Impending COVID-19 Pandemic Establishes Strict Criteria for End-of-Life Decisions
In the midst of the COVID-19 pandemic, the focus on end-of-life decision criteria for dying patients has become increasingly important. One principle that has gained attention is the Pain Principle (PP), which prioritises avoiding harm and suffering over the Best Interest (BI) principle.
The BI principle, often used for deciding on the discontinuation of care for unconscious or non-autonomous patients, has been a subject of public debate, particularly in cases like Charlie Gard and Alfie Evans in Britain. On the other hand, the PP is preferred for end-of-life care, as it suggests that treatments should be changed or reduced in intensity when intractable stress or pain is detected, not with the aim of giving death, but in order to reduce suffering.
The PP can be measured with laboratory tools available to the clinician, such as electronic instruments, hormone changes, activation of the sympathetic system, and multifactorial scales. If we wait to withdraw life-sustaining treatments until pain is evident, the solution is not to suspend care, hydration, and nutrition, but to improve the environment and provide psychological support.
Therapeutic Obstinacy (TO), on the other hand, refers to the unnecessary insistence on medical therapies that have no chance of prolonging life. In English-speaking countries, TO is a synonym for futility and means avoiding useless therapies. However, it is not always against the Best Interest of the patient, as it can provide time for the family to cope and adjust.
The limits of Therapeutic Obstinacy would be evident if it was the supreme criteria for withholding end-of-life therapies, especially in cases of COVID-19 terminal patients. In cases of limited resources, such as ventilators during a pandemic, the criterion of giving precedence to those who suffer more without the treatment should be used.
Discussions have occurred about withholding intensive care for severe COVID-19 patients, particularly regarding access to cures in cases of insufficient life-support tools. In some languages, Therapeutic Obstinacy is referred to as "accanimento" (Italy), "encarnizamiento" (Spain), or "encharnement" (France), all meaning "fury, rage".
It is important to note that the Best Interest principle is vague and difficult to define. Proposals have been made to exclude certain groups, such as the elderly and disabled, from resuscitation, which raises ethical concerns. The necessity to add a principle to deem therapeutic obstinacy immoral arises especially in COVID-19 intensive care patients to prevent futile treatment and respect patient dignity.
In conclusion, the Pain Principle and the avoidance of Therapeutic Obstinacy play crucial roles in making end-of-life decisions, particularly in the context of the COVID-19 pandemic. By focusing on reducing suffering and avoiding futile treatments, healthcare providers can make informed decisions that respect the dignity and autonomy of their patients.
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