Non-malignant palliative care is very topical. The study of ethics and the use of ethical principles have been found to be of great value when dealing with cancer patients.
While this is part of the normal approach in cancer patients, it tends to be used less so in non-malignant palliative care. Part of the difficulty with this is that many diseases such as end-stage heart failure and COPD, end-stage renal disease, motor neurone disease and other degenerative neurological disease have not been thought of as palliative by mainstream clinicians, until relatively recently.
Clinicians still struggle with this as a concept, but it is well known that the prognosis in advanced chronic diseases can be worse than some cancers.
The principles of palliative care are about providing good symptom control, psychological and social care. These principles apply across all patients who are dying, even if they are not in the immediate phase of dying. Nor should these principles be reserved for only those patients who are dying of cancer-related disease.
Applying an ethical framework (see box) to look at a case helps to see a case from different perspectives.
For example, a patient with severe dementia has taken to bed and refuses food and water. Do you admit him to hospital for potential hydration?
In this case it is difficult to apply the principle of autonomy if the patient is unable to give informed consent.
To be able to do this, the patient must be considered 'competent'. They must be able to comprehend and understand the decision to be taken.
They must be able to retain this information, consider it, weigh up the pros and cons and make a reasoned decision.
If a patient is unable to give informed consent, then their wishes can still be respected if they have made a living will at a time when they were considered competent.
Advanced directives or living wills are becoming increasingly popular in UK. They allow a patient to set out in advance what their wishes would be in certain situations, if at that time they no longer have the capacity to give informed consent.
The other factors to consider in this case are beneficence - doing what is best for the patient.
If the patient has not provided a living will, is provision of fluids doing good for the patient or is it prolonging the act of dying?
If applying the non-maleficence principle by minimising harm through admission to hospital, is this likely to cause more distress for the dementia patient by changing the environment from a familiar to an unfamiliar setting?
Consideration must be given to whether it is just to prolong the life of all patients who are dying by admitting them to hospital for parenteral treatment?
Ethics do not always simplify the answer, and in fact it can make a dilemma seem even more complex.
For example, a patient with heart failure has had six hospital admissions in the past six months, each lasting for a week or more. The patient is requesting not to be readmitted a seventh time.
In this case, if the patient is in sound mind and can give informed consent, then the patient is expressing their autonomy or choice.
We would be carrying out an act of beneficence because we could be doing the patient much good from a psychological aspect.
If we apply the principle of non-maleficence, are we avoiding or minimising harm? If by admission to hospital we are causing psychological and physical distress, then are we increasing harm or reducing it?
The request of a patient to stay at home makes decision-making difficult.
While it often feels easier to make a decision when it is a patient with cancer, it is somehow harder when it is a non-malignant case.
This may be because in cases of patients with cancer there is an expectation that the patient will die.
In the cases of patients with non-cancer condition, both patients and families expect that more and more can be done to treat their condition.
The simple ethical principles discussed help me to see several sides of the same situation. Some cases can be difficult, and having an ethical principle approach can be of great value.
Non-malignant palliative care patients should be permitted the same principled approach as patients with malignant disease.
- Dr Auty is Macmillan GP facilitator in palliative care in Salford, Greater Manchester
Autonomy: Respect for a patient's choice.
Beneficence: Doing good for the patient.
Non-maleficence: Avoiding doing harm to the patient.
Justice: Fair use of resources and equality of approach.