END-OF-LIFE treatment involves ethical dilemmas and different healthcare professionals may take different approaches, according to Prof David Smith of the Irish Council for Bioethics.
Prof Smith was speaking at a conference on advance care directives organised by the Law Reform Commission yesterday. The commission launched a consultation paper on the subject at the conference, recommending a legislative framework for such directives.
This would mean that people could set out in advance what treatment they did not wish to receive in the event of them being incapacitated by serious accident or illness.
Prof Smith said approaches to end-of-life decisions in Europe differ greatly. This underlined the need for a legislative basis for advance care directives.
"Decisions that run contrary to patients' strongly held religious or personal beliefs, which are made without the patient's or family's knowledge or discussion, represent a serious ethical problem in end-of-life care," he said.
Advance care directives are an expression of a person's autonomy in decision-making, he said, but not making a directive was also an expression of such autonomy.
A controversial issue was a requirement on healthcare professionals that they implement a patient's request, even if it was contrary to their ethical beliefs, until a professional who was prepared to carry it out was found, he said.
Mervyn Taylor, manager with the Hospice Friendly Hospitals programme, said feedback from this programme raised a number of concerns. These included the level at which decisions on resuscitation are made; concerns about the way in which decisions were made without consultation; concerns about the wishes of patients being ignored and the avoidance of discussion of patient preferences among some care staff.
Research had shown people would like more control over their final days, but few would be willing to formalise their instructions too far in advance, he said.
He said advance directives are widely advocated for end-of-life decisions, but they should be seen as part of an overall process aimed at improving the culture of end-of-life care. At the moment, the law was unclear about the status of wishes expressed by the deceased, including those relating to funeral services and burial or cremation.
Responding to the debate, Prof Desmond O'Neill, an expert in gerontology, told The Irish Times the appropriateness of advance care planning had come under increasing scrutiny in recent years. Older people may suffer from institutionalised ageism and a failure to access healthcare. The findings of a survey of older people in Ireland suggested the emphasis on advance care planning for older people be matched to whether there was a need for service or support, rather than applied indiscriminately, he said.