End-of-Life Decision Making: Ethical, Legal, and Practical Aspects

This essay examines the multifaceted issue of end-of-life decision-making, addressing its significance as a critical healthcare topic. It delves into various forms of decision-making, including advance directives and DNR orders, while highlighting the ethical and legal complexities involved. The essay explores the ethical dilemmas faced by healthcare providers, such as balancing patient autonomy with the preservation of life, and the potential conflicts between healthcare providers and patients or their families. It further discusses the legal issues surrounding advance directives and the evolving landscape of euthanasia in Australia, particularly in Victoria, where assisted dying is now legal under specific conditions. The author agrees with the current approach, emphasizing the importance of individual rights and the ability to make informed choices about one's own life and death, especially when facing unbearable pain and suffering, and the importance of regulated end-of-life decisions to prevent potential abuse or misuse.

End of Life Decision Making

Table of Contents
Introduction................................................................................................................................3
Why is the topic the area you have chosen a significant health issue?......................................3
What are some of the ethical issues in this area?.......................................................................5
What are some of the legal issues in this area?..........................................................................6
What is happening in Victoria/ Australia this year in relation to your chosen issue?...............6
Do you agree with the current approach? If so, why If not, Why?............................................7
Conclusion..................................................................................................................................8
Bibliography...............................................................................................................................9

Introduction
End of life decision making in simple words can be understood as the process through which
the healthcare experts, patients as well as their families undergo at the time of treatment of
life threatening illness (Thelen, 2018). There are a number of forms available during this
decision- making process. The first is the advance directives in which the patient’s are given
opportunity to showcase their preference in writing before the occurrence of the critical
illness. It has been proved that advance directives have minimal impact on the actual care that
is being received by the patient at the time of end of life (Medline Plus, 2018). Another such
decision is related to resuscitative efforts. This is related to DNR orders that are Do-Not-
Resuscitate which may vary from content to content depending upon the patient’s request that
is to use no resuscitative efforts or to use limited efforts at the time of cardiac arrest (Weiss &
Hite, 2000). The third type of end of life decision is related to the withholding or withdrawing
of the life sustaining therapies and equipments being used during the end of life. These
include antibiotic therapy dialysis, mechanical ventilation administration of fluids nutritional
feeding, etc. (Curtis, et al., 2002). Many experts have shown their interest towards improving
the decision -making process near the end of life. It has been seen that many times conflict
arises when the meaningful survival of patients is not possible but, the expert’s main aim is to
preserve life and take decisions that benefits the patients. This has taken the shape of ethical
decisions in the field of health care. This is so because the current law and policies have made
the patients self determination as priority while taking decisions related to end of life. The
new laws have given the power to patients to refuse the medical treatment (Rosenfeld,
Wenger, & Kagawa-Singer, 2000).

Why is the topic in the area you have chosen a significant health issue?
End of life decision making is a very important and crucial topic that is related to the ethics of
health care. This issue is important as it requires critical scrutiny as it has been seen that very
rarely health care researches have focused or questioned the bioethics practice that is based
on the power of autonomy. Many of the researches have just focused over the idealized
discourse of the patients and their decision towards the embracement of their dying condition
(Drought & Koenig, 2002). Some of the issues revolving around the end of life decision
include autonomous decision -making. This is an issue as, at the time of decision- making
many complex thoughts arise which poses a serious challenge in front of the patient as well
as their family members at the time of end of life. (Emanuel & Scandrett, 2010). Conflict
between the healthcare providers and patients is also an important issue that is seen in such
cases. This usually arises when the patient or their families and the healthcare providers are
not able to adopt a mutual decision (Winzelberg, Hanson, & Tulsky, 2005). Another issue
related to this is that when the family is supposed to take decisions as surrogate or proxy, then
they tend to take emotional decisions as they are emotionally attached to the patient. Also,
there are chances that their decision may be influenced on the basis of their emotional
condition or financial pressure and hence, such decision taken may not be in favour of the
patient’s benefit. Hence, this may give rise to legal and ethical issues during the end of life
decision (Monagle & Thomasma, 2004). Another major issue related to this is that because of
the technological advancements like life support systems etc. the unaffordable cost of
healthcare is on an increase and hence, this is giving rise to inequitable healthcare services
(Hopkins, 2010). Hence, it can be said that many ethical issues are connected to this issue and
hence, this is the major reason for selecting this issue. Many times it has been seen that the
healthcare providers has to consider patient’s perspective and has to go against their ethics
which asks them to take decisions that are beneficial to the patient. Hence, this issue is

challenged by many medical experts and many areas still need to be explored over this topic
(Karnik & Kanekar, 2016).
What are some of the ethical issues in this area?
End of life decision making is seen as an ethical problem in the clinical practice by the
healthcare providers. This is so because the physicians have to write the orders related to the
end of life decisions and so they feel heavy burden of responsibility while doing so
(Nordgren & Olsson, 2004). This is so because during such situations, they feel like who are
they to take such decisions. It has also been seen that apart from physicians and families
conflict arises even between nurses and physicians. This is so because they find themselves in
dilemma when the physician either stops the treatment too soon or continue the treatment for
too long when it is not required (Tripathy, Routray, & Mishra, 2017). This results in moral
distress as nurses start to believe that they are contributing in the patient’s suffering and is
working against the benefit of the patient (Oberle & Hughes, 2001). Hence, this is a serious
issue and therefore requires many ethical perspectives at the time of dealing with such issue.
It has been seen that healthcare providers find them in difficulty when it comes to equitable
and distributive justice in the cases of such patients where expensive treatment is required.
Also, healthcare providers find them in a fuss when they do not have the required resources
to offer to the patient at the time of end of life decision making. Also apart from this, it has
been seen that the physicians find it very difficult to make the families of patient understand
about the seriousness of the situation and to agree them on taking certain decisions that is
beneficial for the patient (Thorns, 2018). The main ethical dilemma in case of physicians is
experienced when the families are not able to come to a conclusion and the main decision is
required to be taken by the healthcare providers. At such situations, the physicians are not
able to decide the difference between what is ethically correct and what should actually be
done (Matzo, Sherman, Nelson-Marten, Rhome, & Grant, 2004). The right of the patients to

refuse treatment is also seen as an ethical issue in front of the physicians. This is so because,
the physicians want to take care of the patient till the end of the last breathes of the patient,
but if the patient denies receiving treatment, then it stands as an ethical dilemma in front of
the doctors and nurses (Kyba, 2002).
What are some of the legal issues in this area?
Any person who is suffering from any sort of pain and not just dying deserves to get
treatment and get relief from pain (NAP, 2018). The physicians and nurses have both the
legal as well as ethical right to protect the life of a person. But, it has been seen that many
laws are being adopted in several cou-ntries that are legalizing that the end of life decision
should be left on the patient and the final decisions will be on the basis of the patient’s
decisions. It has been seen that these legalities stand as issues in front of the physicians when
they want to help the patient but, the ultimate decision is of the patient (Rahman, 2017).
Some of the major legal issues that are faced during the end of life decision are related to the
advance directives. That is, if the person has already developed his or her advance directive
before losing his or her capacity, then it is fine. But, if the patient has not developed advance
directive, then this poses a serious legal issue. This is so because in such cases the next
person to take decision is the family members of the patient. This may pose serious issue as
the person will decide on the basis of what he or she believes and what is in their best interest
and may not consider the interest of the patient. So in such cases, the patient may not get
what he or she deserves (Queensland University of Technology, 2018).
What is happening in Victoria/ Australia this year in relation to your
chosen issue?
Euthanasia is a form of end of life decision. Euthanasia in simple words can be understood as
an intentional act of a person towards ending the life of another person in order to relive that

person from suffering. Such acts are sometimes considered as assisted dying as it is seen as
one person that is the doctor or the family or friend of the patient assist the patient to
intentionally kill themselves. These acts are illegal in Australian States and Territories. In
Australia, the person caught practicing Euthanasia may be charged with murder or
manslaughter or as they term it as assisting suicide. But, this scenario is going to be changed
in Victoria with effect from 19th June 2019. In Victoria, the assisted dying that is Euthanasia
is going to become legal under certain limited circumstances. In the year 2015, the
Legislative Council agreed to pass the motion related to the discussion of need for laws in
Victoria that will give the rights to patients to take end of life decisions. A committee was
established in 2016 to discuss over this and 49 recommendations were made including
legalizing assisted dying in Victoria. And on the basis of the final result came out in the form
of Voluntary Assisted Dying Bill 2017, which legalized the use of euthanasia under certain
limited conditions (Parliament of Victoria, 2018). One of the prominent neurosurgeons Brian
Owler who has also been the head of the Australian Medical Association is joining hands
with the former chief minister of Northern Territory that is Mr. Marshall Perron to support
the private member’s bill that is related to the repealing of the ban on Australian States
related to the legalization of euthanasia. Hence, it can be said that many experts and veteran
politicians of the country are in the favour of euthanasia and is taking all the possible efforts
to legalize euthanasia in every state of Australia (Murphy, 2018).
Do you agree with the current approach? If so, why If not, Why?
I believe that the current approach adopted by Victoria / Australia towards end of life
decisions is correct. This is so because every person has all the possible rights to take
decisions related to his or her life. If we consider about the human rights, then right to die is
also a human right which should be given to citizens. Also, death is a private matter and if it
is not causing any harm or damage to any other person or state then there is no right to

interfere in the patient’s decision. Another important fact is that it is possible to regulate the
end of life decisions like for example, euthanasia in case of Victoria is regulated by making it
legal under certain conditions. Hence, this will help in keeping a check over any evil
intentions or any wrong doing of the patient’s family members or friends. It is the right of
every person to relief him or her from pain and misery if they want to and no one should
interfere in this. Hence, I believe that this legislation of the Victorian Parliament is right and
all the other states should support this decision of the government.
Conclusion
In the end it can be concluded that if the end of life decision is regulated properly, then there
is no harm in giving the right to decide within the hands of patients and their family
members. Though, many ethical and legal issues are related to this topic but, with the help of
proper regulation these issues can be overcome. Also, it is important that the physicians and
the patients and their family members should take efforts to reach to a mutual agreement so
that the physicians do not find themselves in ethical dilemma during the end of life decisions.

Bibliography
Curtis, J. R., Engelberg, R. A., Wenrich, M. D., Nielsen, E. L., Shannon, S. E., Treece, P.
D., . . . Rubenfeld, G. D. (2002). Studying communication about end-of-life care
during the ICU family conference: development of a framework. Journal of Crtical
Care, 17(3), 147-160.
Drought, T. S., & Koenig, B. A. (2002). "Choice" in End-of-Life Decision Making:
Researching Fact or Fiction? The Gerontologist, 42(3), 114–128.
Emanuel, L., & Scandrett, K. G. (2010). Decisions at the end of life: Have we come of age?
BMC Medicine.
Hopkins, J. (2010). Reasoning Through The Rationing Of End-Of-Life Care. Retrieved from
www.hopkinsmedicine.org:
https://www.hopkinsmedicine.org/news/media/releases/Reasoning_Through_The_Rat
ioning_Of_EndOfLife_Care
Karnik, S., & Kanekar, A. (2016). Ethical Issues Surrounding End-of-Life Care: A Narrative
Review. Healthcare, 4(2).
Kyba, F. C. (2002). Legal and ethical issues in end-of-life care. Critical Care Nursing Clinics
of North America, 14(2), 141-55.
Matzo, M. L., Sherman, D. W., Nelson-Marten, P., Rhome, A., & Grant, M. (2004). Ethical
and Legal Issues in End-of-Life Care: Content of the End-of-Life Nursing Education
Consortium Curriculum and Teaching Strategies. Journal for Nurses in Staff
Development (JNSD), 20(2), 59-66.
Medline Plus. (2018). Advance Directives. Retrieved from medlineplus.gov:
https://medlineplus.gov/advancedirectives.html
Monagle, J. F., & Thomasma, D. C. (2004). Health Care Ethics: Critical Issues for the 21st
Century. Jones & Bartlett Learning.
Murphy, K. (2018, july 25). New push to overturn Australia's Howard-era euthanasia laws.
Retrieved from www.theguardian.com:
https://www.theguardian.com/society/2018/jul/25/new-push-to-overturn-australias-
howard-era-euthanasia-laws
NAP. (2018). 7 Legal Issues. Retrieved from Nap.edu:
https://www.nap.edu/read/5801/chapter/9
Nordgren, L., & Olsson, H. (2004). Palliative care in a coronary care unit: a qualitative study
of physicians’ and nurses’ perceptions. Journal of Clinical Nursing.

Oberle, K., & Hughes, D. (2001). Doctors’ and nurses’ perceptions of ethical problems in
end-of-life decisions. Journal of Advance Nursing, 33(6), 707-15.
Parliament of Victoria. (2018). Voluntary Assisted Dying Bill 2017. Retrieved from
www.parliament.vic.gov.au:
https://www.parliament.vic.gov.au/publications/research-papers/download/36-
research-papers/13834-voluntary-assisted-dying-bill-2017
Queensland University of Technology. (2018). Legal Overview. Retrieved from end-of-
life.qut.edu.au: https://end-of-life.qut.edu.au/legal-overview
Rahman, D. S. (2017). Legal and ethical issues around end of life care in dementia - lecture .
Retrieved from www.hospiceuk.org: https://www.hospiceuk.org/docs/default-
source/What-We-Offer/Care-Support-Programmes/dementia-network/legal-and-
ethical-issues-around-end-of-life-care-in-dementia-14-june.pdf?sfvrsn=2
Rosenfeld, K. E., Wenger, N. S., & Kagawa-Singer, M. (2000). Intensive Care. Retrieved
from www.dartmouth-hitchcock.org: https://www.dartmouth-hitchcock.org/dhmc-
internet-upload/file_collection/Rosenfeld%20K.pdf
Thelen, M. (2018). End-of-Life Decision Making in Intensive Care. Retrieved from
ccn.aacnjournals.org: http://ccn.aacnjournals.org/content/25/6/28.full#ref-9
Thorns, A. (2018). Ethical and legal issues in end-of-life care. Retrieved from
http://www.clinmed.rcpjournal.org:
http://www.clinmed.rcpjournal.org/content/10/3/282
Tripathy, S., Routray, P. K., & Mishra, J. C. (2017). Intensive Care Nurses' Attitude on
Palliative and End of Life Care. Indian Journal of Critical Care Medicine, 21(10),
655–659.
Weiss, G. L., & Hite, C. A. (2000). The do-not-resuscitate decision: the context, process and
consequences of DNR orders. Death Studies, 24(4), 307–323.
Winzelberg, G. S., Hanson, L. C., & Tulsky, J. A. (2005). Beyond autonomy: Diversifying
end-of-life decision-making approaches to serve patients and families. Journal of the
American Geriatrics Society, 53(6), 1046-1050.