Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

The Ethical Implications of Making End-of-Life Decisions

Claire M. Linden
University of Kentucky

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

Abstract
In this paper, ethical implications of making end-of-life decisions and the importance of
communication between physicians and their patients are discussed. Healthcare providers need to
be compassionate towards their patients and provide informative and unbiased advice so that the
patient and his or her family can make an appropriate decision. Recent controversy surrounding
assisted-suicide is important to take into account when discussing end-of-life decisions because
assisted-suicide is becoming an option for many. There are multiple sides to this topic which are
important to discuss in order to reach a consensus. Also, the recent case of Brittany Maynard is
brought up, which drives several people to question the importance of communication between
physicians and their patients. When there is a death in a family, it brings several questions to be
answered, and it is not up to just the family and patient but the healthcare providers with the
knowledge of what might be the best course of action. However, healthcare teams knowledge is
also discussed because it is possible that they are not fully aware of what is best for their
patients, which leaves families with unanswered questions. In addition, Hospice can be an issue
for families if its goals and priorities are not in the right place. Overall, there are many issues
when addressing the subject of end-of-life decision making for families.

Keywords: Assisted suicide, hospice, end-of-life decision, opioids, and pain control

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

When a loved one is at the end of their life, their family wants nothing more than to be
assured their loved one will be in the least pain possible and be at the maximum level of comfort
during their last days. Hospice is an option that is supported by many people. It is founded on the
principle of satisfying the patient and family in managing death, while being cost effective.
However, some patients are being given an alternative: physician-assisted suicide. Patients are
faced with a decision when the end of their life is near, and only adequate information will
ensure this decision is appropriate. Healthcare professionals play a critical role when it comes to
helping patients make end-of-life decisions and need to be in full understanding with their
patients, knowing their needs and wants, both medical and emotional. The intersection of
medical knowledge and the patients needs are critical in order to guide the patient in the best
direction for that individual and their family. Throughout the healthcare field, there is constant
conflict with ethical implications on making end-of-life decisions and miscommunication with
patients and their physicians.
The concept of physician assisted-suicide is a national issue and affects not only doctors
and patients, but also legislators. Currently, assisted suicide is not legal in Kentucky. However, it
is possible for people to travel to one of the states where it is legalized in order to have the
process done after going through extensive paperwork and the process of establishing residency.
Oregon, Vermont, and Washington are the only states that allow physician assisted suicide.
According to National Right to Life (2014):
Refusing a ventilator or some other life sustaining machine or treatment is not assisted
suicide and is legal. The intent of refusing medical treatment is not to end life, but to
allow nature to take its course. With physician-assisted suicide the intent is to kill the
patient (p. 2).

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

Many people argue that once physician-assisted suicide is legal throughout the nation, it will
become impossible to protect lives. People advocating for it to be illegal nationwide adopt this
stance because they believe the rest of the states will follow, and the new law will be impossible
to stop. Similar social issues, such as; abortion and gay marriage, began this same way so people
are nervous that assisted-suicide will follow in the same direction. Oregon reports that there is a
steady increase in patients receiving the medication for assisted-suicide; however, then failing to
follow through with the option (See Figure 1). The people that support it being a state issue
believe it should not become a nationwide issue unless totally necessary. They believe that it will
be blown out of proportion if amplified to the national level. The patients that did receive
physician-assisted suicide expressed their reasoning behind it. These reasons can be addressed
with the use of treatment and healthcare professionals being more aware of their patients needs.

Figure 1. DWDA prescription recipients and deaths. Oregon reports the increase in use of
physician assisted-suicide. (Life News, 2013).

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

Physicians are known to be healers and to grant their patient wishes; however, there
could be a certain extent to which those wishes should be carried out. This is a real world topic
and an actual issue in the medical field. Dr. Jack Kevorkian, an American pathologist who
performed assisted-suicide to more than 130 patients, provides an example where patients
requests may need to be denied. AMA establishes the Code of Ethics for medical professions and
one of the principles that is prioritized is that physicians must not act with the intent to cause
death to their patients. (Did Dr. Jack Kevorkian..?, 2010). Under the Code of Ethics, it is
stated that those who are suffering from a terminal illness must be given adequate comfort care
by their physician. Providing a comfortable setting along with pain relief is an obligation of
physicians, though this is not possible when communication doctor and patient are not
completely open. However, people have different views when approaching this issue; for
example, many people may argue that this principle should be revisited when considering those
who are terminally ill. They support the right of options and choices and that assisted-suicide is a
compassionate practice because patients are able to end their life on their terms. Patients need to
share their thoughts and feelings towards their pain and their idea of death so that physicians can
secure a relaxed environment for them.
Brittany Maynard is a well-known case that has given some people an opinion on
physician assisted-suicide. Maynard was a 29 year-old diagnosed with brain cancer and given a
prognosis of six months to live (CNN, 2014). Maynard shared her decision regarding going into
Hospice, But even with palliative medication, I could develop potentially morphine-resistant
pain and suffer personality changes and verbal, cognitive and motor loss of virtually any kind
(para.7). Maynards opinion led her to look into death with dignity and she ultimately
concluded to follow through with this decision because she did not want her family to witness

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

her cancer destroying her mind. She felt that assisted-suicide would be best for her and her
family.
Amanda Anderson, a critical care nurse in New York City, shared her perspective and
analysis of Maynards case. Anderson explains that Maynards case reminds healthcare providers
how important it is to be educated on every option for patients to assure that they are making the
best decision. Maynards healthcare providers gave her the prognosis of six months to live due to
how the function of her brain would deteriorate and upon receiving this news, she moved to
Oregon to have physician aid in dying. Once she moved, it was imperative for her to find a
physician who would provide care under the bills regulations. So, her healthcare providers prior
to moving played an important role in assisting her to locate a new physician. It was critical for
her healthcare providers to deliver informative, compassionate, and unbiased information
regarding possible physicians and options available to her. Being terminally ill is difficult for all
involved, and this makes it that much more important for an agreeable decision to be made for all
to be happy. This consensus cannot be made without appropriate communication between all
positions, which includes the patient, healthcare providers, and family members of the patient.
Not only do the terminally ill play a role in this issue, but this approach also applies to
those who no longer have a good chance for recovery. The issue of Hospice and the transition
from use of preventive care to palliative care is important to recognize. Craig C. Earle, MD, at
Dana-Farber Cancer Institute (2008) advocates for Hospice, sharing, High-quality palliative
care can be a great benefit to a patient, and the benefit accrues over time (para. 10). The article
continues to mention several benefits of Hospice, such as; a patients quality of life, patient and
family satisfaction, and cost effectiveness (The debate in hospice care, 2008). However,
decision making from the oncologists and their influence on the decision of the patient is critical,

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

so the patient does not choose to be moved to Hospice while the benefits of active and healing
treatment are greater than the benefits of Hospice. A clear understanding of which action is
appropriate to take is important so that life is not cut short for the patient.
Recent cases have been reported of Hospices aggressive profit practices, and patients are
taking this into account when considering Hospice. Patients and their families are being affected
by this because it impacts their decision making when they have to take into account that
hospices prioritize their profit rather than patients satisfaction. Recent growths in for-profit
hospice programs and increasing expensive treatments have created a competitive arena for
hospices (The debate in hospice care, 2008). This article continues and explains that for-profit
hospices are found to be considerably less likely to allow patients with shorter expected lengths
of stay because it would be less profitable (The debate in hospice care, 2008). Again,
physicians need to clear up this issue with their patients so they are capable of making an
informative decision when they are nearing the end of their lives.
Ethical communication between healthcare providers and their patients is critical in order
for patients to receive appropriate prescriptions due to the fact that regulations on drugs prevent
those who need certain medicine from obtaining it. Ethical communication is defined by open
communication between all participants in the decisions, including doctors, patients, care givers,
etc. When patients do not clearly communicate their pain, physicians cannot prescribe them
medication that is necessary. Regulations decrease availability of certain drugs, which can be
disadvantageous in some cases. Often times, patients who do not need pain relievers receive
them, and vice versa. It is important for the physician to step in and make sure that they have a
full understanding of their patients needs and wants.

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

It is critical for physicians to be up to date on appropriate pain management methods

because effective pain control should be another option rather than legalizing killing patients
who are in great pain. Dr. Kathleen Foley, Chief of Pain Services at the Memorial SloanKettering Cancer Center in New York explained, We frequently see patients referred to our
Pain Clinic who request physician-assisted suicide because of uncontrolled pain (Why we
shouldnt, 2013, para. 3). Uncontrolled pain is still a problem, even with abundant access to
proper medicine and technologies used for relieving the pain of ill patients. Solutions are
available to ensure that patients receive adequate treatment in order to control pain. For example,
physicians, nurses, counselors, etc. need to work as a team in order to address patients pain.
Education plays a role in this because healthcare professionals are required to look at the patients
at all angles and treat as a whole. However, there are barriers in delivering appropriate
treatment for pain control even with all the medicine and technology that is available. A list of
examples of these barriers are presented in an article, Poor pain assessment by physicians,
patient reluctance to report pain, and patient hesitance to take and physician reluctance to
prescribe appropriate medication (Balch, B.J., Waters, D., 2013, para. 10). All of these barriers
relate to communication, showing its importance in this field.
Communication between patients and their health providers is essential when patients are
requesting pain control medicine. Receiving the correct drug for the patients individual needs is
very important, especially in cancer patients. Repeated use of opioids can cause patients to
become less sensitive to them as tolerance of the drugs is increased. This change in the brain is a
condition in which opioids are not present so that the brain will send pain signals. (Opioid
Addiction, 2014). Knowledge of this adaptation is taken into account when considering
regulations and the availability of opioids to patients. Patients need to be communicative with

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

their physicians to assure that they are only receiving opioids when necessary. Between 2001 and
2011, a steady increase in the number of deaths caused by Rx Opioid Pain Relievers is shown
above. This increase supports the reasoning behind implementing strict regulations when
prescribing pain relievers (see Figure 2). Opioids are useful when used in moderation; however
physicians have to pay close attention when prescribing these drugs to avoid the issues
mentioned previously. If a cancer patient is experiencing excruciating pain, then opioids would
be advantageous for them. Physicians must diagnose on a case to case basis so that an overabundance of prescriptions does not occur.

.
Figure 2. National Overdose Deaths. Deaths caused by opioid pain relievers have increased.
(National Institute on Drug Abuse, 2011).
Communication between healthcare providers and patients is critical in ensuring that endof-life decisions can be addressed with full understanding. Informative and unbiased advice must

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

10

be given in order to enable patients to feel secure with their decisions. There are barriers to this
communication which can cause patients to make unfitting decisions pertaining to their
individual cases. This issue is frequently discussed today, and it does not appear as though it will
be solved in the near future. However, it needs to be addressed from all angles to ensure that a
fair and fitting consensus can be made.

Running Head: THE ETHICAL IMPLICATIONS OF MAKING END-OF-LIFE DECISIONS

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References Page
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Life.

Retrieved November 19, 2014 from http://www.nrlc.org/

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