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

I believe that the standard for ethical decision-making should be the same for all patients: appropriate medical interventions, careful consideration of their benefits and burdens, and respect for patients' lives. When a cure is not possible, the balance between benefits and burdens should be shifted to greater consideration of the burden side of the equation. The dominance of autonomy over other medical ethical principles is at the centre of most ethical dilemmas encountered in palliative care. This article discusses issues of autonomy, informed consent, patient capacity, advance directives, futility, prohibitions on resuscitation, withholding or withdrawing interventions, euthanasia and sedative therapy. After 41 years of my personal care of more than 4,000 terminally ill patients, mostly at Calvary Hospital, the most practical approach has been to build trust with patients and families, define their goals and meticulously apply the principles of beneficence (benefit) and nonmaleficence (burden) in daily practice.