Bioethical benchmarks in counseling medical

workers ,under palliative care services.

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“As a society, perhaps the most sensitive measurement of our maturity is
the manner in which we care for those who are facing the ultimate
challenge – the loss of life.” (Report of the National Advisory Committee

on Palliative Care, 2001)TITLUL

DIAPOZITIVULUI

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 Death as a part of life
• Illness and death have always been part of
human experience.
• Palliative care is trying to respond to these
changes and uses the tools developed by
modern medicine to meet the needs of the
dying to relieve suffering and enhance quality
of life

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 „It’s not death itself that people fear – rather the
manner of their dying „
Rod MacLeod , Professor in Palliative Care, University of
Sydney, HammondCare.

Dying is an important phase of life, one in

which people have the right to expect
quality of life to ensure a death with dignity
occurs.

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• Medical stuff face a wide range of system issues
and ethical dilemmas that arise in the provision of
palliative care.
• It is now realized that a good understanding of
medical ethics will contribute to the health
professional's decision-making and day-to-day
practice of medicine for a terminally ill patient.

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 SIX VALUES IN MEDICAL ETHICS

• The foundation of medical ethics is supported by four

pillars, namely;
• Autonomy - patient has the right to choose or refuse the
treatment
• Beneficence - a doctor should act in the best interest of the
patient
• Non-maleficence - first, do no harm
• Justice - it concerns the distribution of health resources
equitably.

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• Added to the above four, are two more aspects which form the
cornerstones of medical practice:
• Dignity - the patient and the persons treating the patient have
the right to dignity
• Truthfulness and honesty - the concept of informed consent
and truth telling
• All these together constitute the six values of medical ethics.

Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th

ed. Oxford University Press; 2001.

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• A successful medical practice requires
evidence of effectiveness to address deficits in
care. A treating physician can face dilemmas,
because research that involves patients near
the end of life creates numerous ethical
challenges and awkward situations that
impose a comprehensive approach.

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 “An ethical problem is a situation involving
conflict about the right thing to do. Any health
care decision that involves competing values is
an ethical problem” Cameron, 2002, p 637

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• Ethical issues in palliative care often arise because of
concerns about how much and what kind of care
make sense for someone with a limited life
expectancy.
• There is often conflict between clinicians, nurses,
other health care team members, patients, and family
members about what constitutes appropriate care,
particularly as patients approach death.

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 Shared issues:
•Unrealistic goals of Care
• Patient and family goal conflicts
• Physician and patient goal conflicts
• Transitioning focus of care
• Pain and symptom management

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• Religion and spiritual beliefs and practices
(for some, religious/spiritual belief results
in lower levels of grief, and for others a stronger faith
can lead to more severe experiences of grief).
• Burnout syndrome among medical stuff.
• Insufficient remuniration policy among palliative care
stuff.

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 Aims to follow in counseling medical
workers :
•Assessing the patient’s knowledge if possible
•Teaching the patient about care alternatives
•Examining the patient’s values and beliefs about
dying
•Discussing the patient’s beliefs and choices with
their significant others who will be affected by
their decisions.
•Recording the patient’s care choices.
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 Counseling of family members

• Family members feel a great deal of

uncertainty about the decisions they make
• •They fear that limiting treatment will mean
less care for their loved one so they give
priority to life sustaining treatments
• •We can help by discussing the wishes of
patients and their families before a health crisis
occurs
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 Self-determination

•Recognises the individual’s right and ability to

decide for him - or - herself according to their
beliefs, values and life plan
•Decisions are unique and may be different from
the course that is deemed “right” or “wise”
•Gentle truth-telling and exchange of accurate
information about their health status, options,
planned care and future expectations is essential
•Informed consent

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 Contribution

• “Doing good”
• Standard health care activities including:
•effective pain and symptom management
•sensitive interpersonal support
•acknowledgement of the person as a unique
human being to be respected and valued

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 “Doing no harm”

•unnecessary physical pain

•unnecessary psychological distress
•insensitive truth-telling
•denigration of the individual
•continued aggressive life-prolonging or cure-
orientated treatment not suited to the patient’s need or
wishes
•unnecessary or unwanted over sedation
•premature, unrequested or uninformed withdrawal of
treatment

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 Equity

•Concept of fairness or what is deserved

•Describes what individuals are legitimately
entitled to and what they can claim
•Sometimes justice may serve to limit autonomy;
what the individual wishes, chooses, or feels
entitled to may not be possible or allowable in
the context of the society

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 Cultural considerations

• •Culture is the prism through which we see the

world
• •Cultural perspectives will have a major influence
on our attitudes, values and beliefs around end of
life care
• •Within any cultural group there is a wide range
of similarities and differences in the rituals and
meanings associated with illness, dying and death

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• It is easy for health workers to ignore ethnic
and cultural differences when they are part of
the dominant culture
• •Asking the patient and their family about
their beliefs and values is a way to establish
their personal preferences and gives the
patient a sense of control
• Lum K., Radbruch, L. European Association for Palliative Care. 14 November 2006.

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 Spiritual considerations

• Spirituality involves the search for meaning, a

connectedness with a greater power that may
be much more then purely religious beliefs
•Spiritual beliefs vary widely within ethnicities

•The time approaching death may be one of

contemplation or of personal completion or
preparation

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 Results :
On the basis of a study carried out in 2014 by roumanian
sociologist Alexandra Caruntu, training of medical stuff from 2
institutions specialised in palliative care: (Hospice Casa
Sperantei from Brasov and Centrul de ingrijiri paliative Sfantul
Nectarie from Bucuresti. Adherence of patients to the treatment
increased by approximately 35 % in first case and 48 % in second
case compared to period before training.

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 You are also important!

• Ethical dilemmas may challenge our own values and

beliefs
• Work as a team – need to trust and support each other
• Good communication – share in decision making,
confront difficult issues in non-judgemental way
• Share your feelings and concerns with other staff
• Conflicts may be inevitable but should not be seen as
negative but rather an opportunity for growth and
improvement
• Have strategies to preserve emotional and physical health
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 Conclusion

• The patient is the central figure in end of life decision

making
• Life is a process with death as an integral part of the
continuum
• Ethics or principles of moral conduct are not fixed
and static but subject to change and interpretation

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• Social, historical, cultural, racial, political,
professional and spiritual influences all shape the
ethical beliefs that affect the actions of health care
providers and patients and their families

• A treatment based on satisfying emotional needs of

the patient, showed an increased rate of adherence to
therapy, rising patient’s quality of life.

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 References
• Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. Oxford University Press; 2001.

• Joseph F. A palliative ethic of care: Clinical wisdom at life's end. Jones and Bartlett Publishers; 2006. ISBN:
0763732923.
• Îngrijirea paliativă – importanţa consilierii furnizorilor de servicii
me- dicale paliative, Editura Cuvântul Vieţii, Bucu- reşti, 2014.

• Available from: http://en.wikipedia.org/wiki/medical_ethics. accessed on 22 September 2009.

• Peel M. Human rights and medical ethics. J Soc Med. 2005;98:171–3. [PMC free article] [PubMed]

• Thieren M, Mauron A. Nuremberg code turn 60. Bull World Health Organ. 2007;85:573–4. [PMC free
article] [PubMed]

• Carlson RV, Boyd KM, Webb DJ. The revision of the declaration of Helsinki: Past, present and future. Br J
Clin Pharmacol. 2004;56:695–713. [PMC free article] [PubMed]
• https://www.pharmac.govt.nz/assets/ss-palliative-care-3-ethical-issues-in-palliative-care-prof-rod-
macleod.pdf

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