4) End of life: Breaking Bad News

• Physician behavior towards the terminally ill and hopelessly ill in Palliative Care is a major ethical concern.
• Palliative Care is a broad term that includes hospice care as well as other care that emphasizes symptom management in persons with life-limiting disease but is not restricted to persons near the end of life.
• Palliative Care is a new specialty of medicine that uses an interdisciplinary team to manage patients with an advanced illness, in whom the goal of care is symptom control rather than disease control.
• Hospice Care is the care of patients who are in an advanced stage of an incurable illness.
• Hospice Care is a philosophy of medical care that emphasizes symptom management in persons with life-limiting disease and with a primary focus on quality of life.
• Hospice is an interdisciplinary program of palliative and supportive services funded by third-party payers that is provided both in the home and in institutional settings for persons with weeks or months to live so that they may live as fully and as comfortably as possible.
• Belgium adopted the law on euthanasia in September 2002.
• Colombia legalized euthanasia for terminally ill when they given their consent in May 1997.
• Euthanasia is the termination of life support procedures such as termination of human nutrition.
• Netherlands theoretically considers euthanasia as criminal acts, but since 1993 doctors complied with certain conditions are not prosecuted.
• Japan applies euthanasia if the patient meets certain criteria: unbearable pain which can not be copied with known medical methods, death is inevitable, and the patient has clearly expressed his decision to terminate the life of her/his.
• If the patient's death was caused by high doses of drugs and other medical procedures which form part of the generally accepted norms, it is not euthanasia until proven whether there has been purposeful behavior that led to fatal outcome.
• Oregon, USA has permitted euthanasia under certain conditions since 1994 with amendment in 1997.
• Australia, Northern Territory adopted the rights of terminally ill patients in 1995, but the law was repealed and 3 people were euthanized.
• Ethical issues in Palliative Care include Autonomy/Beneficence, Advance directives/surrogacy, Withdrawing/withholding life support, Double effect, Medical futility, Informed consent, Responsible resource allocation, Euthanasia/Physician Assisted Suicide, Truth-telling, Honoring patient preferences, Non-abandonment, Sedation for intractable symptoms, Competency/decisional capacity.
• Death is the point at which our vital (neurological, respiratory and cardiac) physical functions cease.
• Not telling the truth in the doctor-patient relationship requires special attention because patients today, more than ever, experience serious harm if they are lied to.
• The doctor who tells a dreadful truth must do so at a certain time, and in a certain way.
• Biological death is defined as 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.
• Criteria for determining brain death include exclusion of potentially reversible causes of brain hypoxia, absence of brain stem reflexes, absence of spontaneous respiration during the apnoea test for 5 min.
• A lie is always evil because it harms human discourse and the dignity of every human person.
• Objective, quantitative, scientific truth is abstract and yet it is not alien to the clinical setting.
• Clinical death is defined as a reversible cessation of circulatory and respiratory functions.
• Robert Buckman's Six Step Protocol for Breaking Bad News (SPIKES) includes steps for setting up the interview, assessing the patient’s perception, obtaining the patient’s invitation, and preparing for the conversation.
• Truth-telling in every clinical context must be sensitive and take into consideration the patient's personality and clinical history.
• A clinical judgment is different from a laboratory judgment, and the same is true of clinical and abstract truth (clinical truth strives to address a patient's inquiries without causing the patient unnecessary harm).
• Kant argued for truth and the strict rejection of all lying, stating that truth telling is a duty (imperative) which binds unconditionally (categorical).
• Brain death is defined as an irreversible cessation of brain function.
• Truth telling is always a duty, whether the other has the right to know or whether innocent persons will be severely harmed.
• Brain death can occur when the blood and/or oxygen supply to the brain is stopped due to cardiac arrest, heart attack, blood clot, severe head injury, brain hemorrhage, infections (encephalitis), brain tumor, drowning, overdose, suicide, or homicide.
• Clinical/moral truth is contextual, circumstantial, personal, engaged, and related both to objective/abstract truth and to the clinical values of beneficence and non-maleficence.
• Truth-dumping, or violation of beneficence, usually perceived by patient as cruel and uncaring.
• Some patients who are given a cancer diagnosis and a prognosis of death may use denial for a while and the bad news may have to be repeated, but the use of denial as a coping device does not mean that patients would prefer to be lied to or that truth is not important to them.
• Patients are harmed when doctors lie to them, as are the medical profession and society which depends on humane and trustworthy medicine.
• Terminally ill react in two main ways in truth-telling: some fall into a deep and prolonged depression, their condition worsens and requires psychological treatment, while others fall into depression for 2-3 days and are consumed by thoughts about themselves, reconsider their life and the reasons for this condition.
• Lying in a clinical context is wrong for many reasons (patient is depressed and irrational and suicidal, is overly pessimistic).
• Truth is an essential moral good, but what if it comes into conflict with other essential moral goods like life itself, or beneficence, or freedom?
• To tell the truth in the clinical context requires compassion, intelligence, sensitivity, and a commitment to staying with the patient after the truth has been revealed.
• Truthful disclosure of relevant information is a legal and ethical duty.
• A culturally sensitive dialogue about the patient's role in decision making should take place.