Online Seminar: Sian Atkin & Guy Schofield VIDEO RECORDING

Sian Atkin (Doctor, Brownlow group practice, Liverpool): How can Doctors counsel patients with regard to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) in an ethically sound manner, knowing that the presence of a DNACPR can lead to poorer care for patients?

Guy Schofield (Wellcome Society & Ethics Fellow, University of Bristol) : Day-to-Day Ethics in Palliative Care: A Systematic Review of the Ethical Challenges Identified by Specialist Palliative Care Practitioners in their Clinical Practice

Abstracts

Day-to-Day Ethics in Palliative Care: A Systematic Review of the Ethical Challenges Identified by Specialist Palliative Care Practitioners in their Clinical Practice

Background:

Ethical issues arise daily in the delivery of palliative care. Despite much (largely theoretical) literature, evidence from specialist palliative care practitioners about day-to-day ethical challenges has not previously been synthesised. This evidence is crucial to inform education and adequately support staff.

Aim:

To synthesise the evidence regarding the ethical challenges which specialist palliative care practitioners encounter during clinical practice.

Design:

Systematic review with narrative synthesis (PROSPERO registration CRD42018105365). Quality was dual-assessed using the Mixed-Methods Appraisal Tool. Tabulation, textural description, concept mapping and thematic synthesis were used to develop and present the narrative.

Data sources:

Seven databases (MEDLINE, Philosopher’s Index, EMBASE, PsycINFO, LILACS, Web of Science and CINAHL) were searched from inception to December 2019 without language limits. Eligible papers reported original research using inductive methods to describe practitioner-reported ethical challenges.

Results:

A total of 8074 records were screened. Thirteen studies from nine countries were included. Challenges were organised into six themes: application of ethical principles; delivering clinical care; working with families; engaging with institutional structures and values; navigating societal values and expectations; philosophy of palliative care. Challenges related to specific scenarios/contexts rather than the application of general ethical principles, and occurred at all levels (bedside, institution, society, policy).

Conclusion:

Palliative care practitioners encounter a broad range of contextual ethical challenges, many of which are not represented in palliative care ethics training resources, for example, navigating institutional policies, resource allocation and inter-professional conflict. Findings have implications for supporting ethical practice and training practitioners. The lack of low- and middle- income country data needs addressing.

How can Doctors counsel patients with regard to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) in an ethically sound manner, knowing that the presence of a DNACPR can lead to poorer care for patients?

Cardiopulmonary resuscitation (CPR) is a process of attempted resuscitation which occurs when someone has lost cardiopulmonary output, and has died. The success rates of CPR are regularly overestimated by the public and also medical staff. DNACPR is an advance directive, instigated by doctors, patients or next of kin, and completed by a doctor, which states CPR should not be attempted. A DNACPR only applies to a resuscitation attempt, and should not affect other elements of care. However, in clinical practice patients with a DNACPR can be treated differently to those without.

I will present evidence supporting this statement, using ethical theories such as consequentialism and principlism to explore care discrepancy and the ethics around withholding or divulging this information to patients.

I then consider truth-telling and patient autonomy in further detail; exploring the nature of truth, relational autonomy and the nocebo effect, discussing the inherent value and limitations of each, and the burden of significant requirements these approaches place on patients.

I then discuss the ethics of futility and palliative paternalism, which consider the limitations to an autonomy-driven healthcare ethic, and how this can be balanced with a more supportive, directive approach.

I conclude that in some situations it would be reasonable to withhold information regarding the harms of DNACPR, but there would be significant issues with intermittent disclosure. Therefore, the ethical solution would be to either consistently disclose this information, or to advocate for a more holistic approach to goals of care, for example using the Universal Form of Treatment Options.