Ethics Corner: End-of-Life Ethics
By Ariane Lewis, MD
Patients admitted to neurointensive care units
frequently suffer sudden, unexpected and
severe brain injuries that render them unable
to participate in goals-of-care discussions.
Facilitating decision making for this
population can be very ethically challenging,
particularly when patients are candidates
for organ donation. Although organs are
desperately needed by over 118,000 people
in the U.S. alone, organ donation should not be addressed with
families until after end-of-life decisions have been made.
In this issue of Ethics Corner, we discuss three
recent papers that address end-of-life ethics.
End-of-Life Decision Making
Our understanding of the
process by which an
individual makes decisions
regarding end-of-life care
is supported by little
empirical research. We are
often jaded into making
gross generalizations
about expectations
for decision making
based on a patient’s
cultural or religious
background. In a recent
piece in BMC Medical Ethics
that contradicts previous
findings, Mark Schweda
et al. explore the impact of
culture and religion on endof
life decision making through
assessment of public attitudes in
focus groups in Germany, Israel and
the U.S. Contrary to religious or cultural
stereotypes about end-of-life decision making, the
authors found that there are no clear-cut positions anchored in
nationality, culture or religion, and that the process of decision
making is both personal and nuanced. These findings should
be considered during discussions of end-of-life care, as it is
imperative to avoid making assumptions based on cultural or
religious generalizations (BMC Med Ethics 2017; 18:13).
Orders for Life-Sustaining Treatment
In the United States, 27 states have implemented statutes for
Physician Orders for Life-Sustaining Treatment (POLST), and
23 states are currently developing POLST. The goal of POLST is
to ensure that even if a patient is unable to communicate their
wishes, end-of-life treatment should be consistent with their
preferences. Tarzian and Cheevers describe the Maryland Medical
Orders for Life-Sustaining Treatment (MOLST) and present
data evaluating its use. They found that MOLST completion
rates were high and errors were low. Use of POLST/MOLST can
have favorable implications for the neurocritical care
community, as increased usage of these orders
will give us insight into patient preferences
about code status, artificial nutrition,
antibiotics and dialysis. However,
while completion of POLST/MOLST
provides general information about
patient wishes, it does not require
specification of management in
the setting of various degrees of
debilitation such as inability
to walk, perform activities of
daily living or communicate (J
Palliat Med 2017; Epub ahead
of print).
Transplant Ethics
In conjunction with nurse
donor coordinators and organ
procurement organizations,
several provinces in Canada
have begun to designate donation
physicians to be involved with donor
care, education, training and advocacy.
To assist donation physicians in navigating
ethically complex situations, Sam Shemie et
al. created an ethics guide that was endorsed by
the Canadian Medical Association. Institutions that wish to
centralize care for patients at the end-of-life who are candidates
for organ donation may benefit from identification of donation
physicians. Individuals who take on this novel position can
benefit from Shemie et al.’s ethical framework (Transplantation
2017; 101: S41-47).
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