Attitudes towards end-of-life decisions and the subjective concepts of consciousness: an empirical analysis

Decision-Making at End-of-Life for Children With Cancer: A Systematic Review and Meta-Bioethical Analysis

Background

Evidence shows that medical education includes a variety of basic and clinical skills. Ethical and human values are not typically considered in medical school curricula, and this is evident in medical practice in certain scenarios such as decision-making at pediatric cancer patients' end of life.

Methods

This study explores a bioethical approach to address complex decision-making at the end of life in children and adolescents with cancer. We are a cross-functional group of scientists from several academic disciplines who conducted a systematic review of the literature using our newly developed meta-bioethical analysis and synthesis of findings. The search was carried out in five databases, resulting in 10 research papers. Following quality screening, seven articles were ultimately selected for further analysis.

Results

Our focus is on the state of the art to better understand the bioethical deliberation at the end of life in pediatric oncology. Here, we report a systematic review that includes (i) classification of the screened articles by the type of decision-making they use, ii) the system values that are at the core of the decision-making at the end of life, and iii) bioethical and ethical discernment queries. We conclude with a discussion regarding the best practices of ethical discernment and decision-making at the end of life.This study highlights the need to develop more research to better understand the influence and origin of these multidimensional factors determining critical decisions that define the quality of life of patients in a highly sensitive moment.

Conclusion

We conclude that personal aspects of the physician define their actions more than knowledge or organized structure. It is thus necessary that pediatric oncologists receive ethics and humanistic education.

How many patients in a prolonged disorder of consciousness might need a best interests meeting about starting or continuing gastrostomy feeding?

OBJECTIVE:

To estimate the number of people in a prolonged disorder of consciousness (PDOC) who may need a formal best interests decision-making process to consider starting and/or continuing life-sustaining treatment each year in the population of a developed country.

METHOD:

Identification of studies on people with a PDOC giving information about incidence, and/or prevalence, and/or cause, and/or location of long-term care. Sources included systematic reviews, a new search of MEDLINE (April 2018), and a personal collection of papers. Validating information was sought from existing data on services.

RESULTS:

There are few epidemiologically sound studies, most having bias and/or missing information. The best estimate of incidence of PDOC due to acute onset disease is 2.6/100,000/year; the best estimate of prevalence is between 2.0 and 5.0/100,000. There is evidence that prevalence in the Netherlands is about 10% of that in other countries. The commonest documented causes are cerebral hypoxia, stroke, traumatic brain injury, and tumours. There is some evidence suggesting that dementia is a common cause, but PDOC due to progressive disorders has not been studied systematically. Most people receive long-term care in nursing homes, but a significant proportion (10%-15%) may be cared for at home.

CONCLUSION:

Each year, about 5/100,000 people will enter a prolonged state of unconsciousness from acute onset and progressive brain damage; and at any one time, there may be 5/100,000 people in that state. However, the evidence is very limited in quality and quantity. The numbers may be greater.

Determinants of Public Attitudes towards Euthanasia in Adults and Physician-Assisted Death in Neonates in Austria: A National Survey

Background

Euthanasia remains a controversial topic in both public discourses and legislation. Although some determinants of acceptance of euthanasia and physician-assisted death have been identified in previous studies, there is still a shortage of information whether different forms of euthanasia are supported by the same or different sub-populations and whether authoritarian personality dispositions are linked to attitudes towards euthanasia.

Methods

A large, representative face-to-face survey was conducted in Austria in 2014 (n = 1,971). Respondents faced three scenarios of euthanasia and one of physician assisted death differing regarding the level of specificity, voluntariness and subject, requiring either approval or rejection: (1) abstract description of euthanasia, (2) abstract description of physician-assisted suicide, (3) the case of euthanasia of a terminally-ill 79-year old cancer patient, and (4) the case of non-voluntary, physician assisted death of a severely disabled or ill neonate. A number of potential determinants for rejection ordered in three categories (socio-demographic, personal experience, orientations) including authoritarianism were tested via multiple logistic regression analyses.

Results

Rejection was highest in the case of the neonate (69%) and lowest for the case of the older cancer patient (35%). A consistent negative impact of religiosity on the acceptance across all scenarios and differential effects for socio-economic status, area of residence, religious confession, liberalism, and authoritarianism were found. Individuals with a stronger authoritarian personality disposition were more likely to reject physician-assisted suicide for adults but at the same time also more likely to approve of physician-assisted death of a disabled neonate.

Conclusion

Euthanasia in adults was supported by a partially different sub-population than assisted death of disabled neonates.

Precedent autonomy should be respected in life-sustaining treatment decisions

In the 2011 landmark case of W v M, the English Court of Protection ruled that it was unlawful to withdraw artificial nutrition and hydration from a woman who had been in a minimally conscious state for 8 years. From the perspective of the court, the absence of a written advance directive negated the woman's previous, autonomous interests and, consequently, emphasis was given to her current welfare and well-being. While life itself is a moral good, prolonging life for a person in regular pain with no hope of recovering to a more complete state of awareness simply because that person only verbalized her wishes about her treatment decisions seems to drastically undervalue the principle of autonomy. We refute the notion that it is the role of the court to prolong life insofar as it can and argue that withholding and withdrawing life sustaining technologies from patients in a minimally conscious state can be ethically justified.

Death, treatment decisions and the permanent vegetative state: evidence from families and experts

Some brain injured patients are left in a permanent vegetative state, i.e., they have irreversibly lost their capacity for consciousness but retained some autonomic physiological functions, such as breathing unaided. Having discussed the controversial nature of the permanent vegetative state as a diagnostic category, we turn to the question of the patients' ontological status. Are the permanently vegetative alive, dead, or in some other state? We present empirical data from interviews with relatives of patients, and with experts, to support the view that the ontological state of permanently vegetative patients is unclear: such patients are neither straightforwardly alive nor simply dead. Having defended this view from counter-arguments we turn to the practical question as to how these patients ought to be treated. Some relatives and experts believe it is right for patients to be shifted from their currently unclear ontological state to that of being straightforwardly dead, but many are concerned or even horrified by the only legally sanctioned method guaranteed to achieve this, namely withdrawal of clinically assisted nutrition and hydration. A way of addressing this distress would be to allow active euthanasia for these patients. This is highly controversial; but we argue that standard objections to allowing active euthanasia for this particular class of permanently vegetative patients are weakened by these patients' distinctive ontological status.

Should we provide life-sustaining treatments to patients with permanent loss of cognitive capacities?

A very troubling issue for health care systems today is that of life-sustaining treatment for patients who have permanently lost their cognitive capacities. These include patients in persistent vegetative state (PVS), or minimally conscious state (MCS), as well as a growing population of patients at the very end stage of dementia. These patients are totally dependent on life-sustaining treatments and are, actually, kept alive "artificially." This phenomenon raises doubts as to the ethics of sustaining the life of patients who have lost their consciousness and cognitive capacities, and whether there is a moral obligation to do so. The problem is that the main facts concerning the experiences and well-being of such patients and their wishes are unknown. Hence the framework of the four principles-beneficence, non-maleficence, autonomy, and justice-is not applicable in these cases; therefore we examined solidarity as another moral value to which we may resort in dealing with this dilemma. This article shows that the source of the dilemma is the social attitudes towards loss of cognitive capacities, and the perception of this state as loss of personhood. Consequently, it is suggested that the principle of solidarity-which both sets an obligation to care for the worst-off, and can be used to identify obligations that appeal to an ethos of behavior-can serve as a guiding principle for resolving the dilemma. The value of solidarity can lead society to care for these patients and not deny them basic care and life-sustaining treatment when appropriate.