NUR 390: Bioethical Issue Paper Grading Criteria

BUY A PLAGIARISM-FREE PAPER HERE

ORIGINAL ARTICLE

Timing of code status documentation and end-of-life outcomes in patients admitted to an oncology ward

Amanda Caissie & Nanor Kevork & Breffni Hannon & Lisa W. Le & Camilla Zimmermann

Received: 4 June 2013 /Accepted: 11 September 2013 /Published online: 28 September 2013 # Springer-Verlag Berlin Heidelberg 2013

Abstract Purpose Guidelines recommend documentation of care pref- erences for patients with advanced cancer upon hospital ad- mission. We assessed end-of-life outcomes for patients who did or did not have code status (CS) documented within 48 h of admission. Methods This was a retrospective cohort study of patients who died on an inpatient oncology ward between January 2004 and February 2009. Primary end-of-life outcomes were “code blues” and cardiopulmonary resuscitation (CPR) at- tempts; secondary outcomes included unsuccessful CPR at- tempts, intensive care unit (ICU), consultations, and ICU admissions. Using logistic regression, outcomes were com- pared between those with and without CS documentation ≤48 h from admission (full code or do-not-resuscitate), con- trolling for significant confounders. NUR 390: Bioethical Issue Paper Grading Criteria

Results The 336 patients had a median age of 61 years; 97 % had advanced cancer. The median time from admission to death was 12 days (range <1–197 days); 151 patients (45 %) had CS documentation ≤48 h from admission. Controlling for confounders of reason for admission and marital status, pa- tients with CS documentation ≤48 h from admission had fewer “code blues” (2 vs. 15 %; adjusted odds ratio (AOR) 0.12, 95 % confidence interval (CI) 0.02–0.43), CPR attempts (1 vs. 11 %; AOR 0.12, 95 % CI 0.01–0.51), unsuccessful CPR attempts (0 vs. 11 %), ICU consultations (9 vs. 30 %; AOR 0.19, 95 % CI 0.08–0.40) and ICU admissions (2 vs. 5 %; AOR 0.18, 95 %CI 0.02–0.85). Conclusions In patients who died on an oncology ward, CS documentation within 48 h of admission was associated with less aggressive end-of-life care, regardless of the reason for admission. NUR 390: Bioethical Issue Paper Grading Criteria

Keywords Cancer . Code status . Intensive care unit .

Cardiopulmonary resuscitation . Advance directives

Introduction

When first introduced around 1960, cardiopulmonary resus- citation (CPR) was used mainly intra-operatively [1]. In the 1970s, The American Medical Association recommended documentation of code status in the hospital chart, and hospi- tal policies made CPR the default unless do-not-resuscitate (DNR) orders were written [2]. Decades later, this policy remains in place, yet there are low rates of code status docu- mentation in hospitalized patients [3–5] Such documentation is important, given the low rates of CPR success in hospital inpatients. Although approximately 4 out of 10 patients have a return of spontaneous circulation, only 10–20 % survives to hospital discharge [6, 7]. NUR 390: Bioethical Issue Paper Grading Criteria

A. Caissie Department of Radiation Oncology, Dalhousie University, Halifax, NS, Canada

B. Hannon :C. Zimmermann Division of Medical Oncology and Hematology, Department of Medicine, University of Toronto, Toronto, Canada

N. Kevork : B. Hannon :C. Zimmermann (*) Department of Psychosocial Oncology and Palliative Care, Princess Margaret Hospital, Toronto, University Health Network, 610 University Ave., 16-712, M5G 2M9 Toronto, ON, Canada e-mail: camilla.zimmermann@uhn.on.ca

C. Zimmermann Campbell Family Cancer Research Institute, Ontario Cancer Institute, Princess Margaret Hospital, Toronto, University Health Network, Toronto, Canada

L. W. Le Department of Biostatistics, Princess Margaret Hospital, Toronto, University Health Network, Toronto, Canada

Support Care Cancer (2014) 22:375–381 DOI 10.1007/s00520-013-1983-4. NUR 390: Bioethical Issue Paper Grading Criteria

The success rate of CPR is even lower in patients with cancer, and is further reduced by metastatic disease, poor performance status, advanced age, and acute illnesses includ- ing infection [6, 8, 9]. A meta-analysis of 42 studies from 1966 to 2005, specifically in hospitalized patients with cancer, reported an overall survival rate to discharge of 6.2 % (9.5 % in patients with localized disease and 5.6 % in patients with metastatic disease) [9]. For patients whose cardiac arrest was anticipated, rather than occurring unexpectedly, the survival rate to discharge after CPR was 0 % [8]. NUR 390: Bioethical Issue Paper Grading Criteria

Due to these exceedingly low rates of success for CPR in hospitalized patients with cancer, guidelines recommend that for patients with advanced cancer, goals of care should be reviewed and documented within 48 h of any admission to a hospital [10]. While the latter publication does not explicitly define advanced cancer, it has been defined elsewhere as cancer that is incurable [11]. NUR 390: Bioethical Issue Paper Grading Criteria. These recommendations for goals of care discussions are in line with the Patient Self Determination Act, which requires that all institutions in the USA that are receiving Medicare/Medicaid funds inform pa- tients, upon admission, of their right to accept or refuse treatment and their right to an advance directive, regardless of whether or not their cancer is in the advanced stages [12]. NUR 390: Bioethical Issue Paper Grading Criteria. However, the guideline of documenting goals of care within 48 h is founded only from level III evidence (textbooks, opinions, and descriptive studies) [10]. Scant evidence exists regarding both the frequency with which code status is actu- ally documented within 48 h of admission, and whether this serves to reduce aggressive end-of-life care [13]. NUR 390: Bioethical Issue Paper Grading Criteria

Early code status documentation may decrease the number of patients subjected to aggressive interventions not appropri- ately aligned with goals of care. The aims of the current study were (1) to assess the timing of code status documentation in all patients who died after admission to an oncology ward and (2) to examine whether code status documentation within 48 h was associated with less aggressive end-of-life care. We hypothe- sized that code status documentation within 48 h would be associated with fewer “code blues” and CPR attempts. Second- ary outcomes included unsuccessful CPR attempts and inten- sive care unit (ICU) consultations and admissions before death. NUR 390: Bioethical Issue Paper Grading Criteria

Materials and methods

Study site and sample

The study took place at Princess Margaret Hospital (PMH), a comprehensive cancer center and member of the University Health Network (UHN) in Toronto, Canada. In addition to PMH, the UHN also includes two general hospitals: Toronto General Hospital and Toronto Western Hospital. The study sample included consecutive inpatients that died between Janu- ary 2004 and February 2009, inclusive, on the two general oncology (medical or radiation oncology) wards at PMH, which have a total of 40 beds. Patients admitted to these wards all have solid tumors, with the exception of a small minority of patients with lymphoma or multiple myeloma who are admitted for palliative radiation. NUR 390: Bioethical Issue Paper Grading Criteria. PMH also has 69 beds allocated for patients with hematologic malignancies and a 12-bed palliative care unit (PCU); patients who died on these units were not included in the study. PMH has no emergency department; however, patients have access to the emergency departments of the other UHN hospitals. Patients may be admitted either directly from ambula- tory care; transferred from general medical or surgical wards at another hospital; or transferred after presenting at the emergency department at another hospital.While PMH has no ICU, patients have access to ICU care at the adjacentMount Sinai Hospital via a bridge connecting the two hospitals. NUR 390: Bioethical Issue Paper Grading Criteria

This research was conducted following approval of the UHN Research Ethics Board. Two investigators (AC and NK) conducted a thorough retrospective chart review, using a standardized abstraction spreadsheet. Data abstracted included information on patient demographics, cancer diagnosis and stage, admission date, reason for admission, admitting service, status of the physician admitting the patient (patients may be admitted onto the service of a staff physician by this physician personally or by a hospitalist, fellow, or resident), code status documentation, ICU consultations and admissions, CPR at- tempts (and outcome thereof), and date and cause of death. NUR 390: Bioethical Issue Paper Grading Criteria

Data collection was facilitated by the availability of data- bases and standardized forms. The reason for admission is specified by the admitting physician at the time that the patient is placed on the waiting list for admission, and is then entered into the standardized database by the admissions coordinator (a registered nurse) using a drop-down menu of different potential reasons for admission. NUR 390: Bioethical Issue Paper Grading Criteria. When there are multiple reasons for admission, the primary reason is recorded. For this study, the 28 reasons for admission listed in the database were grouped into three categories: symptom control, cancer treat- ment or investigation, and palliative planning (Table 1). The last category was taken unaltered from the database, and refers to patients whose condition is deteriorating at home, and who are admitted with the anticipation of transfer to hospice or PCU or discharge home with further support. NUR 390: Bioethical Issue Paper Grading Criteria

Code status documentation and ICU consultations and admissions were abstracted from the physician’s orders and from the chart notes. Code status documentation was taken from the inpatient medical orders, because according to UHN policy, this is where DNR documentation must be, to be followed for inpatients. Code status was classified as “full code” or “DNR”. A DNR order precludes the interventions of chest compressions, defibrillation, or intubation in the event of a cardiopulmonary arrest, but does not preclude an ICU consultation or admission. Details of code blues and CPR attempts and outcomes were abstracted from standardized forms completed by the code blue team. The date and cause. NUR 390: Bioethical Issue Paper Grading Criteria

376 Support Care Cancer (2014) 22:375–381

of death was obtained from the death certificate, a copy of which was included in each chart.

A “code blue” was defined as any medical emergency where there was documented involvement of the code blue team (cardiopulmonary arrest or near-cardiopulmonary ar- rest). CPR attempts were defined as instances where there were documented attempts at resuscitation, including chest compressions, defibrillation, and/or intubation. CPR was de- fined as “successful” if the patient was revived and survived for one or more days and “unsuccessful” if the patient was not revived or survived for less than 1 day. All ICU admissions at PMH are preceded by an ICU consultation, but an ICU consultation does not necessarily result in an admission to the ICU. NUR 390: Bioethical Issue Paper Grading Criteria. All code blues result in an ICU consultation; in addition, the ICU staff may provide consultations on the PMH oncology wards for medical emergencies that have not yet progressed to the severity of a code blue. ICU consulta- tions may also be requested pre-emptively, to provide input regarding whether or not CPR and ICU admission would be appropriate for a particular patient. These pre-emptive consul- tations are rare and supplement rather than replace the more usual situation of a code status discussion with the primary oncologist, admitting oncology team, or palliative care team. NUR 390: Bioethical Issue Paper Grading Criteria

A UHN policy is in place to guide the medical team through decision making with respect to life support interventions and code status discussions. During the study period, there was no institutional policy or guideline regarding the actual timing of such code status discussions, nor is there one currently. NUR 390: Bioethical Issue Paper Grading Criteria

Statistical analysis

Associations between timing of initial code status documen- tation (≤48 h from admission, vs. longer or not at all) and patient characteristics were assessed using chi-square, Fisher’s exact, and t tests, as appropriate. Associations between timing of code status documentation and end-of-life outcomes (code blue, CPR attempt, unsuccessful CPR attempt, ICU consulta- tion, ICU admission) were then assessed using multivariable logistic regression analyses, adjusting for significant con- founders. NUR 390: Bioethical Issue Paper Grading Criteria. Confounders were defined as patient characteristics associated with both timing of code status documentation and any end-of-life outcome (p <0.05). Marital status and reason for admission met criteria as confounders and were included in the multivariable analysis. Among the reasons for admis- sion, inclusion of “palliative planning” caused separation of the data, because a large majority of patients admitted for palliative planning also had code status assessed within 48 h of admission. Therefore, patients admitted for palliative plan- ning were excluded from the multivariable analysis. NUR 390: Bioethical Issue Paper Grading Criteria

Results

Table 2 shows the timing of relevant end-of-life events for the 336 patients who died on the oncology wards during the study period. Of 336 patients, only 151 (45 %) had code status documentation ≤48 h from admission (141 as DNR and 10 as full code) and 28 (8 %) had no documentation of their code status before death. Of note, 16 patients had a change in their code status: for 12 patients (whom had code status documen- tation within 48 h), an initial “full code” status was subse- quently changed to DNR; for 4 patients, (whom had code status documentation within 48 h) an initial DNR status was changed to full code, and then back to DNR prior to death. NUR 390: Bioethical Issue Paper Grading Criteria. Twenty-eight patients died within 48 h of admission; 23/28 had code status documented, and 5/28 did not. Of the 23 who did have code status documented, one (documented as full

Table 2 End-of-life milestones

End-of-life events All patientsa

Code status documented before death 308 (92) NUR 390: Bioethical Issue Paper Grading Criteria

Code status documentation within 48 h of admission 151 (45)

Code status documentation within 48 h of death 88 (26)

Time from admission to death; median (range), in days 12 (1–197)

Time from admission to initial documentation of code statusb; median (range), in days

3 (1–178)

Time from initial code status documentation to deathb; median (range), in days

6 (1–97)

Time from initial code status to final code statusc; median (range), in days

3 (1–39)

Time from final code status to deathc; median (range), in days

6 (1–34) NUR 390: Bioethical Issue Paper Grading Criteria

a Unless specified, units for all characteristics are number (%), and n =336 b n=308 patients who had their code status documented c n=16 patients who had a change in code status

Table 1 Categories of reasons for admission listed in oncology database

Category Reasons for admission listed in oncology database

Symptom control Pain control, dehydration, neurological changes, biochemical abnormality, hematological abnormality, bleeding, bowel obstruction, nausea/vomiting, distal vein thrombosis/ pulmonary embolus, superior vena cava obstruction, seizures, hypercalcemia, fever not yet diagnosed, off-treatment deterioration, febrile neutropenia, infection, pleural effusion, respiratory problems, other medical problem

Cancer treatment or investigation

Radiation therapy, radiation chemotherapy, chemotherapy, investigation, cord compression, staging, gastrostomy tube, on- treatment deterioration

Palliative planning Palliative planning

Support Care Cancer (2014) 22:375–381 377 NUR 390: Bioethical Issue Paper Grading Criteria

code) was transferred to the ICU after a code blue and success- ful CPR. Of the five who did not have code status documented, all had unsuccessful CPR after a code blue. All of these patients had advanced illness and deteriorating status on admission.

The demographics of all 336 patients are presented in Table 3, both for the entire study population and according to timing of code status documentation. Of all patients, (295/336) had stage IV disease on admission; of those with non-stage IV disease, all but 10 (3 % of the whole sample) had advanced, incurable disease at admission (for example advanced glioblastoma). Ninety-six percent died of their cancer, with the remaining 13 patients dying either from complications of the disease or from severe medical comorbidities. NUR 390: Bioethical Issue Paper Grading Criteria. Code status documentation ≤48 h after admission was associated with being married and admis- sion for palliative planning and negatively associated with ad- mission for cancer treatment or investigation. Specifically, 29/34 (85 %) of patients admitted for palliative planning, 87/195 (45 %) admitted for symptom control, and 35/107 (33 %) of patients admitted for cancer treatment or investigation, had code status documentation within 48 h.NUR 390: Bioethical Issue Paper Grading Criteria

After excluding the 34 patients who were admitted for palliative planning, and adjusting for other reason for admis- sion and marital status, patients with code status documenta- tion ≤48 h from admission had significantly fewer code blues, CPR attempts, and ICU consultations and admis- sions (Table 4). All 20 CPR attempts in the group that did not have code status documented within 48 h after admission were unsuccessful (for 18 attempts the patient was not revived; for 2, the patient survived less than 24 h), whereas the 2 in the ≤48 group (both “full code” documentations) were successful in reviving the patient. In both of these cases with successful CPR attempts, the patient’s code status was changed to DNR upon transfer back to the oncology ward (3 to 11 days post- CPR), and cancer-related death occurred within 3 weeks of initial resuscitation. NUR 390: Bioethical Issue Paper Grading Criteria

We repeated the analyses discounting the patients who died within 48 h of admission, and the results remained significant for all outcomes (p <0.05).

Discussion

Current recommendations for patients with advanced cancer are to discuss and document goals and preferences for care within 48 h of admission to hospital [10]. This 48-h window allows for appropriate code status documentation, while leav- ing time for the oncology team to gather information that may aid in the discussion, including the input of the primary treating oncologist. The results of our study support documen- tation of code status within this time frame. NUR 390: Bioethical Issue Paper Grading Criteriat

The large majority of patients who died on the inpatient oncology service during the 5-year study period had incurable cancer. Although code status was documented in more than

90 % before they died, documentation was completed within 48 h of admission in only 45 % of the overall sample, and did not take place consistently even in patients admitted for pal- liative planning. In those patients who had code status docu- mented within 48 h, there was less aggressive end-of-life care for all measured outcomes, even after adjusting for confound- ing variables of reason for admission and marital status. NUR 390: Bioethical Issue Paper Grading Criteria

Other studies have demonstrated the effect of end-of-life discussions on less aggressive medical care near death, dem- onstrating lower rates of ventilation, resuscitation, and ICU admissions [14, 15]. In a recent study of patients with ad- vanced lung or colorectal cancer, those who had end-of-life discussions before the last 30 days of life were less likely to receive aggressive measures at the end-of-life, including che- motherapy and acute hospital-based care [16]. NUR 390: Bioethical Issue Paper Grading Criteria. As well, in a retrospective study of 118 terminally ill oncology inpatients, earlier recognition that the patient was dying was associated with timelier establishment of goals of care, including earlier DNR code status documentation and discontinuation of anti- cancer therapy [13]. Our study adds to this body of literature encouraging appropriate discussion of end-of-life planning, by specifically supporting the documentation of code status in patients with advanced cancer within 48 h of hospital admission. NUR 390: Bioethical Issue Paper Grading Criteria

It is increasingly accepted that aggressive end-of-life care for patients with advanced cancer is not only cost-ineffective but also represents poor quality care [17–20]. CPR is a highly costly intervention [21], and the very small chance that pa- tients with advanced cancer have of surviving to discharge after a cardiopulmonary arrest [9] approaches zero when the arrest is anticipated [8]. NUR 390: Bioethical Issue Paper Grading Criteria. In the current study, 11 % of those who had their code status documented greater than 48 h after admission died after an unsuccessful CPR attempt, compared to none in the ≤48 h group. This is an unpleasant way to die and can have adverse effects for all involved. Aggressive care in the final week of life has been associated with poor patient quality of life, as well as with a higher risk ofmajor depression in bereaved caregivers [15]. Unsuccessful CPR attempts are also highly disturbing for those performing it; generally, phy- sicians in training [22]. NUR 390: Bioethical Issue Paper Grading Criteria

Code status discussions are complex and challenging, and physicians may feel reluctant to discuss such a sensi- tive topic [23]. Patients generally have a poor understand- ing of CPR and its low success rate in patients with advanced illnesses [24] and this is important to convey in a clear and sensitive manner [25]. Evidence suggests that patients are receptive to discussions about code status and other advance directives on admission to hospital [26, 27], and that code status discussions at admission do not affect patient or surrogate satisfaction with care [28]. Indeed, having a DNR order at the time of death has been associ- ated with higher quality of end-of-life care ratings by family members [29]. Ideally, these discussions take place

378 Support Care Cancer (2014) 22:375–381 NUR 390: Bioethical Issue Paper Grading Criteria

Table 3 Patient characteristics according to timing of code status

Characteristic All patients (n =336) Code status documented within 48 h of admission Univariable

Numbers (%) Yes (n =151) No (n =185) OR (95 % CI) p Value

Age (years)

median (range) 61 (23–94) 63 (23–87) 61 (27–94) 1.00 (0.98-1.01) 0.71

Sex

Female 186 (55) 81 (54) 105 (57) 0.88 (0.57–1.36) 0.57

Male 150 (45) 70 (46) 80 (43) –

Marital status

Married/common law 229 (69) 112 (76) 117 (64) 1.76 (1.08–2.84) 0.02

Not marrieda 102 (31) 36 (24) 66 (36) –

Unknown 5 3 2 –

Interpreter needed

Yes 37 (11) 20 (87) 17 (9) 1.51 (0.76–3.00) 0.24

No 299 (89) 131 (13) 168 (91) –

Religious affiliation

Yes 136 (41) 65 (43) 71 (38) 1.21 (0.78–1.88) 0.39

No 200 (59) 86 (57) 114 (62) –

Primary cancer site 0.16

Gastrointestinal 74 (22) 32 (21) 42 (23) 1.27 (0.62–2.58)

Lung 64 (19) 37 (25) 27 (15) 2.28 (1.10–4.76) NUR 390: Bioethical Issue Paper Grading Criteria

Gynecological 55 (16) 22 (15) 33 (18) 14.11 (0.52–2.39)

Breast 30 (9) 13 (9) 17 (9) 1.28 (0.52–3.14)

Genitourinary 30 (9) 17 (11) 13 (7) 2.18 (0.88–5.37)

Head and neck 27 (8) 9 (6) 18 (10) 0.83 (0.32–2.19)

Other 56 (17) 21 (14) 35 (19) –

Stage at admission

Stage IV 295 (88) 134 (89) 161 (87) 1.18 (0.61–2.28) 0.63

Other 41 (12) 17 (11) 24 (13) –

Cause of death

Cancer 323 (96) 147 (97) 176 (95) 1.88 (0.57–6.23) 0.30

Other 13 (4) 4(3) 9 (5) –

Admitting service

Medical oncology 249 (74) 119 (79) 130 (70) 1.57 (0.95–2.60) 0.08

Radiation oncology 87 (26) 32 (21) 55 (30) –

Admitting physician

Staff/hospitalist 155 (46) 68 (45) 87 (47) 0.92 (0.60–1.42) 0.72

Otherb 181 (54) 83 (55) 98 (53) –

Reason for admission <0.0001

Palliative planning 34 (10) 29 (19) 5 (3) 7.20 (2.67–19.37)

Cancer treatment or investigation 107 (32) 35 (23) 72 (39) 0.60 (0.37–0.99)

Symptom Control 195 (58) 87 (58) 108 (58) –

Time from diagnosis to admission 0.27

>1 year 103 (31) 53 (35) 50 (27) 1.54 (0.88–2.69)

>1 month to ≤1 year 135 (40) 58 (38) 77 (42) 1.09 (0.64–1.85) ≤1 month 98 (29) 40 (26) 58 (31) –

a Not married includes single, separated, divorced or widowed bOther includes fellows, residents and unknown

Support Care Cancer (2014) 22:375–381 379 NUR 390: Bioethical Issue Paper Grading Criteria

with the primary oncologist prior to admission as a part of advance care planning, in which case, the status just needs to be reverified and documented on admission to a hospital. NUR 390: Bioethical Issue Paper Grading Criteria

Patients and family members may be reassured by knowing that a DNR status does not preclude other active treatments directed either at the cancer itself or at complications such as infections [30]. As well, not all code status discussions necessarily result in a DNR order. Interest- ingly, in the current study, all those patients who initially had “full code” status documentation (whether before or after 48 h from admission) either had successful codes (n =2), or had their code status subsequently changed to DNR before a code blue was called (n =10). This may indicate that early code status discussions resulting in full code orders may also allow patients and substitute-decision makers the time to consider less aggressive end-of life care and reconsider DNR orders. NUR 390: Bioethical Issue Paper Grading Criteria

In the present study, only 33 % of those admitted for cancer treatment or investigation had documentation of code status within 48 h. However, the large majority of the latter group of patients had incurable disease, and the treatments offered were thus of palliative intent. Patients undergoing such treatments may have misconceptions re- garding the purpose of palliative treatment or of the poor prognosis associated with their disease [31]. Of note, there was an increased rate of DNR discussions ≤48 h from admission in patients with a spouse/partner, which is sim- ilar to results of another study documenting lower rates of CPR in married individuals [32]. These results may reflect an opportunity for discussions about advance directives amongst partners and/or the desire of patients not to place the burden of end-of-life decisions on their spouse in the case of incompetence to make decisions. NUR 390: Bioethical Issue Paper Grading Criteria

Our study has strengths and limitations. Unlike other studies [4, 5, 13], we used as our main variable timing of any code status documentation, including “full code” as well as DNR. We felt that what was important was the discussion regarding code status and the documentation of this decision, regardless of whether it was full code or DNR. It is possible that additional code status discus- sions took place, for which the outcome was not docu- mented as an order, particularly as a full code is implied unless a DNR order is written. Other limitations of this study include its retrospective nature and the collection of data from a single tertiary cancer care center. NUR 390: Bioethical Issue Paper Grading Criteria. The cohort of patients examined all died on the oncology wards; thus we do not have information on patients who were admitted and survived, or who were admitted and subsequently died in a different setting after being transferred. In particular, this likely resulted in an under- estimation of ICU admissions, because patients who were transferred to the ICU and died there were not included in the study. NUR 390: Bioethical Issue Paper Grading Criteria

Routine discussion and documentation of code status on admission in all patients with advanced cancer can avoid misunderstandings regarding patient wishes and prevent aggressive end-of-life care. It has been recom- mended that all healthcare institutions should have a “do not attempt resuscitation” policy [33]. Many health care facilities, including our own, have established policies to guide clinical-decision making with respect to wishes regarding CPR as a treatment and establishing limits when CPR is deemed almost certainly of no benefit to a patient. The results of this study provide support for the inclusion within such policies of guidelines for routine docu- mentation of code status within 48 h. NUR 390: Bioethical Issue Paper Grading Criteria

Table 4 Timing of code status and end-of-life outcomes

Code status ≤48 h OR (95 % CI) Exact p Value AOR (95 % CI) Exact p Value

Yes (n =151) No (n =185)

Code blue 3 (2 %) 28 (15 %) 0.11 (0.03–0.38) 0.0004 0.12 (0.02–0.43) 0.0001

CPR attempt 2 (1 %) 20 (11 %) 0.11 (0.03–0.48) 0.0005 0.12 (0.01–0.51) 0.001

Unsuccessful CPR attempt 0 (0 %) 20 (11 %) NE NE NE NE

ICU consultation 13 (9 %) 56 (30 %) 0.22 (0.11–0.42) <0.0001 0.19 (0.08–0.40) <0.0001

ICU admission 3 (2 %) 11 (5 %) 0.32 (0.09–1.17) 0.10 0.18 (0.02–0.85) 0.03

AOR adjusted odds ratio (adjusting for reason for admission and marital status), CPR cardio-pulmonary resuscitation, ICU intensive care unit, NE not evaluable (due to zero value for outcome with code status ≤48 h)

380 Support Care Cancer (2014) 22:375–381 NUR 390: Bioethical Issue Paper Grading Criteria

Disclosures There are no financial disclosures from any of the authors. This research was funded by the Canadian Cancer Society (grant #700862; CZ), the Bluma Appel Research Fund and the Ontario Ministry of Health and Long Term Care. Dr. Zimmermann is supported by the Rose Chair in Supportive Care, Faculty of Medicine, University of Toronto.NUR 390: Bioethical Issue Paper Grading Criteriat

References

1. Kouwenhoven WB, Jude JR, Knickerbocker GG (1960) Closed- chest cardiac massage. JAMA 173:1064–1067

2. Loertscher L, Reed DA, Bannon MP, Mueller PS (2010) Cardiopul- monary resuscitation and do-not-resuscitate orders: a guide for clini- cians. Am J Med 123(1):4–9

3. Fairchild A, Kelly KL, Balogh A (2005) In pursuit of an artful death: discussion of resuscitation status on an inpatient radiation oncology service. Support Care Cancer 13(10):842–849

4. Middlewood S, Gardner G, Gardner A (2001) Dying in hospital: medical failure or natural outcome? J Pain Symptom Manage 22(6): 1035–1041

5. Becker G, Sarhatlic R, OlschewskiM,Xander C,MommF, BlumHE (2007) End-of-life care in hospital: current practice and potentials for improvement. J Pain Symptom Manage 33(6):711–719

6. Ebell MH, Afonso AM (2011) Pre-arrest predictors of failure to survive after in-hospital cardiopulmonary resuscitation: a meta- analysis. Fam Pract 28(5):505–515 NUR 390: Bioethical Issue Paper Grading Criteria

7. Peberdy MA, Kaye W, Ornato JP, Larkin GL, Nadkarni V, Mancini ME et al (2003) Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the National Registry of Cardiopulmonary Resuscitation. Resuscitation 58(3):297–308

8. Ewer MS, Kish SK, Martin CG, Price KJ, Feeley TW (2001) Char- acteristics of cardiac arrest in cancer patients as a predictor of survival after cardiopulmonary resuscitation. Cancer 92(7):1905–1912

9. Reisfield GM, Wallace SK, Munsell MF, Webb FJ, Alvarez ER, Wilson GR (2006) Survival in cancer patients undergoing in- hospital cardiopulmonary resuscitation: a meta-analysis. Resuscita- tion 71(2):152–160

10. Walling A, Lorenz KA, Dy SM, Naeim A, Sanati H, Asch SM et al (2008) Evidence-based recommendations for information and care planning in cancer care. J Clin Oncol 26(23):3896–3902

11. Peppercorn JM, Smith TJ, Helft PR, Debono DJ, Berry SR, Wollins DS et al (2011) American Society of Clinical Oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol 29(6):755–760

12. Library of Congress. Bill Text, 101st Congress (1989–1990), H.R.4449.IH. Patient Self Determination Act of 1990 . http://thomas. loc.gov/cgi-bin/query/z?c101:H.R.4449.IH. Accessed 20 May 2013

13. Hui D, Con A, Christie G, Hawley PH (2009) Goals of care and end- of-life decisionmaking for hospitalized patients at a Canadian tertiary care cancer center. J Pain Symptom Manage 38(6):871–881

14. Bradley EH, Hallemeier AG, Fried TR, Johnson-Hurzeler R, Cherlin EJ, Kasl SV et al (2001) Documentation of discussions about prog- nosis with terminally ill patients. Am J Med 111(3):218–223 NUR 390: Bioethical Issue Paper Grading Criteria

15. Wright AA, Zhang B, Ray A, Mack JW, Trice E, Balboni T et al (2008) Associations between end-of-life discussions, patient mental health, medical care near death, and caregiver bereavement adjust- ment. JAMA 300(14):1665–1673

16. Mack JW, Cronin A, Keating NL, Taback N, Huskamp HA, Malin JL et al (2012) Associations between end-of-life discussion characteristics

and care received near death: a prospective cohort study. J Clin Oncol 30(35):4387–4395

17. Earle CC, Park ER, Lai B, Weeks JC, Ayanian JZ, Block S (2003) Identifying potential indicators of the quality of end-of-life cancer care from administrative data. J Clin Oncol 21(6):1133–1138

18. Earle CC, LandrumMB, Souza JM, Neville BA, Weeks JC, Ayanian JZ (2008) Aggressiveness of cancer care near the end of life: is it a quality-of-care issue? J Clin Oncol 26(23):3860–3866

19. Grunfeld E, Lethbridge L, Dewar R, Lawson B, Paszat LF, Johnston G et al (2006) Towards using administrative databases to measure population-based indicators of quality of end-of-life care: testing the methodology. Palliat Med 20(8):769–777

20. Barbera L, Paszat L, Chartier C (2006) Indicators of poor quality end- of-life cancer care in Ontario. J Palliat Care 22(1):12–17

21. Lee KH, Angus DC, Abramson NS (1996) Cardiopulmonary resus- citation: what cost to cheat death? Crit Care Med 24(12):2046–2052 NUR 390: Bioethical Issue Paper Grading Criteria

22. Menezes BF, Morgan R (2008) Attitudes of doctors in training to cardiopulmonary resuscitation. Clin Med 8(2):149–151 NUR 390 : Ethical Dilemma in the Nursing Field Assignment

23. Sulmasy DP, Sood JR, Ury WA (2008) Physicians’ confidence in discussing do not resuscitate orders with patients and surrogates. J Med Ethics 34(2):96–101

24. Heyland DK, Frank C, Groll D, Pichora D, Dodek P, Rocker G et al (2006) Understanding cardiopulmonary resuscitation decision mak- ing: perspectives of seriously ill hospitalized patients and family members. Chest 130(2):419–428

25. Volandes AE, Paasche-Orlow MK, Mitchell SL, El Jawahri A, Davis AD, Barry MJ et al (2013) Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer. J Clin Oncol 31(3):380–386

26. Reilly BM, Magnussen CR, Ross J, Ash J, Papa L, Wagner M (1994) Can we talk? Inpatient discussions about advance directives in a community hospital. Attending physicians’ attitudes, their inpatients’ wishes, and reported experience. Arch Intern Med 154(20):2299– 2308

27. Reilly BM,Wagner M, Ross J, Magnussen CR, Papa L, Ash J (1995) Promoting completion of health care proxies following hospitaliza- tion. A randomized controlled trial in a community hospital. Arch Intern Med 155(20):2202–2206

28. Anderson WG, Pantilat SZ, Meltzer D, Schnipper J, Kaboli P, Wetterneck TB et al (2011) Code status discussions at hospital admission are not associated with patient and surrogate satisfaction with hospital care: results from the multicenter hospitalist study. Am J Hosp Palliat Care 28(2):102–108

29. Finlay E, Shreve S, Casarett D (2008) Nationwide veterans affairs quality measure for cancer: the family assessment of treatment at end of life. J Clin Oncol 26(23):3838–3844 NUR 390: Bioethical Issue Paper Grading Criteria

30. Smith CB, Bunch OL (2008) Do not resuscitate does not mean do not treat: how palliative care and other modalities can help facilitate communication about goals of care in advanced illness. Mt Sinai J Med 75(5):460–465

31. Guo Y, Palmer JL, Bianty J, Konzen B, Shin K, Bruera E (2010) Advance directives and do-not-resuscitate orders in patients with cancer with metastatic spinal cord compression: advanced care plan- ning implications. J Palliat Med 13(5):513–517 NUR 390: Bioethical Issue Paper Grading Criteria

32. Chen JS, Wang HM, Wu SC, Liu TW, Hung YN, Tang ST (2009) A population-based study on the prevalence and determinants of car- diopulmonary resuscitation in the last month of life for Taiwanese cancer decedents, 2001–2006. Resuscitation 80(12):1388–1393

33. Deakin CD (2005) New standards for cardiopulmonary resuscitation. BMJ 330(7493):685–686

Support Care Cancer (2014) 22:375–381 381

Copyright of Supportive Care in Cancer is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. NUR 390: Bioethical Issue Paper Grading Criteria

ORI GIN AL PA PER

Religious, Ethical and Legal Considerations in End-of- Life Issues: Fundamental Requisites for Medical Decision Making

Puteri Nemie Jahn Kassim • Fadhlina Alias

Published online: 10 January 2015 � Springer Science+Business Media New York 2015

Abstract Religion and spirituality have always played a major and intervening role in a person’s life and health matters. With the influential development of patient autonomy and the

right to self-determination, a patient’s religious affiliation constitutes a key component in

medical decision making. NUR 390: Bioethical Issue Paper Grading Criteria. This is particularly pertinent in issues involving end-of-life deci-

sions such as withdrawing and withholding treatment, medical futility, nutritional feeding

and do-not-resuscitate orders. These issues affect not only the patient’s values and beliefs, but

also the family unit and members of the medical profession. The law also plays an intervening

role in resolving conflicts between the sanctity of life and quality of life that are very much

pronounced in this aspect of healthcare. Thus, the medical profession in dealing with the

inherent ethical and legal dilemmas needs to be sensitive not only to patients’ varying

religious beliefs and cultural values, but also to the developing legal and ethical standards as

well. There is a need for the medical profession to be guided on the ethical obligations, legal

demands and religious expectations prior to handling difficult end-of-life decisions. The

development of comprehensive ethical codes in congruence with developing legal standards

may offer clear guidance to the medical profession in making sound medical decisions.

Keywords End-of-life decisions � Religious considerations � Ethical dilemmas � Legal standards

Introduction

Technological and pharmacological advances in medicine have created more challenges to

healthcare professionals as modern medical interventions progress to increase life

P. N. Jahn Kassim (&) Civil Law Department, Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, 53100 Kuala Lumpur, Malaysia e-mail: puterinemie@hotmail.com

F. Alias Ahmad Ibrahim Kulliyyah of Laws, International Islamic University Malaysia, 53100 Kuala Lumpur, Malaysia

123 NUR 390: Bioethical Issue Paper Grading Criteria

J Relig Health (2016) 55:119–134 DOI 10.1007/s10943-014-9995-z

expectancy of terminally ill patients. These life-prolonging measures have made end-of-

life care an emerging aspect in the medical field. Decisions at the end of life are no longer

confined to clinical assessments as to what would be in the best interests of the patient from

a purely medical perspective, but involve due consideration of a patient’s religious beliefs,

customs and values, which ultimately have significant influence on a patient’s response to

illness, suffering and dying. NUR 390: Bioethical Issue Paper Grading Criteria. Furthermore, the decision-making process also affects

healthcare providers, particularly if the doctor and patient come from diverse cultural

backgrounds and adhere to different sets of values. The conflicting ethical views and

developing legal standards in this area on matters concerning the sanctity and quality of

life, patient autonomy and medical paternalism have also made end-of-life decisions an on-

going debate (Agarwal and Murinson 2012; Billings and Krakauer 2011; Cantor 2005;

Chin 2002; da Rocha 2009; Huxtable 2002; Kuhse 1981; Orentlicher 1998; Rabiu and

Sugand 2014). In any event, all affected parties carry with them their own individual life

experiences, values and beliefs to the decision-making process; accordingly, the event of

death itself, the manner in which it takes place, and the patient’s quality of life are

significant matters that have spiritual and psychological consequences for each of them.

The Importance of Ethics, Religion and Law as Guidance for Medical Decision Making

Ethics is classified as a sub-branch of applied philosophy that is intrinsically related to

morality (Padela 2007). NUR 390: Bioethical Issue Paper Grading Criteria. The correlation between ethics and morality is that morality refers

to social norms that distinguish from right to wrong, while ethics describes moral conduct

based on the character and principles in each profession (Elsayed and Ahmed 2009).

Medical ethics is a subdivision of ethics that is concerned with moral principles as they

relate to biomedical science in the clinical and investigational arenas (Padela 2007).

Ethical principles are essential in helping to guide medical judgements that need to be

made and should be intrinsically linked to the application of clinical skills and knowledge,

which are used for delivering what is in the best interests of the patient (Tallon 2012).

Accordingly, medicine and morality are thus very much interrelated, as the primary

function of medicine is not only ‘‘to cure illness…but to cure people of their illnesses’’ (Steinberg 2003). The importance of observing medical ethics can be outlined as follows: NUR 390: Bioethical Issue Paper Grading Criteria

(1) ethical standards promote the aim of medical care; (2) medical care is built on the

communication, trust and respect between the medical team on the one side, and the patient

and/or family on the other side; (3) ethical standards help generate public support for

healthcare; (4) public awareness and support for healthcare will promote ethical conduct by

healthcare providers in the performance of their duties; and (5) ethical standards promote

moral and social values and facilitate cooperation and collaborative work between different

medical disciplines, leading to a healthy healthcare environment (Elsayed and Ahmed

2009). All existing medical codes of ethics directly and indirectly incorporate into their

provisions the fundamental principles which form the ethical basis of medical care, i.e.

autonomy, paternalism, non-maleficence, beneficence and justice.

In recognition of the fact that culture and its components of religion and spirituality

constitute major social factors that greatly influence the provision of medical care, espe-

cially at the end of life, some countries have also expressly included these components in

their ethical codes. For example, the Good Medical Practice: a code of conduct for doctors

in Australia issued by the Medical Board of Australia (‘‘GMC’’) contains provisions on

‘‘Culturally Safe and Sensitive Practice’’ which state that ‘‘good medical practice involves

120 J Relig Health (2016) 55:119–134

123 NUR 390: Bioethical Issue Paper Grading Criteria

genuine efforts to understand the cultural needs and contexts of different patients to obtain

good health outcomes’’ which includes: (1) having knowledge of, respect for and sensi-

tivity towards the cultural needs of the community that one serves, including those of

indigenous Australians; (2) acknowledging the social, economic, cultural and behavioural

factors influencing health, both at individual and population levels; and (3) understanding

that one’s own culture and beliefs influence one’s interactions with patients (Medical

Board of Australia n.d.; Medical Council of New Zealand 2013). Furthermore, in Clause

3.12 of the GMC, which deals with end-of-life care, respect and support for the values and

wishes of the patient and family members are emphasised, including ‘‘different cultural

practices related to death and dying’’ (Medical Board of Australia n.d.). NUR 390: Bioethical Issue Paper Grading Criteria

Cultural competence, i.e. the acquisition of the knowledge and skills that enhance the

management of cultural issues in the clinical environment requires skilled verbal and non-

verbal communication as a means of appreciating differences (Carey and Cosgrove 2006).

Better healthcare especially at the end of life can only be achieved if these factors are given

due consideration as medicine does not merely deal with elements of pure science, but also

major and intrinsic humanistic and ethical components (Steinberg 2003). In Part 3 of the

End of Life Care Strategy issued by the Department of Health in the UK (UK Department

of Health 2008), guidelines are provided to address the spiritual needs of patients nearing

the end of life. This is complemented by the NHS Chaplaincy (UK Department of Health

2003), which acts as a guidance to those involved in the provision of chaplaincy-spiritual

services. It is submitted however that the content of the End of Life Care Strategy and NHS

Chaplaincy, while respecting and recognising the importance of religious and spiritual

considerations in end-of-life care, is not intended to specifically provide an understanding

of the different values and beliefs on end-of-life issues. It is noteworthy that the

Queensland Health Multicultural Services in collaboration with the Islamic Council of

Queensland has published a series of handbooks for healthcare providers in attending to

Muslim, Hindu and Sikh patients, respectively (Queensland Health and Islamic Council of

Queensland n.d., 2010, 2011). NUR 390: Bioethical Issue Paper Grading Criteria. Specific areas covered in the handbooks include religious

approaches to end-of-life issues, pain management and the concept of death and dying.

These are intended to support healthcare providers by building their knowledge of the

diverse needs of their patients, noting that ‘‘those who display cross-cultural capabilities in

their work use self-reflection, cultural understanding, contextual understanding, commu-

nication and collaboration to provide culturally appropriate, responsive and safe health

care’’ (Queensland Health and Islamic Council of Queensland n.d., 2010, 2011).

In addition to the above, an integrated effort to develop a codified religious-based

system of ethical conduct can also be seen in the form of the Islamic Code of Medical

Ethics (First International Conference on Islamic Medicine 1981) (‘‘Islamic Code’’), which

was drawn up and adopted at the First International Conference on Islamic Medicine in

1981. The Islamic Code aims to provide a guideline to Muslim doctors in understanding

the tenets of Islam, which are relevant to the performance of their duties. The Islamic Code

cites authorities from the Shari‘ah and provides the Islamic perspective on an array of

subject matters concerning medical care, including end-of-life issues such as the preser-

vation of life, the refusal of a patient to a prescribed plan of treatment, medical inter-

ventions and futile therapy. In addition, the duty to respect the autonomy of the patient, as

well as the obligation to ensure that harm is prevented (non-maleficence), and medical

decisions are made to the benefit and best interests of the patient (beneficence), are inherent

ethical values in the Islamic Code. The extent of application of the Islamic Code in

healthcare policies and legislation of countries populated by Muslims, however, are of

varying degrees from one country to the next. NUR 390: Bioethical Issue Paper Grading Criteria

J Relig Health (2016) 55:119–134 121 NUR 390: Bioethical Issue Paper Grading Criteria

BUY A PLAGIARISM-FREE PAPER HERE

123

In general, the majority of Arab countries emphasise the importance of healthcare

professionals to respect human dignity, provide the best care available to patients and their

families, as well as protecting their rights, safety and confidentiality (UNESCO Cairo

Office 2011). Countries such as Jordan, Libya and Indonesia have gone further in their

efforts to take steps to include guidelines pertaining to certain end-of-life decisions in their

regulatory framework (Majelis Kehormatan Etik Kedokteran Indonesia 2001; UNESCO

Cairo Office 2011), while in other countries such as Malaysia and the UAE, the extent of

application of Islamic principles in the same area is uncertain, as specific provisions on the

subject matter have yet to be incorporated in their respective laws or ethical codes

(Malaysian Medical Association 2002; UNESCO Cairo Office 2011). NUR 390: Bioethical Issue Paper Grading Criteria

The intervention of law in the area of medicine has been regarded as pivotal, particu-

larly in offering clear guidance in issues that raise ethical, philosophical and religious

dilemmas. The law has been seen as a means of controlling the medical profession in the

interests of the community as a whole. As advocated by Lord Hoffman in Airedale NHS

Trust v Bland (‘‘Airedale NHS Trust v. Bland’’ 1993), ‘‘…medical ethics [is] to be formed by the law rather than the reverse’’ (‘‘Airedale NHS Trust v. Bland’’ 1993). However, legal

intervention in itself may cause problems particularly when the courts may find themselves

drawn in to act as mediators in complex and frequently distressing clinical matters. In any

event, judges have to make decisions to protect public policy and do justice to both the

patient and the doctor.

The judicial courts in Malaysia have yet to decide on issues involving end-of-life

decisions; thus, at the moment, such matters are considered to be purely medical decisions

(Kassim and Adeniyi 2010; Talib 2002). As the law in this area has yet to reach its fullest

extent, the developments in countries such as the UK and the USA have been able to shed

light on how conflicting ethical principles are resolved by the courts and the application of

different tests in their decisions. Accordingly, their experience would provide invaluable

lessons for Malaysia to develop holistic ethical codes that are in congruence with devel-

oping legal standards. This is because by virtue of section 3 of the Civil Law Act 1956, due

to the lacunae in Malaysian law on end-of-life decisions, English common law and the

rules of equity would be applicable as a source of reference for the courts.

The Scope of End-of-Life Care

End-of-life care refers to the health and social care system required to address the physical,

social, spiritual and emotional needs of patients who are in the final stages of their lives as

well as those who are afflicted with terminal illnesses (Colello et al. 2011; Tallon 2012).

From the healthcare perspective, end-of-life care encompasses both palliative care and

hospice care, which aim to provide a comfortable environment to restore and improve

patients’ quality of life as far as it is practically possible (Centre for Bioethics 2005; Chater

and Tsai 2008; Tallon 2012). The World Health Organization defines palliative care as ‘‘an

approach that improves the quality of life of patients and their families facing the problem

associated with life-threatening illness, through the prevention and relief of suffering by

means of early identification and impeccable assessment and treatment of pain and other

problems, physical, psychosocial and spiritual’’ (World Health Organisation n.d.).

Although both palliative care and hospice care share the same objectives, these two

areas should not be confused with one another. Palliative care focuses on reducing the

severity of disease symptoms for patients who are seriously ill, and can be delivered along

with curative treatment at any time during the course of the patient’s illness (Centre for

122 J Relig Health (2016) 55:119–134

123 NUR 390: Bioethical Issue Paper Grading Criteria

Bioethics 2005; Colello et al. 2011). In addition, palliative care is not restricted to patients

near the end of life and can be used in both acute and long-term settings (Centre for

Bioethics 2005). Hospice care on the other hand is focused on terminally ill patients, who

no longer seek curative medical treatment, and is generally offered when the patient is

expected to live for 6 months or less (Colello et al. 2011). A salient similarity between

palliative care and hospice care is that both involve the mobilisation of an interdisciplinary

team of professionals comprising doctors, nurses, social workers and psychologists, with

the assistance of chaplains, nutritionists, pharmacists and others (Centre for Bioethics

2005; Colello et al. 2011). NUR 390: Bioethical Issue Paper Grading Criteria

The Ethical Considerations in End-of-Life Care

Conflicting ethical values between healthcare providers and patients may impede the

decision-making process in end-of-life care (Carey and Cosgrove 2006; Chater and Tsai

2008; Mazanec and Tyler 2003). On the part of the healthcare provider, respecting the

patient’s autonomy in the decision-making process may at times be inconsistent with the

performance of their ethical obligations of beneficence and non-maleficence. Ethical

challenges are further compounded in cases where the patient is incapable of interaction

and deciding for himself, whereby family members would stand in as proxy to decide what

would have likely been the wishes of the patient pertaining to a certain course of action.

The ethical considerations in end-of-life care which have raised ethical dilemmas can be

looked at from three aspects: NUR 390: Bioethical Issue Paper Grading Criteria

Withholding and Withdrawal of Medical Interventions

Medical interventions such as resuscitation, ventilators and the use of antibiotics in cases of

infection may operate to save and prolong the life of a terminally ill patient. However, such

treatments may run counter to the patient’s wishes who may request that the same be

withdrawn or refuse them altogether. For example, some patients may view cardiopul-

monary resuscitation as a death-delaying act, which contradicts with their values and

beliefs that one should not alter the course of nature (Markwell 2005; Mazanec and Tyler

2003; Sachedina 2005). In cases where the condition of the patient necessitates respiratory

therapy, some patients and family members may view it as a non-beneficial treatment

which only serves to impede in what they believe should be the natural process of dying

(Centre for Bioethics 2005). Consequently, such patients or their family members may

seek a do-not-resuscitate order from their doctor. In such circumstances, doctors are

confronted with ethical dilemmas on whether to adhere to the patient’s and family

members’ wishes or to decide on what is the best course of action for the patient. For

example, if the decision to withdraw treatment is carried out and death is thereby hastened,

would this action violate the ethical principal of non-maleficence which demands that

actions taken must prevent harm to the patient? Nevertheless, it has also been argued that it

is permissible to withhold or withdraw treatment and allow the disease process to progress

to a natural death for the patient (Kinsella and Booth 2007). However, any decision to

withhold or withdraw treatment should be based upon the expectation that the patient can

no longer benefit from that treatment, it is medically futile and the doctor’s intention when

doing so must be to relieve the patient of the burdens associated with that treatment

(Kinsella and Booth 2007). NUR 390: Bioethical Issue Paper Grading Criteria

J Relig Health (2016) 55:119–134 123

123

Withdrawing medical treatment has always been seen as acceptable as there is a clear

distinction between positive acts and omissions. According to the acts–omissions dis-

tinction, ‘‘in certain contexts, failure to perform an act, with foreseen bad consequences of

that failure, is morally less bad than to perform a different act which has the identical

foreseen consequences. It is worse to kill someone than to let them die’’ (Glover 1977).

Thus, acting to kill a patient even for good reasons may seem wrong, whereas omitting to

act by withholding life-saving treatment may seem right in certain compelling circum-

stances. It follows that permitting an illness to progress naturally, as opposed to making

something happen by acting intentionally, appears to be more acceptable legally and

ethically (Glover 1977; McLachlan 2008). NUR 390: Bioethical Issue Paper Grading Criteria

Medical Futility

Medical futility is described as an intervention that will not be able to reach the intended

goal of the intervention (Cavalieri 2001). This usually occurs during assessments on

whether to forego or withdraw life-sustaining treatments (Centre for Bioethics 2005). The

determination of medical futility raises ethical concerns, particularly, on the reasons for

considering the treatment as futile. The fact that such decision rests solely in the hands of

the healthcare providers may lead to possibilities of the discretion being exercised arbi-

trarily. For instance, medical treatment may be discontinued not only because it no longer

benefits the patient, but such continuation may be considered futile in order to save cost

(Centre for Bioethics 2005; Zahedi et al. 2007). NUR 390: Bioethical Issue Paper Grading Criteria. Further, discontinuation of life-sustaining

treatments particularly artificial nutrition and hydration causes a great deal of ethical

tension and emotional burden, especially to the family members of a dying patient (al-

Shahri and Al-Khenaizan 2005; Bülow et al. 2008). Food and water are considered to be

the basic sustenance of human survival, and denying them to a patient may be viewed by

family members as starving their loved one to death (Noah 2006). NUR 390: Bioethical Issue Paper Grading Criteria

However, medical opinions vary on this issue. Some argue that continuing artificial

nutrition and hydration prevents suffering to a certain extent, while others claim that it is an

unnecessary burden with no clear symptom benefit (Olsen et al. 2010). There are also those

that hold the view that nutrition and hydration treatments are palliative care that fulfil a

basic human need and should not be denied at the end of life (Centre for Bioethics 2005;

Zahedi et al. 2007). However, in some circumstances, the continuous supply of nutrition

and hydration may not be beneficial to a dying patient and may in fact be distressing as the

patient’s gastrointestinal function deteriorates (Kahn et al. 2003). It is therefore suggested

that the principle of proportionality be applied with regard to life-sustaining treatments at

end-of-life care. Nutrition and hydration may thus be ethically withheld or discontinued if

the dying patient suffers burdens that outweigh the life-prolonging benefit, irrespective of

whether death will be the result (Centre for Bioethics 2005). NUR 390: Bioethical Issue Paper Grading Criteria

Pain Management/Terminal Sedation

Terminal sedation is used in end-of-life care to relieve severe suffering. It refers to the use

of medications to induce decreased or absent consciousness to the extent that the patient

will no longer feel pain, air hunger or other forms of distress (Kahn et al. 2003; Olsen et al.

2010). In the practice of euthanasia, a lethal injection is administered in an amount that is

certain to bring about and ultimately intended to cause the death of the patient, while

terminal sedation differs from euthanasia in that the dose of medication is maintained

rather than increased once sedation is achieved; the intent being not to hasten death but to

124 J Relig Health (2016) 55:119–134

123 NUR 390: Bioethical Issue Paper Grading Criteria

relieve suffering (Kahn et al. 2003). Several ethical concerns have been raised, particularly

on the unknown effect that terminal sedation may have on hastening death, and the

potential abuse of patients who are rendered unconscious during the process, in which right

to autonomy is inhibited (Centre for Bioethics 2005; Kahn et al. 2003).

On the risk of exposing patients to a premature death, two major arguments have been

forwarded to justify and dispel this notion: firstly being the doctrine of double effect. The

double effect doctrine, as applied in medicine, is based on two basic presuppositions: the

doctor’s motivation is to ease suffering, and the treatment must be proportional to the

illness (Malik 2012). The doctrine applies if (1) the desired outcome is judged to be good,

e.g. relief of suffering and is not in itself immoral; (2) the bad outcome, e.g. death of

patient is not intended even if it is foreseen; (3) the good outcome is not achieved by means

of the bad; and (4) the good outcome outweighs the bad (Malik 2012; Markwell 2005).

Secondly, it has been argued that the fear that palliative sedation hastens the dying process

is unfounded since studies have shown that sedatives administered appropriately and

proportionately are able to prolong the chances of survival and improve the quality of life

(Centre for Bioethics 2005; Olsen et al. 2010; Tallon 2012). NUR 390: Bioethical Issue Paper Grading Criteria

Further, the effects of pain management also give rise to ethical dilemmas in terms of

the patient’s cognitive perceptions. Since critically ill patients who are sedated are put

into a state of reduced consciousness, this results in the loss of their social interaction.

This not only hampers their ability to effectively communicate and partake in any further

decision-making process regarding their medical care, but also affects the emotional state

of their loved ones. The idea of being put into a deep sleep may not be well tolerated

with certain patients and their families whose spiritual belief includes that one should

face death with a clear, alert and unclouded state of mind (Keown 2005; Zahedi et al.

2007). NUR 390: Bioethical Issue Paper Grading Criteria

Religious and Spiritual Considerations in End-of-Life Care

In end-of-life care, religion and religious traditions serve two primary functions, namely

the provision of a set of core beliefs about life events and the establishment of an ethical

foundation for clinical decision-making (Daaleman 2000). Spirituality, on the other hand,

revolves around a sense and purpose of life, which may not necessarily involve religious

beliefs and practices. Both religion and spirituality support a person’s sense of security

and belonging, and can be especially significant in end-of-life care, offering the patient a

way to find meaning in dying as in life (Chater and Tsai 2008; Daaleman 2000; Mazanec

and Tyler 2003). Clinical assessments on quality of life involve the examination of how

a patient’s illness and well-being are influenced by the patient’s physical, social and

psychological conditions (Tallon 2012). Thus, the inclusion of measures of religiousness

and spirituality into such framework will enable doctors to have a better understanding

of patients’ beliefs, values, expectations and needs and at the same time facilitate a

dynamic interaction between patients, family members and healthcare professionals.

Religion and spirituality can potentially mediate quality of life by enhancing a patient’s

well-being through social support, stress and coping strategies (Daaleman 2000). The

following paragraphs outline the different ethical considerations relating to end-of-life

care from the Roman Catholic, Jewish, Buddhist and Islamic perspectives in issues such

as sanctity of life, withholding and withdrawing of medical interventions and pain

management. NUR 390: Bioethical Issue Paper Grading Criteria

J Relig Health (2016) 55:119–134 125

123

The Roman Catholic Perspective

There are two basic human values underlining Catholic bioethics, that is, human dignity,

and interconnectedness of every individual to promote a just social order (Markwell 2005;

Padela 2006). The value of human dignity stems from the fundamental belief that life is

sacred as Catholics believe that they are mere stewards of their human bodies and are

therefore accountable to God for the life that they have been given (Markwell 2005; Padela

2006). The value of interconnectedness relates to the relationship and responsibility that

each member of society holds towards one another. These two central elements of Catholic

bioethics influence end-of-life decisions in the following manner. Firstly, the dignity of the

human person, as one who is oriented towards God, requires him or her to make choices for

the good within a free and informed conscience; and secondly, the interaction between

doctor and patient must take the form of a mutual relationship of trust and respect: the

patient trusts that the doctor’s intentions and acts are carried out in good faith, and the

doctor seeks to understand what the patient’s wishes might be (Markwell 2005).

Accordingly, Christianity prioritises the significance of patient autonomy and veracity in

ethical decision-making. The doctor is under an obligation to provide the patient and

family members with the requisite medical information, advice and analysis, but it is

ultimately the patient who will decide which treatment or course of action is best aligned

with his personal values and beliefs. NUR 390 : Ethical Dilemma in the Nursing Field Assignment

In terms of withholding and withdrawing of futile therapy, the Catholic Church allows

this to be done if it is burdensome, dangerous, extraordinary or disproportionate to the

expected outcome (Bülow et al. 2008). Likewise, the same principle is adopted in cases of

pain management or palliative sedation (Bülow et al. 2008; Markwell 2005). While the

issue of pain and suffering is important to Catholic bioethics as an opportunity to induce

personal growth and gain closeness to God, this belief does not imply that pain relief

should be withheld in order that a patient might come to understand the redemptive nature

of suffering (Markwell 2005). Christianity allows for the administration of analgesia and

sedation to alleviate terminal suffering if this does not, by obtunding consciousness, take

away a final chance for repentance (Zahedi et al. 2007). The aforesaid views of the

Catholic Church take cognizance of the applicability of the doctrine of double effect in

bioethical issues (Bülow et al. 2008; Malik 2012; Markwell 2005), and it is considered to

be one of the ‘‘most significant principles proposed by all Catholic medical ethicists’’

(Curran 2008; Malik 2012). Withdrawal of artificial nutrition and hydration from patients

at the end of life and for people in a persistent vegetative state, however, is a controversial

issue in the Christian faith. In 2004, the then Pope John Paul II issued a pronouncement

stating that the cessation of nutrition and hydration resulting in death by starvation

amounted to euthanasia which is strictly forbidden (Bülow et al. 2008; Noah 2006). This

view has been met with criticism by most bioethicists and medical ethics organisations, as

it contradicts much of the Catholic doctrine on matters of end-of-life care (Noah 2006). NUR 390: Bioethical Issue Paper Grading Criteria

The Jewish Perspective

There are three main principles in Jewish medical ethics: life is of utmost value; ageing,

illness, and death are a natural part of life; and improvement of the patient’s quality of life

is a constant commitment (Padela 2006). When applied in the context of end-of-life care,

the Jewish position is that dying is a natural part of life’s journey that should be addressed

with dignity and compassion (Loike et al. 2010) and human beings have both the per-

mission and the obligation to heal (Zahedi et al. 2007). The principle of sanctity of life

126 J Relig Health (2016) 55:119–134

123 NUR 390: Bioethical Issue Paper Grading Criteria

connotes that any decision that may directly or indirectly result in hastening death is

prohibited. However, Jewish law recognises that ‘‘if situations necessitate foregoing certain

rules and regulations for a higher purpose, for example, that of saving life or improving

quality of life or avoiding harm, then one is allowed to do so’’ (Padela 2006). According to

the Jewish legal system or Halacha (which to those of the Jewish faith represents a

comprehensive guide to human life, regulating all aspects of behaviour through assigning

moral values to actions as well as determining sacred law), there are several basic

guidelines related to end of life that distinguish between: (a) acts of omission and acts of

commission; (b) treatments pertaining to the dying process (or illness) and treatments

unrelated directly to the dying process; (c) treatments that are continuous in nature in

which withdrawing of such treatments is considered an act of commission and treatments

that are cyclic in nature in which the withholding of the next cycle of treatment is con-

sidered an act of omission; and (d) patients who are expected to die within 6 months and

those patients with less serious medical conditions (Loike et al. 2010). NUR 390: Bioethical Issue Paper Grading Criteria

Based on the above, on the issue of withholding and withdrawing life-sustaining

treatment, Jewish law allows for such act or omission to be carried out only if such

treatment is of a recurrent nature and provided that the patient has clearly consented to it.

This includes withholding any life-prolonging activities such as intubation, surgery, che-

motherapy or dialysis, even after initiation of the same, because such action is viewed as

omitting the next treatment rather than committing an act of withdrawal (Bülow et al.

2008). If the same constitutes a continuous form of life-sustaining treatment, for example, a

respirator or cardiac pacemaker, then such withdrawal is forbidden. The strictest position

in Judaism restricts permission to withdraw or withhold treatment to cases where doctors

assume that the patient will die within 72 h (Dorff 2005; Zahedi et al. 2007). Patients and

doctors are allowed to withhold or withdraw clinical treatment in cases where the patient is

diagnosed with incurable terminal illness, as long as it is within the patient’s best interests.

Further, the Halacha considers oxygen, food and fluids to be essential components of life

to which every human being is entitled. Accordingly, a dying patient cannot be denied

these basic needs, and withdrawal of artificial nutrition and hydration is not allowed as it is

seen as an act leading to death. However, in cases where the continuance of artificial

nutrition and hydration cause suffering and complications to a patient who is approaching

death, such support may be withdrawn upon the request of the patient or if it can be

ascertained that that was the patient’s wish (Bülow et al. 2008). NUR 390: Bioethical Issue Paper Grading Criteria

Movement’s Committee on Jewish Law and Standards adopted a somewhat dissimilar

view in classifying artificial nutrition and hydration as medicine, permitting their removal

where there is not likely to be any reasonable prospect for recovery at the end of life

(Zahedi et al. 2007). It is suggested that when the decision is made to discontinue artificial

nutrition and hydration, the focus of communication should be on ‘‘what will be done to

demonstrate respect for the patient, rather than on emphasising what will be withdrawn or

withheld’’ (Gillick 2001; Loike et al. 2010). With regard to palliative sedation, there is a

general agreement in Jewish law that this is permitted in spite of the risk that the

administration of such drugs may shorten life, based on the principle of double effect

(Bülow et al. 2008; Loike et al. 2010). NUR 390: Bioethical Issue Paper Grading Criteria

The Buddhist Perspective

The two most fundamental values in Buddhism are compassion and respect for life (Keown

2005). According to the Buddhist faith, life ‘‘begins at conception and ends at death: in the

interval between these events, the individual is entitled to full moral respect, regardless of

J Relig Health (2016) 55:119–134 127

123 NUR 390: Bioethical Issue Paper Grading Criteria

the stage of psycho-physical development attained or the mental capacities enjoyed’’

(Keown 2005). The manner of dying and death is of particular significance in Buddhism;

death with an unclouded mind is believed to lead to a better rebirth in the next life (Keown

2005; Zahedi et al. 2007), and death is an experience that will recur many times. Con-

sequently, this concept has significant bearing on end-of-life issues such as palliative

sedation and pain management, as the concern would be to maintain a mental and sensory

clarity at all times. In terms of artificial nutrition and hydration, the Buddhist perspective

maintains that such life-sustaining support cannot be discontinued, even from patients in a

persistent vegetative state (Keown 2005; Zahedi et al. 2007). This stems from the notion

that in Buddhism, damage to the brain is not differentiated from injury to any other part of

the human body when considering the ethics of treatment (Keown 2005). NUR 390: Bioethical Issue Paper Grading Criteria

The above does not, however, mean that there is a moral obligation in Buddhism that

life must be preserved at all costs. The ethical validity of an act or omission in Buddhism is

measured against the aim or motive of such conduct. If a patient ‘‘makes death his aim’’,

then the refusal of medical care is considered to be an offence; declining further treatment

due to the patient’s acceptance that recovery is grim and death is inevitable, is on the other

hand legitimate (Keown 2005). NUR 390: Bioethical Issue Paper Grading Criteria. men. It follows that proceeding with futile treatment goes against

the teachings of Buddhism; ‘‘to seek to prolong life beyond its natural span by recourse to

increasingly elaborate technology when no cure or recovery is in sight is a denial of the

reality of human mortality, and would be seen by Buddhism as arising from delusion and

excessive attachment’’ (Keown 2005).

The Islamic Perspective

The Shari‘ah or Islamic law is based on two primary sources, the Holy Qur‘an (the Holy Book

which Muslims believe to be the word of God Almighty) (Al-Qur’an 2:2) and the Sunnah of

Prophet Muhammad (peace be upon him) (his words, conduct and tacit approval) (Al-Qur’an

4:59). The secondary source of the Shari‘ah is found in ijtihad (deductive reasoning) (Su-

laiman 2008, Sunan Abu Dawud, Book 24, Hadith no. 3585). The guiding principles, rules

and regulations in the main sources govern the Islamic way of life and, together with ijtihad,

provide a comprehensive moral and juridical framework to address and accommodate issues

relating to human conditions (Gatrad and Sheikh 2001). In Islamic jurisprudence, each

deliberation towards resolving any given issue must observe the following five fundamental

principles which are known as maqasid al-shari‘ah: preservation of life, protection of an

individual’s freedom or belief, maintenance of intellect, preservation of honour and integrity,

and protection of property. Congruently, end-of-life issues in Islamic bioethics involve

ethical considerations on the sanctity of human life. This ruling is ordained in the Holy Qur’an

in the following verse: ‘‘Do not take life which God has made sacred except in the course of

Justice’’ (Al-Qur’an 6:151). It is accordingly forbidden for anyone to deliberately end a life:

‘‘Whosoever takes a human life, for other than murder or corruption in the earth, it is as if he

has taken the life of all of mankind’’ (Al-Qur’an: 5:32). NUR 390: Bioethical Issue Paper Grading Criteria

The saving of a life is considered one of the highest merits and imperatives in Islam

(Zahedi et al. 2007). Doctors must do everything they can to prevent a premature death.

However, this does not come at all costs; when death is inevitable, and clinically evaluated

treatment is obviously futile, it ceases to be mandatory (Khan 2002). Islam recognises that

there are times in which human beings need to recognise their own limits and let nature

take its course (Al-Qur’an 39:42); resorting to futile treatment in order to put off death is

not acceptable in Islam (Zahedi et al. 2007). Muslim jurists agree that it is possible for a

collective decision to be reached between the attending doctor, patient and family members

128 J Relig Health (2016) 55:119–134

123 NUR 390: Bioethical Issue Paper Grading Criteria

to refuse medical interventions and discontinue life-sustaining treatments if such proce-

dures will in no way improve the condition or quality of life, on the basis of informed

consent (Bülow et al. 2008; Sachedina 2005; Zahedi et al. 2007). However, if invasive

treatment has been intensified to save a patient’s life, Muslim jurists have ruled that life-

saving equipment cannot be switched off unless the doctor is certain about the inevitability

of death (Sachedina 2005). NUR 390 : Ethical Dilemma in the Nursing Field Assignment

Islam maintains the position that patients should not be denied their basic human rights

of nutrition and hydration even at the end of life. This is due to the fact that withdrawal of

such needs would hasten death, which is forbidden in Islam (Bülow et al. 2008; Gatrad and

Sheikh 2001; Khan 2002). However, administering analgesia to lessen suffering in end-of-

life care is permitted even if in the process, death is hastened, based on the Islamic teaching

that ‘‘actions are to be judged by their intentions’’ (Bülow et al. 2008; Gatrad and Sheikh

2001; Sachedina 2005; Zahedi et al. 2007). It follows that the intended purpose of palli-

ative sedation is not to facilitate death, but rather to save a patient from severe discomfort,

which renders it ethically legitimate from the Islamic viewpoint. NUR 390: Bioethical Issue Paper Grading Criteria

In Islam, pain is believed to be a form of trial from God to test a Muslim’s faith and

spiritual standing (Al-Qur’an 2:153–7). Muslims should thus endure pain with patience and

perseverance, but this does not mean that they are forbidden to seek a means to alleviate

the suffering. The Holy Qur’an states that ‘‘surely the good deeds will drive away the evil

deeds [which cause suffering]’’ (Al-Qur’an 11:114); inferentially, this implies the per-

missibility for a person’s endeavour to overcome pain (Albar 2007; Sachedina 2005). This

precept is further substantiated by other verses in the Holy Qur’an and the Sunnah that

encourage Muslims to remove harm and difficulty (Al-Qur’an 2:185, 5:6 and 94:28; al-

Bukhari 1997 (Book 2, Hadith no. 38)). In Islamic ethics, an individual’s welfare is

intimately linked with his or her family and community (Sachedina 2005). Hence, neither

autonomy nor paternalism is the determining factor in deciding a course of action in

matters relating to end-of-life decisions, but rather, a joint decision made by all parties

associated with the patient, which may require the involvement of religious authorities, if

needed (Sachedina 2005). NUR 390: Bioethical Issue Paper Grading Criteria

The Developing Legal Standards

Decision making at the end of life must necessarily take into account the courts’ standing

on such issues and the legal implications that would ensue. In order for a comprehensive

ethico-legal framework to exist where medical codes of ethics are affirmed as good

practice, the latter must be compatible with current developments of the law. In the UK,

when decisions are made on behalf of a patient, the principle of ‘‘best interests’’ has

consistently been the determinative principle in legal cases. A responsible decision by a

team of medical experts to withdraw life-sustaining treatments and withhold further

medical interventions which have been determined to be futile and would not be in the

patient’s best interests is permissible under the law and would not subject healthcare

professionals to criminal proceedings. This principle was enunciated in the landmark case

of Airedale NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’ 1993), where the House

of Lords discussed its legal justification in relation to the principle of sanctity of life and

patient autonomy. NUR 390: Bioethical Issue Paper Grading Criteria

The case concerned one Anthony Bland, a victim of the disaster at the Hillsborough

Football Stadium who suffered irreversible damage to his cerebral cortex which rendered

him in a persistent vegetative state. He was fed artificially and mechanically with a

J Relig Health (2016) 55:119–134 129

123 NUR 390: Bioethical Issue Paper Grading Criteria

nasogastric tube and showed no cognitive response to his surroundings. All his natural

bodily functions had to be operated with nursing intervention, requiring 4–5 h of nursing

attention by two nurses daily. After three and a half years of remaining in this condition, a

court declaration was sought by Bland’s attending doctor to cease further treatment, which

involved extubation, i.e. withdrawal of artificial nutrition and hydration and withholding of

antibiotic treatment in case of infection. The declaration was based on a clinical assessment

by medical experts that there was absolutely no hope for recovery for Bland and thus any

medical intervention would be futile and not in the best interests of the patient. In arriving

at its judgement, the court ruled that the principle of sanctity of life was not absolute; ‘‘it

must yield to the right of self-determination’’ (per Lord Goff in Airedale NHS Trust v

Bland (‘‘Airedale NHS Trust v. Bland’’ 1993 at p. 866). The principle of self-determination

requires that the patient’s wishes be respected to the extent that if a patient of sound mind

refuses to consent to a medical treatment which would prolong his life, the doctor

responsible for his care must abide by the former’s wishes, regardless of the fact that such

refusal is unwise. NUR 390: Bioethical Issue Paper Grading Criteria

In the case of an insensate patient like Bland who lacked the capacity to validly consent

or refuse medical treatment, the lawfulness of such medical treatment depended upon

whether it was in the best interests of the patient (per Sir Thomas Bingham in Airedale

NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’ 1993 at p. 843). The court further held

that doctors were not under an unqualified duty to prolong life at all costs; accordingly, the

duty to provide medical care ‘‘ceases when such treatment can serve no humane purpose’’

(per Lord Hoffman in Airedale NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’ 1993

at p. 856). In Bland’s case, the futility of the treatment in providing him any quality of life

ethically justified its termination (per Lord Goff in Airedale NHS Trust v Bland (‘‘Airedale

NHS Trust v. Bland’’ 1993 at p. 870). NUR 390: Bioethical Issue Paper Grading Criteria

A patient’s right to autonomy was reiterated in Ms B v An NHS Hospital Trust (‘‘Ms B

v An NHS Hospital Trust’’ 2002). Here, the case involved a patient who was mentally

competent and had repeatedly yet unsuccessfully requested for the withdrawal of medical

therapy to which she was subjected. Ms B suffered a spinal cavernoma, which necessitated

neurological surgery to remove it. During the course of her hospitalisation and treatment,

she executed a living will stating that if at any point of time, she was incapable of giving

instructions, she wanted treatment to be withdrawn if she was suffering from a life-

threatening condition, permanent mental impairment or permanent unconsciousness.

Unfortunately, as a result of the surgery, Mrs B became completely paralysed from the

neck down and was treated with a ventilator to ease her respiratory problems. She even-

tually regained some movement in her head and was able to speak, pursuant to which she

requested to her clinicians on several occasions to have the ventilator removed. The

clinicians were not prepared to do so as they considered it to not be in her best interests, i.e.

it would inevitably lead to her death. In allowing Mrs B’s claim for a declaration that the

hospital had been treating her unlawfully, the court upheld the principle of self-determi-

nation, referring to the judgements delivered by the bench in Airedale NHS Trust v Bland

(‘‘Airedale NHS Trust v. Bland’’ 1993) on the interface between the two conflicting

principles of autonomy and preservation of life. It was accordingly ruled that the principle

of ‘‘best interests’’ was not applicable in cases where the patient had the mental capacity to

make relevant decisions about her medical treatment, and therefore, a doctor was under an

obligation to respect the wishes of the patient, even if it was plain to all parties, including

the patient, that death would ensue. NUR 390: Bioethical Issue Paper Grading Criteria

The approach to the issue on end of life adopted by the US courts is not entirely

dissimilar to the law in the UK (it is noted that although the House of Lords in Airedale

130 J Relig Health (2016) 55:119–134

123 NUR 390: Bioethical Issue Paper Grading Criteria

NHS Trust v Bland (‘‘Airedale NHS Trust v. Bland’’ 1993) declined to apply the test of

‘‘substituted judgment’’ used by the US courts in the case of an incapable patient, Lord

Hoffman at p. 857 noted that such principle, to the extent that it pays respects to what most

likely would have been the patient’s views, ‘‘may be subsumed within the English concept

of best interests’’). In the absence of the expressed wishes of a patient (be it in the form of

oral statements or advance directives), decisions are based on the patient’s presumed

wishes (Meisel 2008). This is known as the doctrine of ‘‘substituted judgement’’. Under

this doctrine, a surrogate appointed by a patient is legally authorised to make decisions on

behalf of the patient, or where there is no surrogate, the patient’s family members, based on

the patient’s values and beliefs. This practice marks the difference between the USA and

the UK positions; in the UK, it is not a legal requirement for relatives to assent on behalf of

a patient who is unable to give consent (per Lord Goff in Airedale NHS Trust v Bland

(‘‘Airedale NHS Trust v. Bland’’ 1993 at p. 872). Discussions with relatives are never-

theless of utmost value because they assist in providing indications about the patient’s own

attitudes and values concerning treatment (Kinsella and Booth 2007). NUR 390: Bioethical Issue Paper Grading Criteria

The prolific Florida case of Theresa Marie Schiavo (‘‘Schiavo ex rel. Schindler v.

Schiavo’’ 2005) is noteworthy not only to illustrate the application of the ‘‘substituted

judgement’’ test, but also due to the controversial intervention of the executive body and

conservative groups in the dispute surrounding her medical care, which attracted intense

media coverage. Theresa Schiavo was in a persistent vegetative state for 15 years, fol-

lowing a cardiac arrest. Although she suffered from irrevocable cerebral cortex, she was

able to breathe on her own and was kept alive through artificial nutrition and hydration

which was delivered by way of a tube implanted in her body. After having accepted the

grim medical prognosis that his wife’s incapacity was permanent, Michael Schiavo

attempted to seek the court’s permission for the removal of her feeding tube so that she

could die peacefully, stating that it would have been against Theresa’s wishes and values to

have her life prolonged in a vegetative state with no hope of recovery. Since Theresa

Schiavo had not appointed a surrogate, in accordance with Florida law, her husband was

authorised to act as the proxy decision-maker, ahead of her other family members (‘‘FLA.

STAT. § 765.401(1)’’ 2005; Noah 2006). In an ensuing series of intense court battles over a

period of 7 years, including the controversial intervention of the US Congress, Theresa

Schiavo’s parents, Robert and Mary Schindler, fought against Michael Schiavo’s desig-

nation as legal surrogate and his request to withdraw the life-sustaining treatment from his

wife. Despite immense pressure from political groups, all state and federal courts which

heard the case ruled in favour of Michael Schiavo’s application. NUR 390: Bioethical Issue Paper Grading Criteria

In 2004, in what is seen to have been a response to Theresa Schiavo’s case, a pro-

nouncement was made by the then Pope John Paul II concerning the impermissibility of the

withdrawal of artificial nutrition and hydration (Bülow et al. 2008; Noah 2006). This was

relied on by the Schindlers, arguing that since their daughter was a practising Catholic, she

would have been inclined to abide by the papal decree (Noah 2006). Although the courts

recognised the relevance of a patient’s religious affiliations, no proper inference could be

made as to Theresa’s personal understanding and level of adherence to Catholic principles,

and thus, it was difficult to form a decision in that respect (Noah 2006). This highlights the

need for a more effective mechanism to facilitate religious and spiritual awareness in end-

of-life care, so that ethical and social implications can be ‘‘anticipated and acted upon in

advance rather than post factum’’ (Steinberg 2003). On that note, it is argued that the legal

system is not the most appropriate platform to cope with the different ethical dilemmas

created by the dynamic changes in the medical world; instead, multidisciplinary ethic

committees may prove to be more efficacious in developing and recommending policies

J Relig Health (2016) 55:119–134 131

123 NUR 390: Bioethical Issue Paper Grading Criteria

and procedures to resolve ethical conflict (Steinberg 2003), which are more pronounced at

the end of life.

Conclusion

In a world of increasing cultural pluralism and multi-faith societies, there is an undeniable

need for those involved in health services to have increased awareness and understanding

of the various and distinct value and belief systems of the patients whom they attend to.

Sensitivity towards cultural and religious differences leads to increased trust between

doctor and patient, resulting in a compassionate and improved end-of-life care environ-

ment. Further, aspects of end-of-life care such as withholding and withdrawal of medical

interventions, futile treatments and palliative sedation involve a manifold of ethical

dilemmas, necessitating a structured approach into the different value systems of each

individual patient. It is thus important that healthcare providers inquire into and evaluate a

patient’s religious and spiritual beliefs as well as his personal attitude towards end-of-life

issues such as illness, pain and death. This may accordingly be facilitated through the

formulation and implementation of ethical codes which give due consideration to the

characteristics of religion, culture and locality. The importance of adequate and effective

communication between doctor and patient must also not be underestimated, as it plays a

crucial role in minimising misunderstanding and resolving conflict, as well as promoting a

mutual and collective approach to decision-making. NUR 390: Bioethical Issue Paper Grading Criteria

Acknowledgments This paper was funded by the Ministry of Higher Education Malaysia and presented at the Asian Conference on Ethics, Religion and Philosophy 2014 (ACERP—Osaka 2014).

References

Agarwal, A. K., & Murinson, B. B. (2012). New dimensions in patient–physician interaction: Values, autonomy, and medical information in the patient-centered clinical encounter. Rambam Maimonides Medical Journal, 3(3), 1–11. doi:10.5041/RMMJ.10085.

Airedale NHS Trust v. Bland. (1993). All ER, 1, 821–896. Albar, M. (2007). Seeking remedy, abstaining from therapy and resuscitation: An Islamic perspective. Saudi

Journal of Kidney Diseases and Transplantation, 18(4), 629–637. http://www.sjkdt.org/article. asp?issn=1319-2442;year=2007;volume=18;issue=4;spage=629;epage=637;aulast=Albar.

al-Bukhari, M. (1997). Sahih al-Bukhari. (trans: Khan, M.). Riyadh: Maktaba Dar-us-Salam. al-Shahri, M. Z., & Al-Khenaizan, A. (2005). Palliative care for Muslim patients. The Journal of Supportive

Oncology, 3(6), 432–6. http://www.ncbi.nlm.nih.gov/pubmed/16350430. Billings, J. A., & Krakauer, E. L. (2011). On patient autonomy and physician responsibility in end-of-life

care. Archives of Internal Medicine, 171(9), 849–853. doi:10.1001/virtualmentor.2009.11.8.onca1- 0908. NUR 390: Bioethical Issue Paper Grading Criteria

Bülow, H.-H., Sprung, C. L., Reinhart, K., Prayag, S., Du, B., Armaganidis, A., & Levy, M. M. (2008). The world’s major religions’ points of view on end-of-life decisions in the intensive care unit. Intensive Care Medicine, 34(3), 423–430.

Cantor, N. L. (2005). Deja vu all over again: The false dichotomy between sanctity of life and quality of life. Stetson Law Review, 35(1), 81–100. http://www.ncbi.nlm.nih.gov/pubmed/17099994.

Carey, S. M., & Cosgrove, J. F. (2006). Cultural issues surrounding end-of-life care. Current Anaesthesia and Critical Care, 17(5), 263–270.

Cavalieri, T. A. (2001). Ethical issues at the end of life. JAOA, 101(10), 616–622. Centre for Bioethics, University of Minnesota. (2005). End of life care: An ethical overview. Centre for

Bioethics, University of Minnesota. http://conservancy.umn.edu/handle/189. Chater, K., & Tsai, C. (2008). Palliative care in a multicultural society: A challenge for western ethics.

Australian Journal of Advanced Nursing, 26(2), 95–100.

132 J Relig Health (2016) 55:119–134

123

Chin, J. (2002). Doctor–patient relationship: From medical paternalism to enhanced autonomy. Singapore Medical Journal, 43(3), 152–155. http://www.psy.med.br/textos/medico_paciente/modelo-relacao1. pdf.

Colello, K. J., Mulvey, J., Sarata, A. K., Williams, E. D., & Thomas, K. R. (2011). End-of-life care: Services, costs, ethics, and quality of care. In S. B. Adams (Ed.), Comfort and care at the end of life (pp. 41–68). New York: Nova Science Publishers. NUR 390: Bioethical Issue Paper Grading Criteria

Curran, C. E. (2008). Catholic moral theology in the United States: A history (Google eBook) (p. 368). Wash- ington, DC: Georgetown University Press. http://books.google.com/books?id=enB4otKhEFwC&pgis=1.

Da Rocha, A. C. (2009). Back to basics in bioethics: Reconciling patient autonomy with physician responsibility. Philosophy Compass, 4(1), 56–68. doi:10.1111/j.1747-9991.2008.00190.x.

Daaleman, T. P. (2000). Placing religion and spirituality in end-of-life care. JAMA, 284(19), 2514–2517. Dorff, E. N. (2005). End-of-life: Jewish perspectives. The Lancet, 366(9488), 862–865. Elsayed, D., & Ahmed, R. (2009). Medical ethics: What is it? Why is it important? Sudanese Journal of

Public Health, 4(1), 284–287. http://www.sjph.net.sd/files/vol4i2/SJPH-vol4i2-p284-287.pdf. First International Conference on Islamic Medicine. (1981). Islamic code of medical ethics. Kuwait. FLA. STAT. § 765.401(1) (2005). http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_

Statute&Search_String=&URL=0700-0799/0765/Sections/0765.401.html. Retrieved 02 March 2014. Gatrad, A. R., & Sheikh, A. (2001). Medical ethics and Islam: Principles and practice. Archives of Disease

in Childhood, 84(1), 72–75. Gillick, M. R. (2001). Artificial nutrition and hydration in the patient with advanced dementia: Is with-

holding treatment compatible with traditional Judaism? Journal of Medical Ethics, 27(1), 12–15. Glover, J. (1977). Causing death and saving lives. Harmondsworth: Penguin. Huxtable, R. (2002). D(en)ying life: The sanctity of life doctrine in English law. Retfaerd, 25(3), 60–81.

http://www.retfaerd.org/gamle_pdf/2002/3/Retfaerd_98_2002_3_s60_81.pdf. Kahn, M. J., Lazarus, C. J., & Owens, D. P. (2003). Allowing patients to die: Practical, ethical, and religious

concerns. Journal of Clinical Oncology, 21(15), 3000–3002. Kassim, P. N., & Adeniyi, O. B. (2010). Withdrawing and withholding medical treatment: A comparative

study between the Malaysian, English and Islamic law. Medicine and Law, 29, 443–461. Keown, D. (2005). End of life: The Buddhist view. The Lancet, 366(9489), 952–955. Khan, F. (2002). Religious teaching and reflections on advance directive-religious values and legal

dilemmas in bioethics: An Islamic perspective. Fordham Urb. LJ, 30(1), 267–275. Kinsella, J., & Booth, M. (2007). Ethical framework for end of life decisions in intensive care in the UK.

Journal of National Institute on Public Health, 56(4), 387–392. Kuhse, H. (1981). Debate: Extraordinary means and the sanctity of life. Journal of Medical Ethics, 7(2), NUR 390 : Ethical Dilemma in the Nursing Field Assignment

74–82. doi:10.1136/jme.7.2.74. Loike, J., Gillick, M., Mayer, S., Prager, K., Simon, J. R., Steinberg, A., & Fischbach, R. L. (2010). The

critical role of religion: Caring for the dying patient from an Orthodox Jewish perspective. Journal of Palliative Medicine, 13(10), 1267–1271. NUR 390: Bioethical Issue Paper Grading Criteria

Majelis Kehormatan Etik Kedokteran Indonesia. (2001). Kode Etik Kedokteran Indonesia. Jakarta. http:// www.dikti.go.id/files/atur/sehat/Kode-Etik-Kedokteran.pdf.

Malaysian Medical Association. (2002). Code of medical ethics (MMA). Malaysia: Malaysian Medical Association.

Malik, M. (2012). Islamic and Catholic bioethics of pain medication: A response to mercy argument. Journal of Islam in Asia, 9(1), 213–227.

Markwell, H. (2005). End-of-life: A Catholic view. The Lancet, 366(9491), 1132–1135. Mazanec, P., & Tyler, M. K. (2003). Cultural considerations in end-of-life care. AJN, 103(3), 50–58. McLachlan, H. V. (2008). The ethics of killing and letting die: Active and passive euthanasia. Journal of

Medical Ethics, 34(8), 636–638. doi:10.1136/jme.2007.023382. Medical Board of Australia. (n.d.). Good medical practice: A code of conduct for doctors in Australia. http://

www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx. Medical Council of New Zealand. (2013). Good medical practice. In S. G. IM (Ed.), Cole’s Medical practice

in New Zealand (12th ed., pp. 5–28). Wellington: Medical Council of New Zealand. Meisel, A. (2008). End-of-life care. In M. Crowley (Ed.), From birth to death and bench to clinic: The

Hastings center bioethics briefing book (pp. 51–54). Garrison: The Hastings Center. Ms B v An NHS Hospital Trust. (2002). All ER (D), 362, 1–25. Noah, B. (2006). The role of religion in the Schiavo Controversy. Houston Journal of Health Law and

Policy, 6, 319–346. Olsen, M. L., Swetz, K. M., & Mueller, P. S. (2010). Ethical decision making with end-of-life care:

Palliative sedation and withholding or withdrawing life-sustaining treatments. Mayo Clinic Proceed- ings, 85(10), 949–954. NUR 390: Bioethical Issue Paper Grading Criteria

J Relig Health (2016) 55:119–134 133

123NUR 390: Bioethical Issue Paper Grading Criteria

Orentlicher, D. (1998). The alleged distinction between euthanasia and the withdrawal of life-sustaining treatment: Conceptually incoherent and impossible to maintain. U. Ill. L. Rev., (3), 837–860. http:// heinonlinebackup.com/hol-cgi-bin/get_pdf.cgi?handle=hein.journals/unilllr1998&section=29.

Padela, A. (2006). Medical ethics in religious traditions: A study of Judaism, Catholicism, and Islam. JIMA, 38, 106–117. NUR 390: Bioethical Issue Paper Grading Criteria

Padela, A. (2007). Islamic medical ethics: A primer. Bioethics, 21(3), 169–178. Queensland Health and Islamic Council of Queensland. (2010). Health care providers’ handbook on Muslim

patients (2nd ed., pp. 1–21). Brisbane: Queensland Health and Islamic Council of Queensland. Queensland Health and Islamic Council of Queensland. (2011). Health care providers’ handbook on Hindu

patients (2nd). Brisbane: Division of the Chief Health Officer, Queensland Health. http://www.health. qld.gov.au/multicultural/support_tools/hbook-hindu.pdf. NUR 390: Bioethical Issue Paper Grading Criteria

Queensland Health and Islamic Council of Queensland. (n.d.). Health care providers’ handbook on Sikh patients. Division of the Chief Health Officer, Queensland Health. http://www.health.qld.gov.au/ multicultural/health_workers/hbook-sikh.asp.

Rabiu, A.-R., & Sugand, K. (2014). Has the sanctity of life law ‘‘gone too far’’? Analysis of the sanctity of life doctrine and English case law shows that the sanctity of life law has not ‘‘gone too far’’. Phi- losophy, Ethics, and Humanities in Medicine: PEHM, 9(1), 1–6. doi:10.1186/1747-5341-9-5.

Sachedina, A. (2005). End-of-life: The Islamic view. The Lancet, 366, 774–779. Schiavo ex rel. Schindler v. Schiavo. 404 F.3d 1270 (11th Circuit 2005). Steinberg, A. (2003). Encyclopedia of Jewish medical ethics: A compilation of Jewish medical law on all

topics of medical interest (trans: Rosner, F.). Jerusalem: Feldheim Publishers. Sulaiman, A. D. (2008). Sunan Abu Dawud (trans: al-Khattab, N.). Riyadh: Maktaba Dar-us-Salam. Talib, N. (2002). Euthanasia: A Malaysian perspective. Petaling Jaya: Sweet and Maxwell Asia. Tallon, C. (2012). Ethics and end of life care. Journal of Observational Pain Medicine, 1(1), 1–7. UK Department of Health. (2003). NHS chaplaincy: Meeting the religious and spiritual needs of patients and

staff. http://www.nhs-chaplaincy-spiritualcare.org.uk/dh_MeetingtheReligiousNeeds2003.pdf. UK Department of Health. (2008). End of life care strategy: Promoting high quality care for all adults at the

end of life. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/136431/End_ of_life_strategy.pdf. NUR 390: Bioethical Issue Paper Grading Criteria

UNESCO Cairo Office. (2011). Ethics and law in biomedicine and genetics: An overview of national regulations in the Arab states (p. 82). Cairo: UNESCO. http://unesdoc.unesco.org/images/0021/ 002152/215207e.pdf.

World Health Organisation. (n.d.). WHO definition of palliative care. World Health Organization. http:// www.who.int/cancer/palliative/definition/en/. Retrieved 01 March 2014.

Zahedi, F., Larijani, B., & Bazzaz, J. T. (2007). End of life ethical issues and Islamic views. Iran Journal of Allergy Asthma and Immunology, 6, 5–15.

134 J Relig Health (2016) 55:119–134

123

Copyright of Journal of Religion & Health is the property of Springer Science & Business Media B.V. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.