End-of-Life Issues

EOL Basics - Defining Dignity

• Core: Patient dignity implies autonomy, respect, comfort, freedom from distress.
• Ethics: Autonomy, Beneficence, Non-maleficence, Justice.
• Care Models:

  Aspect	Palliative Care	Hospice Care
  Primary Goal	QoL improvement, symptom relief	Comfort, peace, dignity at EOL
  Timing	Any illness stage, with curative tx	Terminal phase (often last 6 months)

⭐ India Legal: Passive euthanasia is lawful (Aruna Shanbaug). Advance Directives are recognized (Mental Healthcare Act, 2017; Common Cause ruling).

Patient Wishes - Honoring Autonomy

• Uphold patient's right to make informed healthcare choices (autonomy). Assess Decision-Making Capacity (DMC).
• Advance Medical Directives (AMD): Legally valid documents (e.g., living will, durable power of attorney for healthcare).

  ⭐ Valid AMD (India, Common Cause judgment): Must be written, voluntary, by a competent adult, clearly state treatment preferences, be attested by two witnesses, and countersigned by a Judicial Magistrate First Class (JMFC).

• Communication is Key:
  • Employ shared decision-making.
  • 📌 SPIKES protocol for difficult conversations: Setting, Perception, Invitation, Knowledge, Emotions, Strategy/Summary.

Mind Matters - EOL Distress

• EOL Distress Spectrum: Key differences & screening tools:

  Condition	Core Features	Screening (Cut-off)	Mnemonic
  Depression	Persistent low mood, anhedonia	GDS-15 (>5), HADS-D (>7)	📌 SIGECAPS
  Anxiety	Excessive worry, restlessness, somatic sx	HADS-A (>7), GAD-7 (>10 mod.)
  Delirium	Acute, fluctuating attention & cognition	CAM (Feat. 1+2 AND 3 or 4)	📌 I WATCH DEATH
  Grief	Natural loss response; complicated if persistent	Differentiate from Major Depression

⭐ Depression prevalence in terminally ill patients is high, potentially 25-77%.

Comfort Care - Soothing Symptoms

• Pharmacological Management (Terminal Agitation/Delirium):

• Non-Pharmacological (Anxiety/Depression):

  • Supportive psychotherapy
  • Relaxation techniques
  • Music therapy
  • Spiritual care

⭐ The principle of 'double effect': Administering opioids/sedatives for symptom control is ethically permissible, even if it unintentionally hastens death, provided the primary intention is symptom relief.

High-Yield Points - ⚡ Biggest Takeaways

• Advance directives (living will, healthcare proxy) ensure patient autonomy in EOL decisions.
• Palliative care focuses on symptom relief and quality of life; hospice for prognosis < 6 months.
• Actively screen for and treat depression and anxiety in EOL care.
• Differentiate normal grief from complicated grief (prolonged, impairing).
• Delirium is frequent near death; manage causes and prioritize comfort.
• Capacity assessment is vital for EOL decision-making.
• Clear communication with patient/family on goals of care is paramount_