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Moral and Ethical Dilemmas
in End of Life Care and Dementia
Ethical Dilemmas
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Truth Telling
Consent
Confidentiality
Hydration
Feeding
Justice
Euthanasia
Symptom Management
Ethical Frameworks
Principles based
 Duties based
 Consequentialist
 Non-consequentialist
 Utilitarian
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Ethics – not universal
Time
 Place
 Society
 Culture
 Religion
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Principle Based Approach to
Bioethics
Beneficence
 Non-malficence
 Respect for autonomy
 Justice
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Beneficence
Non-malficence
Autonomy
Respect for the autonomy of others in so far
as such respect is compatible with respect
for the autonomy of others
 Make decisions based on deliberation and
values
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Autonomy
Capacity – situation specific
 Affected by cognitive (and communication)
deficits
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Bodily Autonomy
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Resistive behaviour to care
Justice
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Fairness
Justice
Distributitive justice
 Rights based justice
 Legal justice
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Justice
Treat equals equally
 Treat unequals unequally
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Ethical Aspects of Symptom Management in
Dementia
Patient report essential
 Limited evidence base
 No effective symptom-assessment tools
 ? Under management
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Artificial Feeding in Advanced
Dementia
No evidence of reduction in pressure sores,
infection, improved function, comfort,
survival
Finucane, Christmas, Travis
JAMA, 1999: 282(14), 1365-70
Percutaneous endoscopic gastrostomy does
not prolong survival in patients with
dementia
Murphy and Lipman
Arch Int Med 2003, 163; 1351-3
Artificial Hydration
What is the purpose
 Benefits - prolong life
- relieve symptoms
 Burdens
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IV access
Subcutaneous inflammation
Hospitalisation
Fluid overload
Artificial Hydration
A blanket policy is ethically indefensible
 Towards death a person’s desire for food
and drink lessens
 Evidence suggest Artificial Hydration in
imminently dying patients influences
neither survival or symptom control
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An Bord Altranais
‘So long as there is a means of nutrition and
hydration it is the duty of the nurse to
provide nutrition and hydration’
Medical Council of Ireland
‘The Council reiterates its view that access to
nutrition and hydration remain one of the
basic needs of human beings and all
reasonable and practical efforts should be
made to maintain both of them’
Advance Directive / Care Plan
Ethical to respect if current situation
reflects envisaged situation
 May be formally written
 May be informal – patient’s wishes
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Advance Directive/ Care Plan
The role of family/social network
 Substituted decision
 Not ’legal’ but likely to be recognised by
courts
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Confidentiality
An ethical obligation
 May need to be breached if a patient is
not able to make decisions about care
 Views of family about what patient would
have wanted
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Truth Telling
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What is the ethical obligation?
 Consequentialist
 Nonconsequentialist
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‘Negotiated’ truth telling
Moral and Ethical Dilemmas at the
End of Life and Dementia
Do the right thing
 The patient’s voice
 Forward planning
 Framework for decision making informed
by professional code and an ‘ethical guide’
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