Analysis of Legal and Professional Issues

Running head: case study analysis of legal and professional issues
Analysis of Legal and Professional Issues
Name of the Student
Name of the University
Authors Note

1Analysis of Legal and Professional Issues
Introduction
This essay is focused on the withdrawal treatment for a patient who is quadriplegic
due to spinal cord injury. Ms A, the patient, was fit and active before the injury and worked
in a tourism adventure company. She remained cognitively competent and receives end of life
care in the hospital. The main objective of the assignment is to focus on the legislations and
laws related to withdrawal of the treatment and withholding the medications in context of two
countries such as Australia and Singapore.
Discussion
Patient’s legal concerns on provision of nutrition and fluids
Artificial nutrition and hydration are used as a life sustaining way of provision of
nutritional supplements. The artificial methods are provided to the patients, who are critically
ill and unable to support themselves (Anderson et al., 2019). In palliative care treatment, PEG
(Percutaneous Endoscopic Gastronomy) tube is used for providing nutrition and fluids. The
patient’s mental capacity at the time of request is also important for withdrawal of life
support. The patient has to give consent for the treatment of care.
Mental Health Capacity Act (2008) was introduced for the people who do not have
the decision-making ability due to physical impairment or any disturbances in functioning of
brain so that the act can only be availed by those persons who are unable to understand and
retain to the information which are related to decision (Morriss et al., 2017). These people
are unable to use and prioritise the decisions through decision-making process. The person
should be unable to communicate about the decisions verbally or non-verbally. Victoria’s
Medical Treatment Act 1988 describes the provision for the appointment of medical
treatment decision maker. The act allows the decision maker to take any decisions for the
person who cannot take decisions for him or herself. Ms A is capable of making decisions

2Analysis of Legal and Professional Issues
and is of sound mind. The Medical Treatment Act (MTA) (1988) permits patients, who can
understand their health condition to refuse any medical assistances (Gray et al., 2016). Ms A
is above 18 years old and can take decisions regarding to her treatment procedures. In
Singapore, the legislations do not allow the patient for the withdrawal of treatment. Advance
Medical Directive of Singapore allows patients above 21 years old to decline life-sustaining
treatment. The rules have legislations which will certify Ms B to plead for withdrawal of PEG
tube and stop medical treatment as she is mentally competent.
Clinically Assisted Nutrition and Hydration (CANH) includes several apparatus,
which are used in the treatment of critical patients. PEG tube is included in CANH and
provides fluids to maintain hydration to avoid spoon-feeding techniques for nursing.
According to MTA (1988) and AMD (1996), patients are not permitted to withdraw
themselves from palliative care. The CANH was not included in any particular legislation of
medical industry and there was no legal clarity whether PEG tube is a part of palliative care
or not. CANH was included as a part of palliative care after the breakthrough decision of the
United States (US) Supreme Court in the case of Cruzan v. Director, Missouri Department of
Health in 1990 (Miller, 2017). This set legal precedence for other common law position as its
legal viewpoint regarding CANH.
The patient can lawfully reject clinical assistance through the PEG tube based on
decision-making capacity as the law permits the rights to refuse treatments. The Supreme
Court of Western Australia approved the decision of Brightwater Care Group (Inc) v.
Rossiter (2009) case. Therefore, the judgement supported the concept of withdrawal of food
and nutritional supply for those patients, who are mentally competent. The verdict supported
autonomous right and personal wishes to discontinue CANH and medical assistance
(Cockburn & Madden, 2018). To maintain autonomy of patient care, the judgement
supported removal of PEG tube and artificial nutritional support.

3Analysis of Legal and Professional Issues
If you comply with Ms A’s request, does this constitute euthanasia?
Euthanasia is a Greek term and means “good death”. This practice is focused on
providing end of life care to reduce pain and suffering of the patients. Different types of
euthanasia are present such as voluntary, involuntary, active and passive. Voluntary
euthanasia takes place on basis of the patient’s concern (Emanuel, 2017). In Singapore,
assisting suicide is considered as an illegal act of clinical practise. In different countries, such
as Netherlands, Colombia, Belgium, Switzerland and different states of the United States,
euthanasia is legal. In 1995, Euthanasia was legalised in Northern Australia for a short time
period but the legislation overturned by the federal government. There is a bill associated
with the end of life care in Victoria which is known as Voluntary Assisted Dying Bill (2017)
(White & Willmott, 2019). The bill allows people of 18 years or older to avail the euthanasia.
Only Australian citizens and permanent residents of Victoria who have the decision making
ability in relation to the voluntary assisted dying. Incurable, advanced and progressive health
condition which can be resulted into death within or less than 12 months are the reasons for
approving euthanasia. A person with mental illness and only physical disability cannot be
approved for euthanasia. Patients with terminal illness such as cancer, AIDS, advanced heart
disease and acute respiratory disease, are eligible for Voluntary Assisted Dying Bill and
withdrawal of treatment.
What is the difference between withdrawal of treatment and euthanasia?
Withdrawal of treatment involves different end-of-life key terminologies and different
health professionals with various designations (Naylor et al., 2019). There are different health
professionals (such as legal experts, allied health professionals and patient’s health advocacy
group) who are involved with the end of life care or withdrawal of care. The withdrawal of
care defines the removing or eliminating all life support systems and medications with the
consent of the patient or his/her medical attorney. The process incorporates withdrawal of

4Analysis of Legal and Professional Issues
mechanical life support, antibiotics and elimination of CANH from the procedure. As per the
above discussion, withdrawal of treatment is also a legalised procedure.
The international act of killing method with the consent of the patient or the medical
attorney or the family members of the patient is called as active euthanasia (Curtin, 2018). In
active euthanasia the process involves the removal of life-sustaining treatments which leads
to patient’s death. According to international community the terms related to active
euthanasia is not a legalised procedure and this means shortening of the dying process with
the active involvement of the artificial equipment. The active euthanasia involves different
precise intentions to accelerate the death of the patient and elimination of life sustaining
treatment procedures. The active euthanasia is addressed as the “Mercy Killing” in some
literatures (Khazali, 2017). In some countries, “Mercy Killing” is not legalised. Moreover,
active euthanasia is legal in very few European countries.
Therefore, from the above discussion, it can be stated that the withdrawal of treatment
is differed from the active euthanasia. The former one is elimination of the life sustaining
procedures whereas the latter one is a deliberate act to terminate the life of the
patient .Thereafter , both the terminologies are different from each other from and do not
overlap one another. Withdrawal of treatment is legalised in wider range than the active
euthanasia in many countries.
What risks, if any, might staff face if they comply with this request?
Criminal culpability and civil ability are two terms which are related to the concerns
of the healthcare professionals. The situations regarding active euthanasia and withdrawal of
the life support are legally very sensitive or important for the health workers.

5Analysis of Legal and Professional Issues
The health professionals can face the risks of acquisition or allegation of murder.
They can be convicted as the alleged person and are needed to the prosecution to establish
their innocence in front of the Court. There are some conditions which must be proved by the
criminal lawyer for the health professionals if needed. These conditions are: 1) The act was
not intentional, 2) The alleged was not the cause of death of the deceased patient, 3) The act
was referred with the laws, 4) The patient was not killed intentionally or deliberately. The
health professionals should prove that the act of withdrawal of treatment was legalised action
and performed with the patient’s consent (Henneberg, 2017). On the other hand the
prosecution would try to prove that the professionals had withdrawn all the life support
intentionally and the patient was died in that process. In this case, it would be critical to put
an allegation on the health workers or the staffs of hospitals for removing the life supporting
equipment or CANH. For Ms A, the main cause of death could not be the withdrawal of the
equipment but her disease which was responsible for the deterioration of her health. On the
contrary, the patient was mentally competent and able to take her own decisions. Therefore,
this action can be regarded as a legalised act which was taken for maintaining the autonomy
of the patient. As the patient was mentally competent and her decision-making ability was not
affected, it can be stated that the patient might refuse to remove CANH if the staffs of the
nursing home performed the act without her permission.
The nursing staffs can be accused with the allegation of abetting suicide. The common
law states that one who wants to end his/ her life for seeking death, attempts suicides. In the
case of Ms A, she wanted to end her life for reducing the sufferings she was faced due to her
deteriorating health condition (Vanderspank-Wright, Efstathiou & Vandyk, 2018).
Discontinuation of the treatment or life supports was done as per the patient’s will. Therefore,
the nursing staffs cannot be blamed for the death of Ms A. There are laws and regulations
(s.309 and s.107) in Singapore for abetting and attempting suicide under Penal Code (1871)

6Analysis of Legal and Professional Issues
(Yeo, 2016). In Victoria, suicide is not considered as a crime and abetting suicide comes
under the section 6A and 181 of the Crimes Act. In Victoria, Voluntary Assisted Dying Act
supports the doctors and health care members for physician assisted suicide to the end of life
care patients (Mishara & Weisstub, 2016). Before the establishment of Voluntary Assisted
Dying Act (2017), elimination of life support with the consent of the patient was a crime. Ms
A has legal right to avail the facility regarding the physician assisted death. Therefore, the
nursing staffs cannot be blamed or accused legally for abetting the suicide in the case of Ms
A.
Civil rights and liabilities are another risk for the members of the hospital in this case.
Withdrawal of the life support during treatment can be accused as the act of negligence from
the family members of the patient. There are instances which show that the doctor withdraws
life support with the consent of medical attorney of the patient but in the absence of the
medical attorney, other family members filed a case against the institution or the
organisation. Thereafter, risks of legal turmoils can be present in the case of Ms A. The
withdrawal of treatment may lead to the consequences of legal procedures with the references
of breaching the responsibilities of caregivers. The health care providers can be accused of
foreseeable death of the patient. There are different legal immunity present for safeguarding
the health care providers from undesired circumstances from the civil and criminal laws.
On a professional level, can you personally refuse to comply with Ms A’s request?
The healthcare providers are inclined to give different kinds of values and beliefs like
civilians. Sometimes, the nurses and doctors are not agreed with the decisions of the
withdrawal of treatment on behalf of the patients. However, for the sake of maintaining the
autonomy of the patient, they have to execute patients’ consent over their personal opinions
(Vazirani et al., 2019). These lead to the ethical dilemma of the care giver during the
treatment. They have to manage the professional duties with the personal morals or beliefs.

7Analysis of Legal and Professional Issues
The health professional can take the help of conscientious objection which means
refusal of providing the health care service to those who are opposing the beliefs and personal
values of the health professionals (Lamb et al., 2019). Biasness and lack of self-interests, are
some significant reasons for objection, which are not ethically right also. According to
NMBA standards and Singapore Nursing Board, nurses can the right to have conscientious
objection when they face contradiction of interests and moral values with the patients. The
doctors and the other medical assistants should involve themselves to be part of this as the
Medical Board of Australia regarding code of conduct for doctors and Singapore Medical
Council shared the same views for the medical practice related to withdrawal of treatments
(Stahl & Emanuel, 2017). To avoid compromise in care, doctors refers other clinicians and
responsibilities of the patient is handed over to other nurses as well.
Conclusion
The assignment concludes that Ms A can attain the withdrawal of treatments with her
conscience and no healthcare workers will be responsible for her death. She can approach for
euthanasia which is a legalised procedure in Australia but is an illegal practice in Singapore.
However, the civil and criminal laws related to euthanasia and end of life care have been
discussed in the assignment. Sometimes, the nurses and doctors are not agreed with the
decisions of the withdrawal of treatment on behalf of the patients which leads them to ethical
dilemma. The assignment focuses on the referral procedure of doctors and nurses during
treatment for avoiding the compromises of patient care.

8Analysis of Legal and Professional Issues
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