A clinician's understanding of ethics in palliative care: an American perspective

I believe the standard for making ethical decisions should be the same for all patients: appropriate medical interventions, carefully weighing their benefits and burdens, and trying to honor the wishes of the patients. When cure is not possible, the balance between benefits and burdens should shift to greater consideration of the burden side of the equation. The ascendancy of autonomy over other medical ethical principles is the center for most of the ethical dilemmas encountered in palliative care. This paper discusses the issues of autonomy, informed consent, patient capacity, advance directives, futility, 'do-not-resuscitate' orders, withholding or withdrawing interventions, euthanasia, and sedation therapy. After 41 years of my personally caring for over 4000 terminally ill patients, primarily at Calvary Hospital, the most practical approach has been to establish trust with patients and families, determining their goals, and diligently applying the principles of beneficence (benefits) and nonmaleficence (burdens) in everyday practice. (C) 2003 Published by Elsevier Science Ireland Ltd.