUTHANASIE = Murder
Do we need to change?
Do we need a new culture for
the end of life?
For dying in „one‘s own way“?
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CD 2017
Respect of the patients‘ will
Appropriate care for the patient
CD 2017
Doctors‘ Personal End-of-Life
Preferences
CD 2017
Thank you for your attention!
www.josephinum.ac.at