Class 7 - End of Life Ethics Flashcards
1982
Criminal Code of Canada is introduced
Suicide is decriminalized
1982:
Charter of Rights and Freedoms signed into Law
1975-1985: Karen Quinlan
**Read story in our google doc
Takeaways from this case:
- Started discussions on the difference between withholding and withdrawal care.
- Court highlights that withdrawal of care can be done ethically based on the patient’s right to privacy (US constitution term, for us a bit different) - right to make decisions free from government or outside interferences. Idea of right to autonomy and right to refuse care. Idea that withholding and withdrawing can both be viewed from this lens.
- Idea that we need to make decision based on patient wishes and what they would want in those circumstances
1990: Nancy Cruzan
24 year old woman who was in a car accident in 1983 and she was thrown from the car
She suffered a cardiac arrest she was unresponsive, like Karen Quinlan, she was stabilized
But she was found having non-oxic brain injury, she was in a persistent vegetative state
Unlike Karen Quinlan she was not ventilator dependent but she required artificial nutrition and hydration to survive
Some of the important things to take away was in this court case, they found that artificial nutrition and hydration should be conceptualized as the same as other form of medical treatments (patients should have the right to consent or to refuse it)
Feeding is considered a medical intervention that requires consent and can be refused
1992: Nancy B v. Hôtel Dieu de Québec
Nancy B suffered from GB syndrome, she was paralyzed from the neck down but unlike Nancy Cruzan and K.Q. she was fully competent , lucid able to make her own decisions
She had been in the state where she was ventilator dependent, she lived in an ICU for two and a half years and she said: “I don’t have quality of life. This is not what I want”
At the time in the civil court of Quebec, recognized that patients have the right to refuse life sustaining treatment. But at the same time, the federal law stated that euthanasia or physician assisted suicide was illegal.
So the question of the hospital: they worried that stopping the ventilator would allowing her to die, it would be equivalent to euthanasia. There’s questions about who had the right to decide and what withdrawing that care would mean…did it mean euthanasia? would they be culpable under the Criminal Court of Canada?
It went to the Quebec Superior Court there was a lot of publicity about this case
Some disability rights Advocates were very concerned about this case, because they they worry that they were framing sort of a life on a ventilator is not worth living. They worried that maybe Nancy hadn’t been given options to have a better quality of life to move out of the ICU to live with events later. That it was stigmatizing sort of a life of disability. Her lawyers said she had been giving these options but that she’s still did not want to live in the state
The Quebec courts then ruled in favor of Nancy B; that competent patients should have the right to refuse treatment. That it honored their autonomy to make decisions about what they wanted in terms of care.
1993: Rodriguez v British Columbia
Sue Rodriguez made a challenge to the Supreme Court to access medical aid in dying, but thr 5-4 majority of Supreme Court justices upheld the status quo
S.R is already dying of arterial lateral sclerosis (lugaric disease - ALS) she asked the Supreme Court the right to die
2013: Cuthbertson v Rasouli
In this pivotal case, the healthcare team felt that continuing life support for Mr. Rasouli with minimal brain function was no longer justifiable. His substitute decision-makers petitioned the supreme court to prevent removal of life support as they did not consent to this. The decision fell in their favor. As noted by Chief Justice Beverley McLachlin in this case, “No legal principle can avoid every ethical
Dilemma”.
The Supreme Court clarifies that this ruling is NOT a decision about who has the ultimate say on life sustaining Tx. The judgment focused on how Ontario Health Care Consent Act is applied.
- BC, Yukon, Manitoba, QB, PEI have similar laws
- The act says that we need consent for treatment
- And today the court ruled that withdrawing life support = treatment
- Thus withdrawing life support = requires consent
2015: Carter v. Canada (Kay Carter and Gloria Taylor change the law)
Gloria Taylor, suffering from ALS, and Kay Carter, with severe spinal stenosis, “challenged the constitutionality of the Criminal Code provisions prohibiting assistance in dying”.
After their death, the Carter family continued the legal process.
Contrary to the Rodriguez case, the courts found that “Insofar as they prohibit physician-assisted dying for competent adults who seek such assistance as a result of a grievous and irremediable medical condition that causes enduring and intolerable suffering, ss. 241(b) and 14 of the Criminal Code deprive these adults of their right to life, liberty and security of the person under s. 7 of the Charter.”
2019: Truchon and Gladu v. Canada and Quebec
Montrealers who challenged assisted dying laws see ruling as ‘ray of hope’
Nicole Gladu and Jean Truchon, the two Montrealers who challenged the country’s assisted dying laws, say a ruling that deemed parts of the legislation too restrictive should be seen as a victory for those who struggle with debilitating conditions.
Quebec Superior Court Justice Christine Baudouin determined provisions in the existing federal and provincial assisted-dying laws that require death to be “reasonably foreseeable” are an infringement on the “life, liberty and security of the person” under the Charter of Rights and Freedoms.
Baudouin gave the federal and provincial governments six months to come up with something new before suspending that provision of the laws.
It also granted an exemption to Gladu and Truchon that allows them to apply for medically assisted death immediately.
2021: Revision to Medical Aid in Dying Legislation
Federal legislation brought into compliance with the Quebec Superior Court ruling that found that it was unconstitutional to prevent people for whom death WAS NOT reasonably foreseeable from access to a medically assisted death
What did Glenda Sandy Discuss when talking about defining ‘family’ and privacy/confidential information in indigenous populations?
Indigenous define family as more than blood related, but she still must advocate for patients to have their personal information and confidentiality respected
no matter the bonds they may share with individuals of their community.
Concept of individualism versus collectivism.
Duties with regards to the code of ethics and confidentiality…But Glenda’s community has expectations of a member of the community = tension can arise.
11 Conditions for a good death
- Relief from physical pain and other physical symptoms
- Effective communication and relationships with healthcare providers
- The performance of cultural, religious or other spiritual rituals
- Relief from emotional distress or other forms of psychological suffering
- Autonomy with regards to treatment and decision making
- Dying in the preferred place
- Life not being prolonged unnecessarily
- Awareness of the deep significance of what is happening
- Emotional support from family and friends
- Not being a burden on anyone
- The right to terminate one’s life
A good death: Challenges
Literature shows people would prefer to die at home - most people die in hospitals in Canada (people want to die in the preferred place)
Relief from physical pain and suffering, performance of rituals, emotional support from family and friends
- in COVID, family presence was restricted
- CHSLDs had a total system failure
what type of ethics do we focus on for end of life nursing?
applied ethics
What are the ethical issues facing nurses providing end of life care?
(3 common ones)
Provision of “futile” care (“Acharnement therapeutique”) - When care has more burdens than benefits
Poor DaNR/LOC discussion
Conflict over goals of care
Ethical considerations:
(using a principilism lens)
beneficence, non-maleficence, autonomy, professional integrity, quality of life, sanctity of life, procedural justice
How have discussions regarding QOL, sanity of life and professional integrity shifted?
Before: pt and families wanted treatment to be withdrawal which made HCP uncomfortable
Now: pt and families ask for Tx to be continued, making HCP uncomfortable
**generally this is what we see
Order of the surrogate decision makers in Qb
Mandatary, tutor or curator
Spouse
Close friend or relative
Futility as will not work
Objective standard
Rare
Treatment will not be physiologically effective in achieving its goal
EX: Dialysis will not work due to hypotension
CPR will not work due to underlying pathology
