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Ethical Issues at the End-of-Life in the Cancer Patient

  • Colleen M. GallagherEmail author
  • Jessica A. Moore
  • Allen H. RobertsII
Reference work entry

Abstract

The issues surrounding end-of-life and medical futility are often very challenging and when confounded with misunderstandings about the difference between withholding or withdrawing certain treatments while never withholding care these issues can easily prompt confusion and conflict. When combined with the complexities of social dynamics and cultural differences, sorting through the issue of medical futility or even more general end-of-life issues can prove to be daunting. Sensitivity and awareness to the intricacies of this issue are important to resolving conflict when it arises. This chapter highlights some of these intricacies and presents steps and methods for working through the issues. The suggestions provided here will not serve as a cure-all. Instead, they represent strategies that have been employed in our practice and may prove useful in other settings. The most important point to note is that end-of-life concerns are often ameliorated when caring clinicians work respectfully and firmly with families and surrogate decision-makers in doing what is best for the patient using compassion, communication, and collegial co-management.

Keywords

End-of-life Physician-assisted death Euthanasia Nonbeneficial care Ethics consultation Communication of bad news Decision-making Advance care planning 

References

  1. 1.
    Modified Uniform Rights of the Terminally Ill Act and the DNR Identification and Do-Not-Resuscitate Order Law. Ohio Revised Code: 2133 (1991).Google Scholar
  2. 2.
    Advance Directives. Texas Health and Safety Code;166 (1999).Google Scholar
  3. 3.
    Uniform Health Care Decisions Act. California Probate Code;4736 (2000).Google Scholar
  4. 4.
    American Academy of Hospice and Palliative Medicine (AAHPM). Expand your knowledge. Enhance your practice. 2018. http://AAHPM.org/Education/Overview. Accessed 16 May 2018.
  5. 5.
    American Academy of Hospice and Palliative Medicine Board of Directors. AAHPM position statements. 2018. http://AAHPM.org/about/position-statements. Accessed 16 May 2018.
  6. 6.
    American Hospital Association. Standards and guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiac care (ECC). Part VIII: medicolegal considerations and recommendations. JAMA. 1974;227:864–6.Google Scholar
  7. 7.
    American Medical Association. Code of medical ethics. 2.035. 2009.Google Scholar
  8. 8.
    American Medical Association. Code of medical ethics. 2.037. 2009.Google Scholar
  9. 9.
    American Medical Association Council on Ethical and Judicial Affairs. Medical futility in end-of-life care: report of the council on ethical and judicial affairs. JAMA. 1999;281:937–41.  https://doi.org/10.1001/jama.281.10.937.CrossRefGoogle Scholar
  10. 10.
    American Society for Bioethics and Humanities Clinical Ethics Task Force. Improving competencies in clinical ethics consultation: an education guide. Glenview: American Society for Bioethics and Humanities; 2009.Google Scholar
  11. 11.
    Arnold RM, Youngner SJ, the Members of the Core Competency Task Force. Core competencies for healthcare ethics consultation: a report of the American Society for Bioethics and Humanities. Glenview: American Society for Bioethics and Humanities; 1998.Google Scholar
  12. 12.
    Aulisio MP, Arnold RM, Youngner SJ. Health care ethics consultation: nature, goals, and competencies: a position paper from the Society for Health and Human Values–Society for bioethics consultation task force on standards for bioethics consultation. Ann Intern Med. 2000;133:55–7.  https://doi.org/10.7326/0003-4819-133-1-200007040-00012.CrossRefGoogle Scholar
  13. 13.
    Azoulay E, Soares M, Darmon M, et al. Intensive care of the cancer patient: recent achievements and remaining challenges. Ann Intensive Care. 2011;1:5.  https://doi.org/10.1186/2110-5820-1-5.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Bekelman JE, Halpern SD, Blankart CR, et al. Comparison of site of death, health care utilization, and hospital expenditures for patients dying with Cancer in 7 developed countries. JAMA. 2016;315:272–83.  https://doi.org/10.1001/jama.2015.18603.CrossRefPubMedGoogle Scholar
  15. 15.
    Bernat JL. Ethical aspects of determining and communicating prognosis in critical care. Neurocrit Care. 2004;1:107–17.  https://doi.org/10.1385/ncc:1:1:107.CrossRefPubMedGoogle Scholar
  16. 16.
    Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191:1318–30.  https://doi.org/10.1164/rccm.201505-0924st.CrossRefPubMedGoogle Scholar
  17. 17.
    Brody H. Medical futility: a useful concept? In: Zucker MB, Zucker HD, editors. Medical futility and the evaluation of life-sustaining treatment. Cambridge: Cambridge Press; 1997. p. 1–14.Google Scholar
  18. 18.
    Buckman R, Kason Y. How to break bad news: a guide for health care professionals. Baltimore: The Johns Hopkins University Press; 1992.CrossRefGoogle Scholar
  19. 19.
    Burns JP, Edwards J, Johnson J, et al. Do-not-resuscitate order after 25 years. Crit Care Med. 2003;31: 1543–50.  https://doi.org/10.1097/01.ccm.0000064743.44696.49.CrossRefPubMedGoogle Scholar
  20. 20.
    Burns JP, Truog RD. Futility. Chest. 2007;132:1987–93.  https://doi.org/10.1378/chest.07-1441.CrossRefPubMedGoogle Scholar
  21. 21.
    Callahan D. Medical futility, medical necessity: the-problem-without-a-name. Hast Cent Rep. 1991; 21:30–5.  https://doi.org/10.2307/3562999.CrossRefGoogle Scholar
  22. 22.
    Cantor MD, Braddock CH III, Derse AR, et al. Do-not-resuscitate orders and medical futility. Arch Intern Med. 2003;163:2689–94.  https://doi.org/10.1001/archinte.163.22.2689.CrossRefPubMedGoogle Scholar
  23. 23.
    Center to Advance Palliative Care (CAPC). Improving Palliative Care in ICU New York, New York. 2018. https://www.capc.org/ipal/ipal-icu/. Accessed 16 May 2018.
  24. 24.
    Chen Y, Youngner SJ. Allow natural death is not equivalent to do not resuscitate: a response. J Med Ethics. 2008;34:887–8.CrossRefGoogle Scholar
  25. 25.
    Chwang E, Landy DC, Sharp RR. Views regarding the training of ethics consultants: a survey of physicians caring for patients in ICU. J Med Ethics. 2007;33:320–4.  https://doi.org/10.1136/jme.2006.016287.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med. 2014;370: 2506–14.  https://doi.org/10.1056/nejmra1208795.CrossRefPubMedGoogle Scholar
  27. 27.
    Cook D, Swinton M, Toledo F, et al. Personalizing death in the intensive care unit: the 3 wishes project. Ann Intern Med. 2015;163:271–9.  https://doi.org/10.7326/m15-0502.CrossRefPubMedGoogle Scholar
  28. 28.
    Curtis JR, Burt RA. Point: the ethics of unilateral “do not resuscitate” orders. Chest. 2007;132:748–51. 754–755.  https://doi.org/10.1378/chest.07-0745.CrossRefPubMedGoogle Scholar
  29. 29.
    Desandre PL, Fairbrother H, Rosenberg M, Jesus J (2016) End-of-life discussions in the emergency department. In: ACEP Now. http://www.acepnow.com/end-life-discussions-emergency-department/. Accessed 16 May 2018.
  30. 30.
    Dowdy MD, Robertson C, Bander JA. A study of proactive ethics consultation for critically and terminally ill patients with extended lengths of stay. Crit Care Med. 1998;26:252–9.  https://doi.org/10.1097/00003246-199802000-00020.CrossRefPubMedGoogle Scholar
  31. 31.
    Dubler NN, Webber MP, Swiderski DM, et al. Charting the future: credentialing, privileging, quality, and evaluation in clinical ethics consultation. Hast Cent Rep. 2009;39:23–33.CrossRefGoogle Scholar
  32. 32.
    Emanuel EJ, Fairclough D, Clarridge BC, et al. Attitudes and practices of U.S. oncologists regarding euthanasia and physician-assisted suicide. Ann Intern Med. 2000;133:527–32.  https://doi.org/10.7326/0003-4819-133-7-200010030-00011.CrossRefPubMedGoogle Scholar
  33. 33.
    Emanuel EJ, Onwuteaka-Philipsen BD, Urwin JW, Cohen J. Attitudes and practices of euthanasia and physician-assisted suicide in the United States, Canada, and Europe. JAMA. 2016;316:79–90.  https://doi.org/10.1001/jama.2016.8499.CrossRefPubMedGoogle Scholar
  34. 34.
    Emanuel EJ, Onwuteaka-Philipsen BD, Cohen J. Euthanasia and physician-assisted suicide – in reply. JAMA. 2016;316:1600.  https://doi.org/10.1001/jama.2016.14080.CrossRefPubMedGoogle Scholar
  35. 35.
    Ewanchuk M, Brindley PG. Ethics review: perioperative do-not-resuscitate orders-doing ‘Nothing’ when ‘Something’ can be done. Crit Care Med. 2006;10:2019.  https://doi.org/10.1186/cc4929.CrossRefGoogle Scholar
  36. 36.
    Ewer MS, Kish SK, Martin CG, et al. Characteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer. 2001;92:1905–12.  https://doi.org/10.1002/1097-0142(20011001)92:7<1905::aid-cncr1708>3.0.co;2-6.CrossRefPubMedGoogle Scholar
  37. 37.
    Fine RL. Point: the Texas advance directives act effectively and ethically resolves disputes about medical futility. Chest. 2009;136:963–7.  https://doi.org/10.1378/chest.09-1267.CrossRefPubMedGoogle Scholar
  38. 38.
    Fletcher JC, Siegler M. What are the goals of ethics consultation? A consensus statement. J Clin Ethics. 1996;7:122–6.PubMedGoogle Scholar
  39. 39.
    Frick S, Uehlinger DE, Zenklusen RMZ. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors – a prospective comparative study*. Crit Care Med. 2003;31:456–61.  https://doi.org/10.1097/01.ccm.0000049945.69373.7c.CrossRefPubMedGoogle Scholar
  40. 40.
    Gallagher CM, Holmes RF. Handling cases of ‘medical futilty’. HEC Forum. 2012;24(2):91–8.CrossRefGoogle Scholar
  41. 41.
    Garrison M, Schneider CE. The law of bioethics: promoting autonomy and protecting life. St. Paul: West Academic Publishing; 2009.Google Scholar
  42. 42.
    Goligher EC, Ely EW, Sulmasy DP, et al. Physician-assisted suicide and euthanasia in the ICU. Crit Care Med. 2017;45:149–55.  https://doi.org/10.1097/ccm.0000000000001818.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Haidet P, Hamel MB, Davis RB, Wenger N, Reding D, Kussin PS, et al. Outcomes, preferences for resuscitation, and physician-patient communication among patients with metastatic colorectal Cancer. Support investigators. Study to understand prognoses and preferences for outcomes and risks of treatments. Am J Med. 1998;105:222–9.CrossRefGoogle Scholar
  44. 44.
    Heyland DK, Rocker GM, Kutsogiannis DJ, et al. Family satisfaction with care in the ICU: the results of a multicenter study. Crit Care Med. 2002;30:1413–8.CrossRefGoogle Scholar
  45. 45.
    Heyland DK, Cook DJ, Rocker GM, et al. Decision-making in the ICU: perspectives of the substitute decision-maker. Intensive Care Med. 2003;29:75–82.  https://doi.org/10.1007/s00134-002-1569-y.CrossRefPubMedGoogle Scholar
  46. 46.
    Humphry D. Liberty and death: a manifesto concerning an individual’s right to choose to die. In: Assisted suicide-information on right-to-die and euthanasia laws and history; 2009. http://www.assistedsuicide.org/liberty_and_death_manifesto_right_to_die.html.Google Scholar
  47. 47.
    Kon AA, Shepard EK, Sederstrom NO, et al. Defining futile and potentially inappropriate interventions. Crit Care Med. 2016;44:1769–74.  https://doi.org/10.1097/ccm.0000000000001965.CrossRefPubMedGoogle Scholar
  48. 48.
    Kouwenhoven WB, Jude JJ, Knickerbocker GG. Closed-chest cardiac massage. JAMA. 1960;173: 1064–7.  https://doi.org/10.1001/jama.1960.03020280004002.CrossRefPubMedGoogle Scholar
  49. 49.
    Lang F, Quill T. Making decisions with families at the end of life. Am Fam Physician. 2004;70:719–23.PubMedGoogle Scholar
  50. 50.
    Lantos JD, Singer PA, Walker RM, et al. The illusion of futility in clinical practice. Am J Med. 1989;87:81–4.  https://doi.org/10.1016/0002-9343(89)90542-1.CrossRefPubMedGoogle Scholar
  51. 51.
    Levin TT, Li Y, Weiner JS, et al. How do-not-resuscitate orders are utilized in cancer patients: timing relative to death and communication-training implications. Palliat Support Care. 2008;6:341–8.  https://doi.org/10.1017/s1478951508000540.CrossRefPubMedGoogle Scholar
  52. 52.
    Manthous CA. Counterpoint: is it ethical to order “do not resuscitate” without patient consent? Chest. 2007;132:751–6.  https://doi.org/10.1378/chest.07-0912.CrossRefPubMedGoogle Scholar
  53. 53.
    Miller AH, Sandoval M, Wattana M, Page VD, Todd KH. Cardiopulmonary resuscitation outcomes in a cancer center emergency department. Springerplus. 2015;4:106.CrossRefGoogle Scholar
  54. 54.
    Misak CJ, White DB, Truog RD. Medical futility. Chest. 2014;146:1667–72.  https://doi.org/10.1378/chest.14-0513.CrossRefPubMedGoogle Scholar
  55. 55.
    Moore JA, Denton K, Epner DE. Experience matters: a partnership between patient and physician. In: Gallagher C, Ewer M, editors. Ethical challenges in oncology: patient care, research, education, and economics. San Diego: Elsevier; 2017. p. 19–39.CrossRefGoogle Scholar
  56. 56.
    Northwestern University Feinberg School of Medicine. Education in Palliative and End-of-Life Care (EPEC). 2017. http://bioethics.northwestern.edu/programs/epec/curricula/index.html. Accessed 16 May 2018.
  57. 57.
    O’Rourke MA, O’Rourke MC, Hudson MF. Reasons to reject physician assisted suicide/physician aid in dying. J Oncol Pract. 2017;13:683–6.  https://doi.org/10.1200/jop.2017.021840.CrossRefPubMedGoogle Scholar
  58. 58.
    Pentz RD, Flamm AL. Code status discussion: just have one. Cancer. 2013;119:1938–40.  https://doi.org/10.1002/cncr.27983.CrossRefPubMedGoogle Scholar
  59. 59.
    Pereira J. Legalizing euthanasia or assisted suicide: the illusion of safeguards and controls. Curr Oncol. 2011;  https://doi.org/10.3747/co.v18i2.883.
  60. 60.
    Pope TM. Legal briefing: medical futility and assisted suicide. J Clin Ethics. 2009;20:274–89.PubMedGoogle Scholar
  61. 61.
    Pope T. Texas advance directives act: nearly a model dispute resolution mechanism for intractable medical futility conflicts. In: William Mitchell law review, vol 27, Iss 4; 2016. https://open.mitchellhamline.edu/facsch/378/. Accessed 16 May 2018.
  62. 62.
    Presidents Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Deciding to forego life-sustaining treatment: a report on the ethical, medical, and legal issues in treatment decisions. 1983.Google Scholar
  63. 63.
    Reisfield GM, Wallace SK, Munsell MF, et al. Survival in cancer patients undergoing in-hospital cardiopulmonary resuscitation: a meta-analysis. Resuscitation. 2006;71:152–60.  https://doi.org/10.1016/j.resuscitation.2006.02.022.CrossRefPubMedGoogle Scholar
  64. 64.
    Rhondali W, Perez-Cruz P, Hui D, et al. Patient-physician communication about code status preferences. Cancer. 2013;119:2067–73.  https://doi.org/10.1002/cncr.27981.CrossRefPubMedGoogle Scholar
  65. 65.
    Rothchild E. End-of-life decisions: a psychosocial perspective. In: Maurice D. Steinberg and Stuart J. Youngner (eds) Washington, D.C., American Psychiatric Press; 1998.Google Scholar
  66. 66.
    Schellongowski P, Sperr WR, Wohlfarth P, et al. Critically ill patients with cancer: chances and limitations of intensive care medicine – a narrative review. ESMO Open. 2016;  https://doi.org/10.1136/esmoopen-2015-000018.
  67. 67.
    Schneiderman LJ. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990; 112:949–54.  https://doi.org/10.7326/0003-4819-112-12-949.CrossRefPubMedGoogle Scholar
  68. 68.
    Schneiderman LJ, Gilmer T, Teetzel HD. Impact of ethics consultations in the intensive care setting: a randomized, controlled trial. Crit Care Med. 2000;28:3920–4.  https://doi.org/10.1097/00003246-200012000-00033.CrossRefPubMedGoogle Scholar
  69. 69.
    Sears SR, Woodward JT, Twillman RK. What do I have to lose? Effects of a psycho-educational intervention on Cancer patient preference for resuscitation. J Behav Med. 2007;  https://doi.org/10.1007/s10865-007-9128-1.
  70. 70.
    Sulmasy LS, Mueller PS. The ethics, professionalism, and human rights committee of the American college of physicians. Ethics and the legalization of physician-assisted suicide: an American College of Physicians Position Paper. Ann Intern Med. 2017;167:576–8.Google Scholar
  71. 71.
    Sulmasy DP, Sood JR, Ury WA. The quality of care plans for patients with do-not-resuscitate orders. Arch Intern Med. 2004;164:1573–8.  https://doi.org/10.1001/archinte.164.14.1573.CrossRefPubMedGoogle Scholar
  72. 72.
    Sulmasy DP, Ely E, Sprung CL. Euthanasia and physician-assisted suicide. JAMA. 2016;316(15): 1600.  https://doi.org/10.1001/jama.2016.14077.CrossRefPubMedGoogle Scholar
  73. 73.
    Staudinger T, Stoiser B, Müllner M, et al. Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit. Crit Care Med. 2000;28:1322–8.  https://doi.org/10.1097/00003246-200005000-00011.CrossRefGoogle Scholar
  74. 74.
    Taylor RM, Gustin JL, Wells-Digregorio SM. How we do it: improving do-not-resuscitate discussions – a framework for physicians. J Support Oncol. 2010;8:42–4.PubMedGoogle Scholar
  75. 75.
    Tomlinson T, Czlonka D. Futility and hospital policy. Hast Cent Rep. 1995;  https://doi.org/10.2307/3562112.
  76. 76.
    Truog RD, Brett AS, Frader J. The problem with futility. N Engl J Med. 1992;326:1560–4.  https://doi.org/10.1056/nejm199206043262310.CrossRefPubMedGoogle Scholar
  77. 77.
    Truog RD, Campbell ML, Curtis JR, et al. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College of Critical Care Medicine. Crit Care Med. 2008;36:953–63.  https://doi.org/10.1097/ccm.0b013e3181659096.CrossRefPubMedGoogle Scholar
  78. 78.
    Truog RD. Counterpoint: the Texas advance directives act is ethically flawed. Chest. 2009;136:968–71.  https://doi.org/10.1378/chest.09-1269.CrossRefPubMedGoogle Scholar
  79. 79.
    Venneman SS, Narnor-Harris P, Perish M, Hamilton M. “Allow natural death” versus “do not resuscitate”: three words that can change a life. J Med Ethics. 2008;34:2–6.  https://doi.org/10.1136/jme.2006.018317.CrossRefPubMedGoogle Scholar
  80. 80.
    Von Gunten CF, Ferris FD, Emanuel LL. Ensuring competency in end-of-life care. JAMA. 2000;284: 3051–7.  https://doi.org/10.1001/jama.284.23.3051.CrossRefGoogle Scholar
  81. 81.
    Vitelli CE, Cooper K, Rogatko A, Brennan MF. Cardiopulmonary resuscitation and the patient with cancer. J Clin Oncol. 1991;9:111–5.  https://doi.org/10.1200/jco.1991.9.1.111.CrossRefPubMedGoogle Scholar
  82. 82.
    Wallace S, Ewer MS, Price KJ, Feeley TW. Outcome and cost implications of cardiopulmonary resuscitation in the medical intensive care unit of a comprehensive cancer center. Support Care Cancer. 2002;10:425–9.  https://doi.org/10.1007/s00520-002-0353-4.CrossRefPubMedGoogle Scholar
  83. 83.
    Wenger N. Waiting for conflict before requesting an ethics consultation. West J Med. 2001;  https://doi.org/10.1136/ewjm.175.1.31.
  84. 84.
    Youngner SJ. Who defines futility? JAMA. 1988;260:2094–5.  https://doi.org/10.1001/jama.1988.03410140106033.CrossRefPubMedGoogle Scholar
  85. 85.
    Zafar SY, Alexander SC, Weinfurt KP, et al. Decision making and quality of life in the treatment of cancer: a review. Support Care Cancer. 2009;17:117–27.CrossRefGoogle Scholar
  86. 86.
    Zahedi F, Tavakoly J, et al. End of life ethical issues and Islamic views. Iran J Allergy Asthma Immunol. 2007;6:5–15.Google Scholar
  87. 87.
    Veterans Health Administration. VHA handbook 1004.3. Do not resuscitate (DNR) protocols within the Department of Veteran Affairs (VA). 2002.Google Scholar
  88. 88.
    Oregon Death With Dignity Act Data Summary 2016. Oregon Health Authority, Public Health Division. Available at: http://www.healthoregon.org/dwd

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Colleen M. Gallagher
    • 1
    Email author
  • Jessica A. Moore
    • 1
  • Allen H. RobertsII
    • 2
  1. 1.Section of Integrated Ethics in Cancer CareThe University of Texas MD Anderson Cancer CenterHoustonUSA
  2. 2.Division of Pulmonary, Critical Care, and Sleep Medicine, Department of MedicineMedStar Georgetown University HospitalWashingtonUSA

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