euthanasia physician assisted suicide advance directives

1. Ethics of End of Life Care
By
Dr. Marwa Magdy
Lecturer of Forensic Medicine & Toxicology

2. When it’s personal, all bets are
off

3. End of life care (EOL)
• EOL: is the care that helps those with advanced, progressive,
incurable illness to live as well as possible until they die.
• It enables the supportive and palliative care needs of both patient
and family to be identified and met throughout the last phase of life
and into bereavement. It includes management of pain & other
symptoms and provision of psychological, social, spiritual and
practical support.

4. Agenda:
• The 4 guiding ethical principles
• What is Palliative care?
• Ethical dilemmas at the end of life
Advance directives
Surrogate decision makers
Refusal of treatment
• Euthanasia
• Physician assisted suicide

5. Ethics
• The discipline dealing with what is good and bad, and with moral duty
and obligation.

6. Medical ethics
• A system of moral principles that apply values and judgements to the
practice of medicine.

7. The 4 guiding ethical
principles

8. Providence Model for
Ethics
Clinical
Integrity
Beneficenc
e
Autonom
y
Justice &
Non-
Maleficence

9. Clinical
Integrity
Beneficenc
e
Autonom
y
Justice &
Non-
Maleficence

10. Clinical Integrity-
My relationship with my profession
• How do we make a care plan when we are
still uncertain about the diagnosis or
prognosis but need to act now?
• What care options should be offered?
• What should we do when the patient’s
or family’s goals seem inconsistent
with traditionally recognized goals of
care?

11. Clinical
Integrity
Beneficenc
e
Autonom
y
Justice &
Non-
Maleficence

12. Autonomy-
My relationship with the patient
• Does the patient understand what’s wrong?
• What does my patient think is a good
outcome?
• What is my patient’s cultural, religious, or
ethnic point of view?
• Can my patient make decisions?
• Can my patient participate in a complex care
plan or follow-up plan?
• What are my patient’s goals and aspirations?
• What/Who are my patient’s support system?

13. • The right of self determination of the patient (to decide for himself)
either to accept or refuse medical interventions is based on his
values, beliefs, preferences,& cultural and religious aspects.
• Principles of informed decision making:
Providing all the adequate information by the physician
Having the mental capacity/competency of understanding and
choosing
Having the freedom to choose whatever suits him.

14. Competency versus decisional capacity
Competency:
Decided by a court/judge
Typically chronic alteration
Expected to be permanent
Decisional capacity (decision-making capacity):
Decided by physicians
Typically acute
fluctuates

15. • Most patients lose the decision-making capacity in terminal illnesses
• Alternatives in case of patient impaired decisional capacity:
Surrogate/proxy decision maker ‫القرار‬ ‫التخاذ‬ ‫البديل‬ ‫او‬ ‫الوكيل‬
Advance directives ‫المسبقة‬ ‫الطبية‬ ‫الوصية‬

16. Paternalism
Don’t worry
just leave it
all to me

17. Let me make my own decisions
Don’t tell
my family
I am dying
Sedate
me
Send me
home to
die
I want
euthanasia
Feed me
until the
end
Resuscitate
me
?
I don’t want
morphine ?
?

18. Clinical
Integrity
Beneficen
ce
Autonom
y
Justice &
Non-
Maleficence

19. Beneficence-
My relationship with the outcomes
• Am I fixing what’s wrong?
• Am I effectively managing a disease
process?
• Am I appropriately managing my patient’s
last days?
• Am I simply delaying the inevitable?
• Am I causing harm to my patient? Or
am I worried I’m causing more harm

20. Clinical
Integrity
Beneficenc
e
Autonom
y
Justice &
Non-
Maleficence

21. Justice &
Nonmaleficence- My
relationship with others
• Do I owe my patient’s family something?
• Do I owe my colleagues something?
• Is my patient at risk for being hurt, and if so
do I have an obligation to prevent harm?
• Are there conflicts of interest that could harm
my patient or someone else?
• Am I being a good steward of resources?
• Do I owe society or the community something?

22. Agenda:
• The 4 guiding ethical principles
• What is Palliative care?
• Ethical dilemmas at the end of life
Advance directives
Surrogate decision makers
Refusal of treatment
• Euthanasia
• Physician assisted suicide

23. What is palliative care?
‫التلطيفية‬ ‫الرعاية‬

24. Clinical
Integrity
Beneficenc
e
Autonom
y
Justice
&
Nonmaleficenc
e
Therapeutic relationship
between patient and
provider

25. Clinical
Context
 Acute  Rescue, Fix
 Chronic Maintain, Manage
 Palliative Alleviate suffering,
Enhance Quality of Life
 Life-Sustaining Prolongation
of
biological life
 Futile  Non-Beneficial

26. • Palliative care is a broad term that includes hospice care
‫المحتضرين‬ ‫رعاية‬as well as other care that emphasizes
symptom management & pain relief, in persons with life-
limiting disease, but is not restricted to persons near the end
of life.

27. More on defining palliative care:
• A new specialty of medicine that uses an interdisciplinary team to
manage patients with an advanced illness, in whom the goal of care is
symptom control rather than disease control.
• Or the care of patients who are in an advanced stage of an incurable
illness, with a primary goal of symptom management and mainly
focus on quality of life.

28. The Disease
Spectrum
http://www.med.umich.edu/geriatrics/patient/palliative-

29. Hospice
Hospice is an interdisciplinary program of palliative
and supportive services that is provided both at
home and in institutional settings for persons with
weeks or months to live; so that they may live as fully
and comfortably as possible.

30. Agenda:
• The 4 guiding ethical principles
• What is Palliative care?
• Ethical Dilemmas at the end of life
Advance directives
Surrogate decision makers
Refusal of treatment
• Euthanasia
• Physician assisted suicide

31. Ethical dilemmas at the
end of life

32. Advance care planning for end of life
‫األجل‬ ‫اقتراب‬ ‫لفترة‬ ‫المسبقة‬ ‫الطبية‬ ‫الرعاية‬ ‫تخطيط‬
• Planning for future medical care in the event is unable to make his
own decisions
• Should be started early in the course of terminal illness
• Should be updated regularly
• Values and goals are explored and documented
• It is a process, not an event
• Designate a proxy/ surrogate decision maker
‫عنه‬ ‫نيابة‬ ‫القرار‬ ‫التخاذ‬ ‫بديل‬ ‫او‬ ‫وكيل‬ ‫تعيين‬

33. Advanced care planning “advance directives”
‫المسبقة‬ ‫الطبية‬ ‫الوصية‬
• Instructions of future medical
care
• Designation of decision maker

34. The living will
• A type of advance directives
• It is a legal document used to state certain future health care decisions only
when a person becomes unable to make the decisions and choices on their
own.
• The living will is only used at the end of life if a person is terminally ill (can't
be cured) or permanently unconscious.
• The living will describes the type of medical treatment the person would
WANT or NOT WANT to receive in these situations.
• This applies to treatments including: dialysis, mechanical ventilation,
hydration or artificial nutrition, DNR orders (don’t resuscitate orders; not to
start chest compression, intubation in case of cardiac arrest), use of
palliative care, organ donation.

35. Physician orders for life-sustaining treatment
P.O.L.S.T
• A type of advance directives signed by patient and physician
• Helps prevent unwanted medical interventions, such as CPR.
• Travels with patient across healthcare venues.

36. Proxy/surrogate decision maker
• Is a person who is assigned by the patient himself (in advance) to
make decisions about future medical care when the patient become
unconscious or incapable to decide for himself; mostly a 1st degree
relative.
‫بالعجز‬ ‫اصابته‬ ‫قبل‬ ‫كتبها‬ ‫وصية‬ ‫فى‬ ‫بنفسه‬ ‫المريض‬ ‫يعينه‬ ‫من‬ ‫هو‬ ‫شخص‬ ‫افضل‬
• If the patient didn’t previously choose a proxy, the court may choose
for him.
• If the patient has previously mentioned his preferences and wishes to
the physician, his wishes should be fulfilled

37. • The doctor should supply the proxy decision maker with all available
information and inform him to decide depending on:
1. The patient’s previously declared/documented wishes
2. If no previously known wishes; proxy try to decide depending on
what would probably suits the patient’s beliefs, thoughts and
wishes.
3. If the physician finds out that the proxy decision maker is acting
against the beliefs and wishes of the incapacitated patient;
physician should decide for the patient’s BEST INTEREST.

38. Refusal of treatment
• The informed consent ‫المستنيرة‬ ‫الموافقة‬ entails either accepting or
refusing the medical treatment or intervention.
• Either accepting or refusing treatment is one of the patient’s rights
and it is the duty of the physician to fulfil his wishes provided that the
terms of informed consent are satisfied(providing all information,
having mental competence/capacity and freedom to choose).
• Refusal of treatment is justified by the ethical principle of “respect of
autonomy”

39. Ethical dilemmas arise if refusal of treatment
occur in the following cases:
1. Emergency situations that require rapid life saving intervention e.g:
renal dialysis, amputation ‫االطراف‬ ‫احد‬ ‫بتر‬, emergency surgery.
2. Refusal of life saving blood transfusion for religious reasons ‫يهوة‬ ‫شهود‬
3. Refusal of life saving treatment of a child, mentally incompetent or
comatose patients by his proxy decision maker. Here, the physician
can act for the patient’s “best interest” against the will of his proxy.
‫المريض‬ ‫مصلحة‬ ‫جانب‬ ‫الى‬ ‫الوقوف‬
‫الموت‬ ‫او‬ ‫الضرر‬ ‫الى‬ ‫ادى‬ ‫اذا‬ ‫جائز‬ ‫غير‬ ‫االسالمية‬ ‫الشريعة‬ ‫فى‬ ‫العالج‬ ‫رفض‬
"
‫التهلكة‬ ‫الى‬ ‫بايديكم‬ ‫تلقوا‬ ‫وال‬
"
‫البقرة‬ ‫سورة‬
195

40. Agenda:
• The 4 guiding ethical principles
• What is Palliative care?
• Ethical Dilemmas at the end of life
Advance directives
Surrogate decision makers
Refusal of treatment
• Euthanasia/ Physician assisted suicide

41. Euthanasia
‫الرحي‬ ‫القتل‬ ‫او‬ ‫الرحمة‬ ‫او‬ ‫الشفقة‬ ‫قتل‬
‫م‬
& physician-assisted suicide
‫طبية‬ ‫بمساعدة‬ ‫االنتحار‬

42. Euthanasia
• It is a Greek word: Eu: well
thanantos: death
• Euthanasia literally means “good death” or “soft death” or “death
without suffering”.
• Euthanasia is the painless killing of a person suffering from an
incurable disease.

43. Types of euthanasia
1. Active euthanasia: ‫االيجابى‬ ‫الرحيم‬ ‫القتل‬
Intentionally administering medications or other interventions by the
physician to cause patient’s death.
‫االالم‬ ‫رفع‬ ‫اجل‬ ‫من‬ ‫والشفقة‬ ‫الرحمة‬ ‫بدافع‬ ‫المريض‬ ‫لقتل‬ ‫مقصود‬ ‫ارادى‬ ‫ايجابى‬ ‫بعمل‬ ‫القيام‬ ‫هو‬
‫قاتلة‬ ‫دوائية‬ ‫جرعة‬ ‫اعطائه‬ ‫مثل‬ ‫عنه‬ ‫والمعاناة‬
.
2. Passive euthanasia: ‫السلبى‬ ‫الرحيم‬ ‫القتل‬
Withholding ‫حجب‬ or withdrawing ‫سحب‬ life-sustaining medical treatment
from the patient to let him die.
‫بالموت‬ ‫بالسماح‬ ‫ايضا‬ ‫ويعرف‬
..
‫اجهزة‬ ‫ايقاف‬ ‫مثل‬ ‫للحياة‬ ‫الداعم‬ ‫العالج‬ ‫عن‬ ‫التوقف‬ ‫هو‬ ‫و‬
‫طبيعية‬ ‫بصورة‬ ‫الموت‬ ‫بحدوث‬ ‫للسماح‬ ‫التنفس‬
.

44. 3. Voluntary euthanasia: ‫االرادى‬ ‫الرحيم‬ ‫القتل‬
To cause patient’s death at the patient’s explicit request and with full
informed consent.
‫الرادته‬ ‫وتنفيذا‬ ‫لرغبته‬ ‫تحقيقا‬ ‫و‬ ‫المريض‬ ‫طلب‬ ‫على‬ ‫بناء‬ ‫يتم‬
.
4. Non voluntary euthanasia: ‫االرادى‬ ‫غير‬ ‫الرحيم‬ ‫القتل‬
To cause patient’s death, while the patient is mentally incompetent
(Alzheimer, dementia), comatose or in children/neonates.
‫المصاب‬ ‫او‬ ‫الوعى‬ ‫فاقد‬ ‫مثل‬ ‫القرار‬ ‫اتخاذ‬ ‫عن‬ ‫العاجز‬ ‫للمريض‬ ‫بذلك‬ ‫القرار‬ ‫الطبيب‬ ‫يتخذ‬ ‫عندما‬
‫المواليد‬ ‫و‬ ‫االطفال‬ ‫لدى‬ ‫او‬ ‫الزهايمر‬ ‫داء‬ ‫او‬ ‫الشيخوخة‬ ‫بعته‬
.

45. 5. Involuntary euthanasia ‫الالارادى‬ ‫الرحيم‬ ‫القتل‬
To cause patient’s death, when the patient is competent but without
the patient’s explicit request or informed consent (patient may not
even know).
‫دون‬ ‫االقل‬ ‫على‬ ‫او‬ ‫القرار‬ ‫اتخاذ‬ ‫على‬ ‫القادر‬ ‫الكفء‬ ‫المريض‬ ‫ارادة‬ ‫ضد‬ ‫الرحيم‬ ‫القتل‬ ‫يتم‬
‫علمه‬ ‫بدون‬ ‫حتى‬ ‫او‬ ‫موافقته‬ ‫و‬ ‫رضاه‬ ‫على‬ ‫الحصول‬
.

46. 6. Physician-assisted suicide: ‫االنتحار‬ ‫على‬ ‫الطبية‬ ‫المساعدة‬
When a physician provides or prescribes, (but doesn’t administer)
medications or other interventions to a patient (either terminally ill or
not), with understanding that the patient intends to use them to
commit suicide.
‫يبقى‬ ‫الحياة‬ ‫انهاء‬ ‫فعل‬ ‫ولكن‬ ‫لالنتحار‬ ‫الالزمة‬ ‫الوسائل‬ ‫و‬ ‫المعلومات‬ ‫للمريض‬ ‫الطبيب‬ ‫يوفر‬
‫بيد‬
‫بنفسه‬ ‫هو‬ ‫ويؤديه‬ ‫نفسه‬ ‫المريض‬
.
*
‫االرادى‬ ‫االيجابى‬ ‫الرحيم‬ ‫القتل‬ ‫حول‬ ‫المجتمعات‬ ‫من‬ ‫كثير‬ ‫فى‬ ‫الدائر‬ ‫الجدل‬ ‫يتركز‬
Voluntary active euthanasia
‫من‬ ‫متكرر‬ ‫طلب‬ ‫على‬ ‫بناء‬ ‫الموت‬ ‫على‬ ‫المشرف‬ ‫المريض‬ ‫حياة‬ ‫بانهاء‬ ‫الطبيب‬ ‫فيه‬ ‫يقوم‬ ‫الذى‬
‫القرار‬ ‫اتخاذ‬ ‫على‬ ‫القادر‬ ‫الكفء‬ ‫المريض‬
.

47. Ethical debates of euthanasia:
• With:
 euthanasia is justified by the right of self determination and respect
of autonomy of patients to choose the suitable time and method to
end their life when it becomes futile ‫الجدوى‬ ‫عديمة‬
Euthanasia alleviates the pain and suffering of terminally ill incurable
patients.
Supporters of euthanasia asks for legalization of the act of euthanasia
‫تقنين‬
(
‫تجريم‬ ‫عدم‬
)
‫الرحيم‬ ‫القتل‬
Euthanasia and physician assisted suicide are legalized in certain
countries e.g: Netherlands, Switzerland, japan, china & Belgium.

48. Ethical debates of euthanasia:
 Against:
Euthanasia is dangerous for many vulnerable groups ‫مستضعفة‬ ‫فئات‬
that might be coerced ‫على‬ ‫تجبر‬ into requesting euthanasia e.g: very
old, the poor, disabled, handicapped, medically impaired, drug
addicts or AIDS patients.
Threatens the moral integrity of medical profession
Doctors don’t kill
Demolish the public trust in medical profession and destroys doctor
patient relationship.

49. According to the Islamic Code of Health Ethics
‫والصحية‬ ‫الطبية‬ ‫لالخالقيات‬ ‫العالمى‬ ‫االسالمى‬ ‫الميثاق‬
‫المادة‬
(
62
:)
‫وهذه‬ ،‫والقانون‬ ‫الشرع‬ ‫دها‬َّ‫د‬‫ح‬ ‫التي‬ ‫اطن‬ َ‫و‬َ‫م‬‫ال‬ ‫في‬ ‫إال‬ ‫إهدارها‬ ‫يجوز‬ ‫وال‬ ،‫رمتها‬ُ‫ح‬ ‫اإلنسان‬ ‫لحياة‬
ً‫ا‬‫تمام‬ ‫الطبية‬ ‫المهنة‬ ‫نطاق‬ ‫خارج‬ ً‫ا‬‫جميع‬
.
‫المريض‬ ‫حياة‬ ‫إنهاء‬ ‫في‬ ‫يساهم‬ ‫أن‬ ‫للطبيب‬ ‫يجوز‬ ‫وال‬
‫المرحمة‬ ‫بقتل‬ ‫عرف‬ُ‫ي‬ ‫مما‬ ‫اآلتية‬ ‫الحاالت‬ ‫في‬ ‫َّما‬‫ي‬‫والس‬ ،‫الشفقة‬ ‫بدافع‬ ‫ولو‬
:
(
‫أ‬
)
‫ورغبته؛‬ ‫إرادته‬ ‫بملء‬ ‫حياته‬ ‫إنهاء‬ ‫يطلب‬ ‫لمن‬ ‫د‬ْ‫م‬َ‫ع‬‫ال‬ ‫القتل‬
(
‫ب‬
)
‫الطبيب؛‬ ‫بمساعدة‬ ‫االنتحار‬
(
‫ج‬
)
‫تهددها‬ ‫ال‬ ‫أو‬ ‫حياتهم‬ ‫د‬ِ‫تهد‬ ‫قد‬ ‫لقية‬ ِ‫خ‬ ‫بعاهات‬ ‫المولودين‬ ‫للولدان‬ ‫د‬ْ‫م‬َ‫ع‬‫ال‬ ‫القتل‬
.

50. ‫المهنة‬ ‫اداب‬ ‫الئحة‬
‫بقرارمعالى‬ ‫الصادرة‬
/
‫رقم‬ ‫والسكان‬ ‫الصحة‬ ‫وزير‬
238
‫لسنة‬
2003
‫مادة‬
20
:
‫وان‬ ‫االمهم‬ ‫تخفيف‬ ‫على‬ ‫يعمل‬ ‫وان‬ ‫مرضاه‬ ‫لعالج‬ ‫وسعه‬ ‫فى‬ ‫ما‬ ‫كل‬ ‫يبذل‬ ‫ان‬ ‫الطبيب‬ ‫على‬
‫تمييز‬ ‫دون‬ ‫الرعاية‬ ‫فى‬ ‫بينهم‬ ‫يساوى‬ ‫وان‬ ‫معاملتهم‬ ‫يحسن‬
.
‫مادة‬
36
:
‫الرحمة‬ ‫او‬ ‫الشفقة‬ ‫بدعوى‬ ‫الحياة‬ ‫اهدار‬ ‫الطبيب‬ ‫على‬ ‫يحظر‬
.

51. ‫الدينية‬ ‫الوجهة‬ ‫من‬ ‫الرحيم‬ ‫القتل‬
‫االنتحا‬ ‫ومثله‬ ‫قاطعا‬ ‫تحريما‬ ‫الرحيم‬ ‫القتل‬ ‫ممارسة‬ ‫تحرم‬ ‫والشرائع‬ ‫السماوية‬ ‫الديانات‬ ‫جميع‬ ‫ان‬
‫ر‬
‫عليه‬ ‫المساعدة‬ ‫او‬
.
‫اإلسالم‬
"
‫رحيما‬ ‫بكم‬ ‫كان‬ ‫هللا‬ ‫ان‬ ‫أنفسكم‬ ‫تقتلوا‬ ‫وال‬
"
‫النساء‬ ‫سورة‬
29
"
‫بالحق‬ ‫إال‬ ‫هللا‬ ‫حرم‬ ‫التى‬ ‫النفس‬ ‫تقتلوا‬ ‫وال‬
"
‫االنعام‬ ‫سورة‬
151
"
‫إمالق‬ ‫خشية‬ ‫أوالدكم‬ ‫تقتلوا‬ ‫وال‬
"
‫االسراء‬ ‫سورة‬
31
"
‫أح‬ ‫فكأنما‬ ‫أحياها‬ ‫ومن‬ ‫جميعا‬ ‫الناس‬ ‫قتل‬ ‫فكأنما‬ ‫االرض‬ ‫فى‬ ‫فساد‬ ‫أو‬ ‫نفس‬ ‫بغير‬ ‫نفسا‬ ‫قتل‬ ‫من‬
‫يا‬
‫جميعا‬ ‫الناس‬
"
‫المائدة‬ ‫سورة‬
32

52. ‫الدينية‬ ‫الوجهة‬ ‫من‬ ‫الرحيم‬ ‫القتل‬
‫المسيحية‬
‫و‬ ‫هللا‬ ‫من‬ ‫هبة‬ ‫هى‬ ‫الحياة‬ ‫ان‬ ‫على‬ ‫مؤكدين‬ ‫الحياة‬ ‫احترام‬ ‫على‬ ‫واالرثوذكسية‬ ‫الكاثوليكية‬ ‫اتفقت‬
‫االلهى‬ ‫لالمتياز‬ ‫تحدى‬ ‫يعتبر‬ ‫واهدارها‬ ‫لالشخاص‬ ‫ملك‬ ‫ليست‬
(
‫االلهية‬ ‫الذات‬
.)

53. ‫القانونية‬ ‫الوجهة‬ ‫من‬ ‫الرحيم‬ ‫القتل‬
•
‫الموت‬ ‫مرض‬ ‫فى‬ ‫للوفاة‬ ‫تؤدى‬ ‫اشياء‬ ‫إعطاء‬
‫المصرى‬ ‫العقوبات‬ ‫قانون‬ ‫حسب‬
,
‫ا‬ ‫مريضه‬ ‫اعطى‬ ‫هو‬ ‫اذا‬ ‫قتال‬ ‫مرتكب‬ ‫الطبيب‬ ‫يعتبر‬
‫لذى‬
‫الوفاة‬ ‫الى‬ ‫حتما‬ ‫به‬ ‫سينتهى‬ ‫مرض؛‬ ‫من‬ ‫يعانى‬
,
‫ال‬ ‫أالم‬ ‫من‬ ‫له‬ ‫تخليصا‬ ‫شىء‬ ‫اى‬ ‫او‬ ‫سما‬
‫و‬ ‫مرض‬
‫أوجاعه‬
.
‫مادة‬
233
" :
‫بال‬ ‫قاتال‬ ‫يعد‬ ‫اجال‬ ‫او‬ ‫عاجال‬ ‫الموت‬ ‫عنها‬ ‫يتسبب‬ ‫بجواهر‬ ‫عمدا‬ ‫احدا‬ ‫قتل‬ ‫من‬
‫سم‬
‫باالعدام‬ ‫يعاقب‬ ‫و‬ ‫الجواهر‬ ‫تلك‬ ‫استعمال‬ ‫كيفية‬ ‫كانت‬ ‫ايا‬
."