European Network of Health Care Chaplaincy
Association of ministers in the Church of Norway.
The State Department of Health and Care issued just recently a new guidance for how to reach decisions in cases of ending / not initiating life-sustaining treatment. The main purpose of the guidance is to draw pathways to secure procedures for the making of decisions.
Not initiating and to withdraw a treatment is considered ethically to be equal.
As a rule, decisions regarding curative or life-sustaining treatment to be initiated or withdrawn, are made by the hospital / doctor responsible for the treatment of the actual patient. A patient can not demand a treatment that is considered by the medical staff to be futile or / and to cause unnecessary pain to the patient. A patient has the right to refuse treatment also when it is recommended by the medical staff. (informed authonomy ) Each hospital has a clinical ethics committee that is to be consulted in cases where it is difficult to reach a consensus. When there is question of impartiality or there is disagreement between medical staff and patient or patient family, there are procedures for how the clinical ethics committee from another hospital should give its opinion. ( the chaplain is member of a clinical ethics committee ) Also there are procedures for how and when second opinions on medical assessments are to be gathered.
In the Standard procedure for palliative treatment, there are procedures also for terminal sedation. As a final option terminal sedation is allowed according to certain procedures and indications. (it seems that terminal sedation is not in use very often ).
Treatment of pain which sometimes, while aiming at relief and less pain, still may shorten life a little, is considered as good and responsible treatment. It is the aim of the treatment that is the crucial point.
Euthanasia and assisted suicide is not legal. In connection with the election for Parliament in the fall of 2009, one of the major political parties came up with a suggestion of changing the law on this point, making euthanasia and assisted suicide legal according to certain procedures. It is not likely to become a real issue in Parliament, as it looks now. It is quite some time (7 years?) since one case of euthanasia was taken to court. The doctor was found guilty but was admitted no sentence.
In the public hearing of the new guidance of ending life-sustaining treatment, the church had the opportunity to express its view. I have noticed a consensus on this matter and the legal situation on end of life issues are very much in agreement with church views on the matter.
3. The main tensions in the chaplains general practice concerning quality of end of life.
a. One tension is this: Hospital units that are curative units, do not always offer an environment that is optimal for the terminal (or pre-terminal) patient and the families. And the number of beds in palliative units is too small. Or as the case is in the local nursing-homes: the staff does not have the professional standard that is required for the type of care that these patients need. Probably the answer to the demand to legalize euthanasia or assisted suicide is the improvement of palliative treatment and care.
b. Another tension is the sort of communication / lack of dialogue on end of life issues between medical staff and patient and their families. Very much can be said about this and this is not the place – maybe a topic for a later consultation.
This has obviously to do with many things: the culture of the hospital unit, the communication patterns within the families, the way doctors view this part of their work, and how life and death issues are treated in the society as a whole.
Too often the communication initiated by the hospital, often is without crucial starting point: How do the patient and family view the situation. And without the crucial question: What is now most important for you (patient, family of patient)?
December 1st 2009.
Torbjørn Skjælaaen
Chaplain at Haukeland University Hospital
Bergen – Norway.