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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. 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