End of Life Flashcards
How can QOL be enhanced?
Caring attitude of staff
Family visits
Physical environment
Maintaining control
Feeling safe/ not alone
How can QOL be diminished?
Lost independence
Lost activities
Pain/ fear of pain
Feeling as though you are a burden
In a scenario where the patient doesn’t want to know their prognosis but the family does, what should you do?
Respect the patient’s autonomy and confidentiality and not tell the family if they don’t want them to know
You shouldn’t tell the patient - non-maleficence/beneficence
What is collusion?
A secret agreement made between clinicians and family members to hide the diagnosis of a serious or life-threatening illness from the patient.
Family members may ask you as the doctor to collude the information. This may be because they want to protect them.
This is unlawful with very limited exceptions.
Reasons for collusion?
Family may be worried that disclosure will:-
- Cause the patient to lose hope
- Lead to depression
- Hasten the progression of the illness and death
- Increase the risk of patient suicide
- Cause psychological pain for the patient
However, family members themselves may not be aware of the nature and severity of the illness or they may be in denial. Family members may be in conflict.
Collusion goes against best clinical practice.
State some patient factors
Telling relatives before the patient breaches patients’ right to medical confidentiality/autonomy of the patient
Patient is unable to give informed consent if they are unaware of their underlying illness
Patients may not be able to complete unfinished business and tasks prior to their deaths
Patients who sense something amiss may come to distrust their relatives and clinicians.
Collusion goes against principles of best clinical practice.
State some family factors
Family members will have to bear the burden of being untruthful or even deceptive to their loved ones, which may lead to guilt later.
Barrier to communication forms between family and patient - may result in the family avoiding the patient
When would collusion be lawful?
The only time collusion is regarded lawful is if someone else had the right to consent on behalf of the patient. I.e in these two scenarios:-
- If the patient was held under the adults with incapacity act (section 47)
- Or if the family had power of attorney
Look
If you have an adult with capacity, whatever the age, if doctors exclude them from the decision making regarding treatment etc then they are breaking the law
Collusion goes against principles of best clinical practice.
State some clinician factors
Collusion results in a breakdown of the clinician–patient relationship and a loss of trust between patients and clinicians.
Clinicians may face treatment non-compliance from patients and may be unable to provide optimal treatment, such as radiotherapy and chemotherapy.
Look
So if a family member asks you as a doctor to collude then you must find out why.
You should find out the patient’s stance on knowing the ins and outs of their condition. If they don’t want to know, you can ask if they are happy for you to share more info with their family - if they say no then you cannot.
What is a DNACPR form?
Do not resuscitate form
It is not a set legal document but it is in the medical records. It is evidence of a decision that has been made.
It provides guidance for clinicians who do not know the patient
Look
If doctors are considering a DNACPR for a patient then they MUST tell the patient (if they have capacity).
- If the patient lacks capacity then doctors must inform those close to the patient (next of kin etc - don’t need power of attorney) without delay
- If there is a power of attorney then their decision cannot be ignored and in this scenario there may be a legal battle
- If they don’t have a power of attorney then doctors can consider their opinion but ultimately they can ignore it.
If there is clinical certainty then a DNACPR will remain in place and does not need to be reviewed.
Discuss the withdrawal of treatment - patient choice
It is a patient’s legal and ethical right to decide to refuse treatment.
If the patient has capacity then this decision must be respected and complied with - even if this leads to death
It is important to have good communication with the patient. This ensures effective planning and preparation.
If treatment is stopped then symptoms should be anticipated and managed effectively
Continuing unwanted treatment is regarded as what?
Battery
