Ethics, Palliative Care, and End-of-Life Decision Making
Core concepts
Understand the ethical principles: autonomy, beneficence, nonmaleficence, and justice. Know surrogate decision-making standards - substituted judgment and best interests. Recognize advance directives, do-not-resuscitate orders, and the difference between withholding and withdrawing life-sustaining therapy (ethically equivalent). Master goals-of-care communication, breaking bad news, and family meetings. Understand palliative care principles: symptom management (pain, dyspnea, agitation), and the role of comfort-focused care. Address conflicts and futility appropriately.
Traps
Withdrawing and withholding therapy are ethically equivalent - do not treat them differently. A surrogate should use substituted judgment when the patient's wishes are known; best interests apply when they are not. Do not assume a DNR order means stopping other treatments. Opioids for dyspnea at end of life are appropriate even if they may hasten death when the intent is symptom relief (principle of double effect).
Worked example
A family requests everything be done for a patient with multiorgan failure and no realistic chance of recovery. The team should hold a structured family meeting, explore the patient's values and previously expressed wishes, clarify prognosis, and reach a shared decision. Rule of thumb: the goal is to align treatment with the patient's values, not to win a debate.