Michael Welker | Eva Winkler | John Witte, Jr. | Stephen Pickard (Eds.): The Impact of Health Care (Leseprobe)

46 Christine Thomas
Ethical conflictsand dilemmas arise here on at least threelevels. First, at the
level of the patient, who is supposed to make autonomously informed decisions
through living wills and participatory decision-making requirements. Conflicts
arise here because of the interpretative leeway of many living wills. In particular,
the “deselection” of certain forms of treatment (for example, artificial nutrition
or ventilation) sometimes does not anticipate the need for medical monitoring
of electrolyte imbalances to avoid potentially fatal cardiac arrhythmias,
or for bridging of independent nutrition in the case of swallowing disorders or
delirium (acute confusion) caused by alack of fluids. Often there is only areference
to an advance directive as adocument limiting therapy, without the actual
regulations being perceived and known.
To prevent patients’ wishes from being misinterpreted and their quality of
life and prospects for therapy from being misjudged, the practice of ethics discussions
has become established in hospitals and nursing homes. This practice
brings together attending physicians from various disciplines, nursing staff
from the intensive and long-term care areas,socialworkers, relatives or friends,
as well as pastoral counselors, and, if possible, even the patient to weigh the
various options under professional moderation (an ethics adviser) and consider
the presumed best therapy and life options. In most cases, the principles of utilitarian
ethics are applied; individual partial interests are named and evaluated
accordingly. For example, the decision to temporarily administer fluids may become
possible if the procedure can enhance the quality of life in the short term,
or apalliative situation may be reevaluated under the expert psychiatric assessment
of atreatable depression. In addition, the severity of the need for care and
the resulting burden on partners, children, and relatives can sometimes be assessed
differently than was possible by the patient alone.
On the other hand, physicians’ rejections of unrealistic demands for maximum
therapy become more understandable through the specialist’s detailed explanation
of the objective lack of efficacy of, for example, resuscitation measures
in old age or with regard to the physical strain of days of ventilation in the case
of severe pneumonia, given the background of already advanced frailty or cognitive
impairment.
Rescue services and emergency physicians, however, often find themselves
in situations where information is lacking or wrong, and they then depend on
verbal statements from individuals present—for example, in the nursing home.
This often results in overprovision of careinanemergency situation due to lack
of documentation of atherapeutic focus strictly oriented to quality of life, leading
in turn to misallocated economic resources and aseemingly inhumane action.
At the same time, anihilism in the treatment of very old people arisingfrom
the personal misjudgment of quality of life in illness and disability must be resisted.
Such nihilism prevents athorough consideration of the life situation and