Catholic Medical Quarterly Volume 66(2) May 2016
Practical Medical Ethics
Ethical Dilemas for Young Doctors:
Care of the Dying
We were recently asked the following question:
I'm a new junior doctor, currently finishing off my placement in geriatric medicine. In my short 4 months as a doctor, I've come across two cases of patients who were put on the End of Life pathway for serious infections which were felt inappropriate to treat.
On the whole, I agree with the reasoning: they were very unwell, very frail in one case and having failed IV antibiotics in another. However, these patients spent a week and a half on this pathway before succumbing. In that time, they would not drink or eat. One of them was put on a syringe driver for about a week. I was concerned that dehydration and starvation were significant contributors to their death given the length of time - which would have likely come soon regardless, but later. My consultant politely turned down my repeated queries as to the benefit of at least subcutaneous fluids, saying it would not make a difference at this stage. Instead, I encouraged mouthcare by the nurses.
What should have been done in this case? And what more could I have done as an F1?
Another ethical dilemma: when treating women of child bearing age, unless prescribing a known teratogenic drug, should a pregnancy test always be performed? Especially in my junior position, if a senior asks me to prescribe for a woman of child bearing age, am I morally expected to highlight the possibility of pregnancy every time and refuse to prescribe until I am satisfied there is no pregnancy or should I trust my senior's judgement and instruction?
Also, the principle of double effect should normally lead: but if prescribing for non-life threatening but distressing conditions (e.g. mild depression, pain relief ) which have a small-large risk of serious harm to a potential (or actual) foetus - where do we draw the line?
I look forward to your assistance.
May God bless you,
Thanks for emailing these important and challenging questions. Many junior doctors and nurses end up feeling very worried about issues such as these.
As a specialist in dementia care, I shall try to answer the first question you pose. I understand that others have answered the second question, though if that is not right do please let us know.
The fundamental position of the Church and of Christ as set out in the Gospels is that every human is uniquely worthwhile and deserving of our absolute respect and love (John 13: 34-35, love one another as I have loved you), and that thou shalt not kill. The parable of the Good Samaritan sets out what we are expected and privileged to do in our daily lives as doctors and nurses as we care for the sick. It is of course, in some ways, a particularly special privilege to care for the sickest and most vulnerable members of our society. In a partisan way, a career in old age psychiatry has been a great joy for me, and the possibility of a career in geriatric medicine or dementia care may well be something you might consider.
Having said all of that, it is clear that we provide care for those who are dying and whose life expectancy is short. Cicely Saunders and Elizabeth Kubler Ross both set out eloquently how controlling the symptoms of those who are dying, and accepting the reality that they are dying are central to excellent medicine and care. None of us, in the end can stand in the way of death and as Catholics we see that death is , as well as a sad farewell, a gateway to a new and promised life. Thus as we care for the dying, acceptance of that dying is centrally important to the care we give. We should be careful to avoid overmedicalisation and providing futile care after a point at which life saving therapy can have an effect. All of that fits in with a limitation of care which should then also enable access to appropriate spiritual care and medication to assure comfort. The two cases that you describe sound as if they very much fit within that category of patients. If they do not fit in that category it is very important to ask for a review of the decision that they are dying. It is very clear now that doctors are bad at making accurate prognoses and diagnosing dying especially in those who are dying of frailty, dementia and other non cancer diagnoses.
The need for appropriate pain relief
In that context it is also therefore very important that we do treat pain and other distress actively and sufficiently aggressively. It is wrong to leave the dying to suffer. At the same time it is also wrong to oversedate people. Deprivation of consciousness is not right, unless there are very grave reasons why a person’s pain and distress cannot be otherwise managed. With the use of some end of life care pathways, we have seen people who have been deeply sedated and this caused scandal when it was done under the auspices of the Liverpool Care Pathway . We would also argue that to do that when someone is not in severe distress which can be alleviated in a less aggressive manner, is wrong. So if someone appears to be oversedated and you are thinking that this is wrong, perhaps a good question to ask the consultant would be “Do you think we are oversedating this person”, or “Are we depriving this person of their consciousness when in fact they might be able to have their symptoms controlled in another way.” It is likely that the answer will be no, and as I said above, you do not want to place that person in jeopardy by causing them to suffer as death inevitably approaches. So talking about the amount of pain relief and sedation given is important, and asking the right question is a duty that you have. There is a useful checklist that may help produced by the Medical Ethics Alliance.
Rebuilding excellent palliative care
There is no doubt that thirst is one of the most distressing symptoms that we can have. There has been a substantial debate about whether or not thirst is significant in those who are dying. [see 3 for an interesting background on this] But many stories of dying people in the Neuberger review of the LCP there were harrowing stories of people who were dehydrated, gasping for breath with acidotic (Kussmaul) breathing and others who would bite the end of a wet sponge when it was offered. Some have begged for water. The prevailing medical view has been that in those who are dying, thirst is not an issue and the used of iv fluids not indicated. But it was made clear in the final version (version12) of the LCP that fluid by mouth should be offered and supported for as long as the patient wishes to have it. Just sometimes, when swallowing reflexes have been lost, offering fluid may lead to very distressing choking due to inhalation of water. In those circumstances, in a dying person I would withhold fluids so as to avoid the inevitable suffering oral fluids will cause.
But if someone is dehydrated and symptomatic, then we ought to consider either subcutaenoeuos or iv fluids. There are clear indications in good palliative care for the use of such fluids and it is far from clear that giving those fluids actually prolongs dying, although it does seem to resolve the (very unpleasant) acidosis which does look very distressing. So if you are worried, try asking the question “do you think this person is symptomatic as a result of dehydration” and “Is there any evidence that if we gave fluids that would prolong this person’s suffering”.
Such questions work well to re-emphasise the central point here. This patient is worthwhile and has a unique value deserving full care and respect right up to the moment they die. Making that prophetic point in a purely medical way can be very powerful and resolve many concerns. Most often those concerns are resolved by the discussion that occurs as a result of the explanation and agreement they trigger. Sometimes, they will lead to changes in care and improve things greatly.
In the end though, it is the consultant’s decision what to do next. Your duty as a doctor is to hold the patient as your first concern (GMC rules of a doctor ) and also to act ethically. If therefore, in good conscience you think that you are being asked to write up or administer drugs which are wrong, or if you think that the patient’s life is being wrongly ended, you may have to withdraw from the aspects of care to which you object. In this circumstance, if you truly and after good discussion feel that opiates are not indicated, you may have to refuse to set them up. The consultant is in charge and therefore he or she may have to be made aware and do them. That would seem very scary for an F1 or F2, but in reality we should not do things which we think to be clearly wrong.
If we do thus struggle, be mindful of the advice given by the US National Catholic Bioethics Centre in its ‘A Manual for Practitioners’ is crucially important. It states: “Generally, if there are two competing but contrary bodies of theological opinion about a moral issue, each held by experts whose work is in accordance with the magisterium of the Church, and if there is no specific magisterial teaching on the issue that would resolve the matter, then the decision makers may licitly act on either opinion until such time that the magisterium has resolved the question."
In an analogous way, if something in your clinical work is clearly wrong, you have to say no. If there is doubt, think, pray and reflect with colleagues but you are not likely to refuse to do something that is not clearly wrong. If you are struggling in such a way, always talk to colleagues for advice. And by all means ask us too for our thoughts. One of the core tasks of the CMA is to support people like yourself as they struggle with these very real ethical dilemmas.
For a bit of further reading look at
- Treloar A WHAT WAS WRONG WITH THE LCP? Submission to the Neuberger Review. CMQ Volume 63(4) November 2013
- PRACTICAL MEDICAL ETHICS: PROTECTING PEOPLE WHILE THEY ARE DYING? Advice from the Medical Ethics Alliance CMQ Volume 63(4) November 2013
McCullagh. THIRST IN RELATION TO WITHDRAWAL OF HYDRATION.
CMQ February 1996.
- General Medical Council Duties of a Doctor
- Dr Michael
PRETERM INDUCTION AND ABORTION CMQ Volume 64(3) August 2014
and the other letters and original articles in that debate