Download A. There is a withdrawing or withholding of life

Terminal Discharges & Passive Euthanasia – Two Fundamentally Different
Entities That Should Not Be Likened to Each Other
Abstract
In Singapore, it is not uncommon for Terminal Discharges (TDs) to be carried out from
hospitals. Such discharges see terminally ill patients being sent home to die, in
accordance to their said wishes.
In practice however, concerns may develop over prognostication, potential
compromises in care and routine cessation of treatments that cannot be maintained in
the home setting. As a result, if due diligence is not exercised, parallels maybe drawn
with Passive Euthanasia (PE).
In this essay, we will discuss the circumstances in which TDs are undertaken and touch
on familial determinations of care and circumnavigation of direct patient involvement.
Using a hypothetical case scenario, we will focus on the case-specific assessments and
highlight the fundamental flaws in associating euthanasia with TD.
We will then see how we can mitigate the risks of carrying out PE by utilising a MultiDisciplinary Team (MDT) for a context and patient-specific approach to TDs.
Key words
Terminal Discharge, Passive Euthanasia, Palliative Medicine, End of life
Introduction
Terminal Discharges (TDs) or ‘Rapid Discharges’ within the palliative medicine setting
sees terminally ill patients being discharged from institutional care to their preferred
place of care1. Such patients suffer from advanced cancer or organ failure. In Singapore,
the most frequent destination for a TD is the patient’s home.
Typically, the decision for TDs are made on very short notice. As such, there may be
little time to determine futility before important treatments are ceased. As both PE and
TDs may involve withdrawal of treatment, parallels may be drawn between the two.
However, in a TD, the aim is to realise a very specific goal of dying at home in a patient
whose death is imminent. Furthermore, the “true” intention behind a terminal discharge
may not be adequately elucidated by the healthcare team, especially when the dying
patient loses capacity and the request for a TD comes from the family. In Singapore,
there is no legislation governing TDs. Since all forms of euthanasia are illegal in
Singapore, it is vital that TDs are distanced from euthanasia.
Prognostication
The terminally discharged patient is imminently dying. This may cause treatment
options to be viewed differently. To begin, life sustaining treatment such as CANH and
antibiotics may be employed at home for patients discharged with longer prognoses so
long as it meets their goals of care. For many local patients with longer prognoses these
goals of care are socio-culturally sensitive and as a result, whilst focused upon
maximising comfort, often include the provision of CANH and sometimes antibiotics
particularly if it helps with their symptom control. Provision of CANH and antibiotics
within the local setting is seen to signify ‘non-abandonment’ of the patient by their
families and medical teams and the maintenance of hope. For such care to be provided
additional support is arranged primarily with private nursing agencies with the cost
being borne by the family.
In the case of the patient being terminally discharged however, prognosis is deemed to
be a matter of hours or sometimes ‘short days’. As a result, continued employment of
CANH and antibiotics are deemed to have little impact on the patient’s life expectancy
and unlikely to provide symptomatic relief. Additionally, these treatments are stopped
as the special arrangements required for their continuation at home would hinder the
immediate discharge of the patients and deny them the chance of a death at home.
Despite its critical role in care determinations for TD patients, the process of
prognosticating is difficult particularly amongst terminally ill patients with primarily
non-cancer diagnosis and multiple comorbidities. Cessation of CANH for example may
have a significant impact upon the life of the patient if the patient survives longer than
two weeks during which timeframe data suggests patients can go without CANH with
no ill effect upon their prognoses.
Physicians are frequently aware that in some cases prognoses are not clear and may
turn to the family to help them decide or determine the goals of care and thus the extent
of care.
Familial Determination
Decisions for TD are often made by the family and when the patient has deteriorated or
no longer responding to treatment. In these cases, decisions for TD are not a concern
since present and alternative treatments are deemed to be futile by medical staff.
However, there are also TD cases where it is the family that initiate a TD. In many
cases the patients are frequently not able to communicate and a surrogate decision
highlighting their final wishes seems reasonable.
In the South East Asian setting however, family determination often sees the circumnavigation of direct patient involvement in end of life care-plans, collusion and family
determinations of care underpinned by cast doubts upon whether patients do wish to
die at home2. Local taboos on talking about death and dying and culturally inspired
practices of ‘maintaining hope’ by sparing patients ‘bad news’ culminate in patients not
being told of their diagnosis and prognosis casts doubts as to whether patients would
accept the inevitable compromises to their end of life care and prognosis as a result of
cessation of treatments and limitations to medical and palliative care in the home
setting3,4. Whilst much attention is drawn to the routine cessation of CANH as a result
of the practical limitations of care at home, these concerns appear to wane in
comparison to the impact surrounding cessations of treatments such as mechanical
ventilation, vasopressors and or antibiotics given their more immediate impact upon a
patient’s life expectancy5. There are also questions as to the underlying motives of the
family who, in the face of sociocultural and familial expectations, are expected to
provide physical, financial, practical, emotional and spiritual support for the patient often at no small compromise to their own interests. This raises the question as to
whether families act to request TDs to hasten the demise of patients especially when
they play such a pivotal role in care determinations locally6.
The accuracy of the prognostication process has a pivotal impact upon the withdrawing
or withholding of life-prolonging treatment. Furthermore, motivations of the family
may be focused upon hastening death as a result of the family’s wider interests or as a
result of the belief that death would be in the patient’s best interests in the setting of
continued suffering and loss of dignity. It is within the confines of these particular
considerations that TDs may be compared with PE.
Likening Terminal Discharge (TD) to Passive Euthanasia (PasE)
Likening TD to Passive Euthanasia can be seen to revolve around the triad of
considerations set out by Garrard and Wilkinson 20057. These are:
A. There is a withdrawing or withholding of life-prolonging treatment;
B. The main purpose (or one of the main purposes) of this withdrawing or withholding
is to bring about (or ‘‘hasten’’) the patient’s death;
C. The reason for ‘‘hastening’’ death is that dying (or dying sooner rather than later)
is in the patient’s own best interests.”
We will consider each element of Garrard and Wilkinson’s prerequisites for PE in
scrutinizing present concerns of TD.
(1) “there is a withdrawing or withholding of life-prolonging treatment”
In TDs, care is ‘simplified’ and treatments such as intravenous antibiotics or
vasopressors cannot be continued at home as there is limited, coordinated medical
support. In instances where parenteral medications are needed for symptom control,
these are given subcutaneously. Compromises are made. For example, intravenous
diuretics for a patient with heart failure may be stopped and dyspnoea is controlled with
subcutaneous morphine (given by non-healthcare professionals) where rapid titration is
not possible. In the rare instances the patient or family hires private nurses, there are
usually no doctors to guide the management. Hence in a TD, there is potential for
withdrawing or withholding life-sustaining treatment.
(2) “the main purpose (or one of the main purposes) of this withdrawing or withholding
is to bring about (or ‘‘hasten’’) the patient’s death”
Enacting a TD with the knowledge of a compromise in care provisions and limitations
in symptom control heightens the concern that the main rationale for TD is to hasten
the demise of the patient. Overarching intentions to hasten death are also highlighted
by the family’s refusal of alternative treatment measures in the hospital. It has been
suggested that these intentions may be fuelled the burdens of physical, emotional,
existential and financial costs of caring for patients1.
In most cases request for TDs are not holistically reviewed. To our knowledge, there
are also no guidelines on determining the acceptability of requests for TD. There is
presently no requirement for the authorization for a TD to be made by senior clinician
or any requirement that a determination that ongoing treatments are futile and
alternative options have been exhausted1. Similarly lacking are frameworks to
balancing the overall effects of a TD upon the symptom management and overall care
of the patient8. These gaps do little to alleviate suspicions that TD could be used by the
family to hasten death.
(3) "the reason for ‘‘hastening’’ death is that dying (or dying sooner rather than later)
is in the patient’s own best interests.”
In most local cases for TD, decisions for TD are motivated by the decision for the
patient to die at home in a manner that is consistent with their cultural, religious and
personal values and beliefs9. For example, Buddhist ceremonies that involve 8 hours of
chanting in which the body of the deceased cannot be touched observed by some locals,
will be difficult to carry out at the hospital. For others dying at home where the soul
can better find peace is a pressing consideration. In some cases, family members believe
that continued medical care was prolonging the dying process, inducing suffering and
or resulting in a loss of dignity. Fuelled by concerns of the afterlife, wishes for death at
home established and with acceptance that many life-prolonging treatments will be
stopped, facilitation of death at a specific time and place in order for religious rites to
be observed are argued to be in the patient's best interests10. In these circumstances
bringing about the patient’s death is seen to be in the patient’s best interests. For the
family meeting such goals would be in keeping with their filial obligations of nonabandonment of the patient.
The coadunation of these considerations would on the surface support the premise that
TD is tantamount to PasE.
Contextualizing TD within the local Palliative Medicine setting
To be clear, this discussion focuses solely upon TDs in the Palliative Medicine setting
and to appropriately contextualize this discussion, a clear understanding of palliative
medicine's unique patient specific MDT-led holistic care approach is required. To
appropriately contextualize this discussion, we present the hypothetical case of Mrs A.
Mrs A was a 70-year-old lady with gastric cancer and peritoneal metastases. Her disease
had steadily progressed despite chemotherapy and she was admitted to the oncology
ward with symptoms of intestinal obstruction. She was deemed too frail for surgery and
her intestinal obstruction was managed conservatively. She had a nasogastric tube for
decompression and required parenteral Morphine and haloperidol for abdominal pain
and nausea respectively. She was also on an intravenous drip for hydration. 6 days into
admission, her symptoms were well controlled but she was clearly deteriorating.
Discussions were carried out with Mrs. A and her family. They were informed that the
intestinal obstruction had not resolved and surgical management is not possible. A
prognosis of days to weeks was given by both the oncology and surgery teams. On the
grounds of medical futility, antibiotics, vasopressors and additional fluid challenges for
hypotension was deemed inappropriate.
Though frail, Mrs. A was judged to have capacity and when asked what she wished for,
now that time was short, she mentioned she wanted to go home as she did not want to
die in hospital. She informed her family about this as well.
Initially, her family were apprehensive but they felt an overriding sense of duty to
respect her wishes. At this point, Mrs. A was referred to the palliative care team. On
review of her case, the team agreed that no further medical management was possible.
The overarching goals of care now included symptom management, good nursing care
and facilitating the discharge home. After discussion with the family, arrangements
were made for private nursing care, a hospital bed and standby oxygen.
Three days later and hours before her discharge, Mrs. A’s blood pressure plummelled
and prognosis was deemed short. Although a decision had been made before that there
will be no further fluid challenges, the oncology team, palliative care team and family
decided on a small bolus of fluids with the aim to increase her BP so that Mrs A could
realize her wish of dying at home. She was successfully discharged home and died a
day later.
The above case illustrates the following:
1. Changing Goals of Care and Capacity
Initially, when Mrs A came into hospital the aim was to reverse the intestinal
obstruction with conservative measures such as nasogastric tube decompression and
bowel rest. When it was clear that the obstruction was not reversible the goals were
discussed again and the patient decided symptom control and passing on at home was
most important.
It was fortunate that Mrs. A had capacity and the discussions were made easily.
However, what if she did not? Then the common practice would be to ask the family
what she would have wanted. Now this is fraught with problems. Firstly, family
members may not know at all what she would have wanted if they have never discussed
dying. Secondly, there may be conflicts of interests, i.e. financial issues as it may well
be cheaper to care for a dying one at home.
How then do we mitigate these issues? Here we will introduce the palliative medicine
MDT and it has a crucial role in elucidating the goals of care11. The common practice
(as we did above) is to ask the family what Mrs. A would have wanted. Now this is not
without problems. Firstly, family members may not know at all what she would have
wanted if they have never discussed dying. Secondly, there may be conflicts of
interests, i.e. financial issues as it may well be cheaper to care for a dying one at home12.
We mitigated these by carrying out interviews with various members of the family and
organised family meetings. With the involvement of the medical social Mrs A’s values,
cultural and religious beliefs were elucidated. An analysis of financial and domestic
issues could also be carried out and eventually the goals of care can be decided upon.
2. Ensuring good care at home
In Mrs A’s case, discussions were held between the palliative care team and the family
and logistic preparations were made. All of these required time and hence we argue that
a TD requires lead time as the primary responsibility of the medical team is to discharge
a patient to a place of safety and to provide effective Care-giver training to carers. Lead
time also allows nurses and social workers to engage the family and address concerns
and practical issues1. Again the MDT will be able to provide direction and support to
the care-givers and on some occasions a terminal discharge may be withheld. As one
can imagine, this cannot rest such difficult decisions cannot rest on an individual’s
shoulders.
Again, Mrs. A’s family had enough resources to hire private nurses but this cannot be
said for most patients. How then do we ensure that our patients are discharged to a place
of safety? This is a difficult question to answer. Frequently, we give care-giver training
to domestic helpers or close family members. These are almost always non-medical
personnel who have been thrust into patient care. How them can we expect them to
administer similar levels of care as trained professionals? Hence there is a need for a
context-specific, patient specific approach with the MDT Again, we have little choice
but doing the next best thing. However, this is when the MDT becomes important. Caregivers need to be continually interviewed with the aim to tease out apprehensions,
anxiety. If there is really is no alternative then a terminal discharge may even have to
be withheld.
3. Distancing Mrs A’s TD from PE
If we consider Gerard and Wilkinson’s definition, passive euthanasia involves
withholding or withdrawing life prolonging treatment with the aim of hastening death.
Critically, it is believed that bringing about death would be to be in the patient’s best
interest7.
Hence, central to the distinction between TD and PasE is the question of intention. As
we showed above, much work must go into elucidating the true intention behind a TD.
In many cases, this can only be inferred by the actions of the physician. Such
discernment is best accomplished by an MDT.
In our patient’s case, the MDT, on review of the available clinical, laboratory and
radiological evidence, appreciated that Mrs A was dying. There was a clearly defined
goal, ie dying at home and the intention behind the TD was clear. Although artificial
hydration may not have altered the clinical course Mrs A did actually receive fluids in
the end to give her the best possible chance of realising her wish. There was also a clear
determination of futility with the involvement of both surgical and oncological teams.
Lastly was it in Mrs A’s best interest to die? Possibly – considering that she was bedbound and deteriorating. But that is not the question that needed answering. What
should be asked instead was ‘Is it in Mr N’s best interest that he dies at home?’ Based
on available evidence, dying away from home was a greater form of suffering than
death itself. This is a subtle but important point as a TD attempts to realize a very
specific aim for an individual.
How do we ensure Appropriate Terminal Discharges?
TDs in Palliative Medicine are aimed at patients who are dying. For such patients on
an inalterable trajectory to death, further treatment options are exhausted and or
determined to be inconsistent with their goals of care. There invariably arises the
question of futility.
Under the aegis of a Palliative Medicine approach determinations of futility are made
by a Palliative Care MDT. An MDT consists of a "group of people of different
healthcare disciplines, which meets together at a given time (whether physically in one
place, or by video or teleconferencing) to discuss a given patient and who are each able
to contribute independently to the diagnostic and treatment decisions about the patient’
as well as to elaborate upon the various biopsychosocial, spiritual and cultural
determinants that may be relevant to the provision of care and support to patients and
their families"11.
Use of a multi-professional, multidimensional approach to ascertain if a TD should be
provided helps overcome some of the notable issues that appear to liken TD to
euthanasia. In an MDT, decisions are made by a group of professionals who are able to
provide various viewpoints. The wide array of expertise within the MDT ensures that
decisions taken effectively evaluate the particular situation upon its own merits guided
by prevailing clinical, institutional and professional guidelines as well as legal
practices. The MDT-led decision-making process also ensures that care and the
interests of the patient are duly considered and decisions taken are documented,
justified and transparent to overcome concerns that care of the patient is compromised
by familial determinations. The MDT approach also ensures all available treatment
options for the patient's condition are considered within the specific confines of the
patient's goals of care and what the medical team can realistically provide12. As a result,
suspension of ongoing treatment and the withholding of alternative treatment options
is only possible if it be adjudged to be futile and unlikely to provide meaningful
improvement in the patient's condition13. Here whether something is ‘meaningful’ or
not is determined by the patient's own views of quality of life and the severity of their
symptoms, after due consideration of the patient's wider psychosocial, spiritual, cultural
and personal factors and through holistic review of their previous actions and wishes.
This process is necessarily specific to each particular patient14.
The MDT also serves a hitherto unreported role of balancing the various clinical,
psychosocial, practical, familial, financial, existential and cultural factors that influence
the decision making process. Weighing up these key, sometimes conflicting
considerations, justifying the importance placed upon them and coordinating a multiprofessional effort to care for the patient helps counter individual inclinations of
clinicians who may be pressured by the family and or patient for TD, who may
subscribe to the same local customs that the family are acting upon, and who may be
unduly influenced by specific considerations on care matters. Ching et al revealed that
physicians were frequently influenced by clinical considerations and rarely took into
account the psychosocial aspect of care15. Balancing individual decision-making
tendencies of the various individual members of the team and ensuring holistic
considerations of patient specific factors are thus key roles of the MDT.
A further role of the MDT is ensuring that care and interests of the patient are preserved.
Underpinning the wish to avert a “self-discharge” or “discharge against medical
advice” through the provision of a TD is frequently fuelled by the wish to maintain the
therapeutic relations that would allow the MDT to provide bereavement care, clinical
and psychosocial support of the family through home care support and allow for
readmission should the need arise. The MDT-led determination inspired by a holistic
appreciation of the situation addresses concerns that decisions to provide a TD come at
the cost of patient care and interests.
Use of the palliative Home Care services to monitor, change, titrate and add treatments
started by the Palliative Medicine team in the hospital or acute setting ensures
continuity of care and that any compromise to care provisions upon TD is attenuated.
Secondly, the home care service will be provided with detailed instructions and
information upon TD and will be able to liaise with the acute medical team should the
need arise. Thirdly, home care services can provide psychosocial and clinical support
for patients and families ensuring that there is both continuity of care plans and holistic
support upon TD.
Correcting Misconceptions and Addressing Clinical Gaps
Use of an MDT approach does assuage some of the concerns surrounding the employ
of TD; ensuring a holistic review of the patient’s needs, care provisions and interests
and in so doing reducing the possibility that life supportive treatments could be stopped
and TDs initiated simply to hasten death. Indeed, key to distancing TD within the
Palliative Medicine setting from associations with PasE lies in is its ‘case specific
context sensitive’ approach overseen by a MDT team and guided by prevailing clinical,
professional and intuitional guidelines and legal standards.
Mrs A’s case does however highlight possible gaps in the TD process not least concerns
surrounding the authorization for TD in light of continued domination of prevailing
family centric practices that limit the ability of the MDT in establishing the patient’s
overall goals of care and priorities. Absent too are means of balancing sometimes
competing considerations within risks and benefits estimations. It is addressing these
issues that Palliative Medicine MDTs need to focus their considerations in order to
maintain acceptability for TDs in Singapore. Perhaps this is best achieved by a welfarebased MDT as described by Krishna et al16. Here, instead of practicing medical
paternalism, the MDT serves to arrive at decisions after tempering biases and analysing
issues of futility and psychosocial importance. This is to ensure the best course of action
is taken for each patient within the context of the individual, family and a society that
is largely Confucian-driven.
The author declares there are no conflicts of interest.
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