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END OF LIFE DECISIONS
The debate
Mzukisi Grootboom
Chairman : South African Medical Association
Council Member: World Medical Association
Presentation Plan
• Ethical aspects of end of life decisions
• Relationship between euthanasia and murder
• Legal position on end of life decisions
• Living Wills
END OF LIFE
Patients are ‘approaching the end of life’
• when they are likely to die within the next 12 months.
• This includes patients whose death is imminent
(expected within a few hours or days) and those with:
(a) advanced, progressive, incurable conditions
(b) general frailty and co-existing conditions that mean they
are expected to die within 12 months
(c) existing conditions if they are at risk of dying from a
sudden acute crisis in their condition
(d) life-threatening acute conditions caused by sudden
catastrophic events
TERMINAL ILLNESS
• Illness or injury which in opinion of 2
competent medical practitioners:
– Will inevitably result in death of patient and
which is causing severe suffering;
– Is causing patient to be in persistent,
irreversible, unconscious condition with no
possibility of meaningful existence
DILEMMAS
• The most challenging decisions in this area are generally
about withdrawing or not starting a treatment when it has
the potential to prolong the patient’s life.
• The evidence of the benefits, burdens and risks of these
treatments is not always clear cut
• There may be uncertainty about the clinical effect of a
treatment on an individual patient, or about the particular
benefits, burdens and risks for that patient
• In some circumstances these treatments may only
prolong the dying process or cause the patient
unnecessary distress
ETHICAL ASPECTS OF END OF LIFE
DECISIONS
• Scientific Advances : double-edged sword
• Life has natural end
• Point at which to change trajectory to palliative
care
• Consultation with family – does not mean family
consent
WMA Declaration on Euthanasia
• Euthanasia , that is, the act of deliberately ending
the life of a patient , even at the patient’s own
request, or that of close relatives is unethical
• Does not prevent physician from respecting the
desire of patient to allow natural process of death
to follow course in the terminal phase of sickness
WMA Declaration on Assisted
Suicide
• Where assistance of the doctor is
intentionally and deliberately aimed at
enabling a patient to end his or her own
life is unethical and should be condemned
• Refusal of treatment is a basic right of the
patient
ETHICAL ASPECTS OF END OF LIFE
DECISIONS
• HPCSA
– wilful act causing death of patient –
unethical & unacceptable, even where
requested by patient or proxy
– duty to alleviate pain & suffering – hence
withhold / withdraw life sustaining
treatments
CURRENT LEGAL POSITION.
In terms of current law, assisted suicide or euthanasia
is unlawful.
.
WMA Declaration on End-of-Life Medical Care
• The dying phase must be recognized and respected as an
important part of a person’s life
• The primary responsibility of the doctor is to assist his or
her patient in obtaining the optimum quality of life through
controlling symptoms and addressing psycho-social needs
and to enable the patient to die with dignity and comfort
• Doctors could not use their medical training to kill
• Ethical imperative is to improve palliative care had been
brought into sharp focus
WMA Declaration on End-of-Life Medical
Care
• Early recognition and planning
• Anticipation and recognition and addressing the
likelihood of pain and other distressing symptoms
• Provision for social , psychological and spiritual needs in
order to help them deal with the fear, anxiety and grief
associated with terminal illness
WMA Declaration on End-ofLife Medical Care
• The cardinal point however, is that the doctor has a duty
to heal and where possible relieve suffering and protect
the best interests of the patient.
• We cannot abandon the patient just because the illness
has reached a terminal stage
Euthanasia & Murder
• Euthanasia: Practitioners actively participate in causing
death of patient
• Murder: unlawful & intentional killing of another person
• Clarke v Hurst NO 1992
• S v Hartmann 1975
INFORMED CONSENT & INFORMED
REFUSAL
• Constitution BoR s12
• NHA s6(1)(d):
– to be informed of right to refuse and implications, risks, obligations of refusal
– hence notion of informed refusal
• Common Law – Re Farrel 529 (1987)
• HPCSA Guidelines
• Patients’ Rights Charter
INFORMED CONSENT & INFORMED
REFUSAL
• Mentally incompetent patient
– NHA : spouse, partner, parent, grandparent,
adult child, sibling
– NHA: allows for “substituted judgement”: patient
can appoint proxy in advance (in writing) to
make decisions on their behalf while they are
incompetent to do so.
LIVING WILLS / ADVANCED DIRECTIVES
• Advance directive stating if at any time a person suffers
from incurable disease or injury which cannot be
successfully treated, life sustaining treatment should be
withheld / withdrawn and patient left to die naturally.
• Takes form of written document drawn up by person of
sound mind and signed in presence of two witnesses who
also sign the LW
ETHICAL ASPECTS OF LIVING WILLS
• Furthers ethical principle of autonomy
• Reluctance on part of some practitioners to recognise validity of living
will
• HPCSA : recognition of LW – patients to be given opportunity and
encouraged to indicate wishes regarding further treatment
• Patients’ Rights Charter: should inform practitioner on wishes regarding
death
• WMA Declaration of Venice on Terminal Illness: doctors to recognise
rights of patients to develop written advance directives
SA Law Commission Recommendations on
Euthanasia and End of Life Decisions
• Proposed in 1994, Bill 1998, not enacted
• Defined terminal illness
• Recognised LW
• Recognised “enduring power of attorney”
• Recognised court order as remedy in absence of LW or power of
attorney
• Recommended legalising of doctor-assisted suicide
OBSERVATIONS
• “Often our fears and imaginings are a lot worse
than reality”
•
Euthanasia, like suicide, is a ‘one-way street with no
possibility of return,’
• Patients emotions swing ‘like a pendulum’
• Death is ‘an opportunity and a process’ in which there
could be, ‘a lot of living, richness, incredible growth and
family interaction’
OBSERVATIONS
• Assisted suicide may be perceived as the ultimate
expression of liberal individualism
• The Bill of Rights enshrined in the Constitution is
firmly rooted in the tradition of liberal individualism
• The rest of our existing health legislation in the
form of statutory law strongly supports individual
patient choice
THE SOUTH AFRICAN CONTEXT
• “SA not a safe and appropriate place , for liberalized euthanasia
legislation”
• This ‘recourse of last resort,’ (euthanasia) could only really be
justified in a country with the very best medical care for all, a wellorganised and universally acceptable palliative care and support
system, stable and well-functioning (particularly judicial) systems
and a strong culture of respect for human life.
• With our severe constraints on health care facilities and the totally
inadequate allocation of resources for effective medical treatments,
there is a real risk of euthanasia becoming a substitute for proper
care for the terminally ill and other patients in dire medical straits,’
Assisted suicide is an emotive topic that is
ethically, legally and culturally challenging
Thank you