Presentation Title: “Hospital admissions towards the end of life: Exploring the moral landscape of clinical decision making”

Abstract:

The way clinicians, carers, families and society treat a person towards the end of their life is morally complex: we seek a “good death” although we may not know what that looks like, and we navigate a complex web of unknown possibilities to take the “right” action for that person. We seek to avoid suffering in all its forms. This presentation will explore one aspect of the journey towards the end of life: whether or not someone who may be in their final months should go to hospital for medical treatments.

 The outcome of hospitalisation towards the end of life ranges from complete cure of a reversible pathology to significant psychological, physical and functional harm. Hospital is a common place of death, which may or may not be in keeping with a person’s own perception of a “good death”. Whether or not someone should be admitted requires careful consideration of the person’s own values and priorities, the risks of all options, and the best clinical prediction of net benefit.

 This presentation will explore three questions around hospitalisation decisions:

1. Why do and should decisions around hospitalisation carry moral weight? I will discuss some of the potential harms of a stay in hospital as well as illustrating the uncertainty often encountered towards the end of life and how this makes decisions around reversibility and risk particularly challenging. It will show the network of individuals involved, and some of the values, beliefs and priorities they may bring to the table.
2. How can theoretical ethics help us navigate these decisions? Historically autonomy, non- maleficence and beneficence have been used to lead ethical practice at the end of life. I will consider how these principles, ethics of care and a patient narrative approach could be used when considering hospitalisation and put forward an argument to combine aspects of the three approaches.
3. Can empirical insight and experience enrich the ethical conversation around hospitalisation? There is some evidence that people experiencing the end of life, and providing end of life care, do not identify the same ethical challenges predominant in the literature (Schofield et al. 2021). We will discuss the potential benefits of framing our normative questions around problems that are experienced on the ground, in order to ensure that any conclusions are practically defensible and applicable. This presentation forms part of a larger Empirical Bioethics project aiming to explore what “good” hospitalisation decisions towards the end of life might look like.

Schofield, G., M. Dittborn, R. Huxtable, E. Brangan, and L. E. Selman. 2021. 'Real-world ethics in palliative care: A systematic review of the ethical challenges reported by specialist palliative care practitioners in their clinical practice', Palliat Med, 35: 315-34.