Ms Julie Letts MBioeth

Principal Policy Analyst (Clinical Ethics), Research and Ethics Branch, NSW Department of Health, Sydney, Australia

Humane end of life care is a social obligation as well as a personal offering for those directly involved. In reality, both society and individuals often fall short of what is reasonably, if not simply, achieved. As a result, people have come to both fear a technologically over-treated and protracted death and to dread the prospect of abandonment and untreated physical and emotional distress. Ongoing efforts, though arguably slow to effect improvements in the quality of end of life care, are occurring. In particular, emphasis on strategies to achieve better coherence between an individual's expressed wishes and expectations, and the care they ultimately receive at the end of life where decision-making capacity is so often lost. This presentation will briefly introduce current trends in how decisions are made to withhold or withdraw life-sustaining treatment as part of appropriate end of life care, principally as these occur in the critical care unit, and how disputes are resolved.

The presentation will however, predominantly focus on the ethical dimensions of several specific issues relevant to anaesthetic practice. First, refusal to provide anaesthesia to a patient considered moribund by the anaesthetist, and in whom anaesthesia and/or surgery are seen as insufficiently beneficial or plainly harmful, contrary to the opinion of the treating surgeon. Such inter-disciplinary disputes often have their genesis in inadequate prior discussions by treating clinicians with the patient or their family about appropriate goals of care. These disputes raise ethical complexities found in other clinical scenarios related to provision of marginally beneficial treatments, the obligations of health professionals in relation to them, and the place of 'conscientious objection' in relation to some. These disputes pose particular challenges in time-critical scenarios. Second, consideration of 'No cardiopulmonary resuscitation orders', including where this has been informed by an advance care directive prepared by the patient him or herself, and how these should be applied during anaesthesia. Decisions to withhold CPR form an important aspect of optimal end of life care. Surgery will however, be indicated in some patients with 'No CPR orders' in place. Careful advance consideration of the status of such orders and appropriate clinical response to acute instability or cardiac arrest under anaesthesia is required. Finally, interface with deceased donation practice and questions about use of anaesthesia during organ procurement from brain dead donors will be discussed. While one rationale is that this improves the quality of procured organs and therefore outcomes for recipients through protection of organs against the effects of catecholamine, the empirical basis for both the need, and appropriate use of anaesthesia is limited. Against the possible benefits of anaesthesia is that provision of anaesthesia to the brain dead donor may undermine health professionals' or community perceptions about the validity of brain death as a pre-condition for organ donation.

NSW Health has developed guidelines to inform end of life decision-making, applicable in the NSW public health system but have relevance to private practice. These are GL2005_057 Guidelines for end of life care and decision-making and GL2005_056 Using Advance Care Directive (NSW). A supplement to the Guidelines for end of life care and decision-making on Decisions relating to Cardio-Pulmonary Resuscitation Orders are currently in development. Publication is anticipated in mid-2008.

Organ donation: organ harvesting or end of life care