Ethical considerations at the End-of-life care in low and middle income countries (LMICs)

Mrs. Khan is a 70-year-old South Asian Muslim woman living in Lahore, Pakistan. She has been diagnosed with advanced stage breast cancer and is receiving palliative care at home. She lives with her husband and two adult children. Her family is deeply religious and strongly believes in the importance of preserving life.

Mrs. Khan’s healthcare team has recommended that she be taken off life support and transitioned to comfort care because her condition has deteriorated and there is no chance of recovery. However, Mrs. Khan’s family members are resistant to the idea and are not willing to make the decision to withdraw life support.

 

What is End-of-life care?

End-of-life care refers to the healthcare services and support provided to individuals who are nearing the end of their lives, usually due to a terminal illness or progressive chronic condition. The goal of end-of-life care is to improve the quality of life for patients in their final days and to provide physical, emotional, and spiritual support to both the patient and their family members.

End-of-life care can include a range of services, including pain and symptom management, emotional and psychological support, spiritual care, and practical assistance with daily activities. Palliative care, which is a specialised form of end-of-life care, focuses on managing pain and other symptoms to improve quality of life, and may be provided in hospice settings, hospitals, or in the patient’s home.

 

In End-of-life care, ethical challenges can arise due to cultural and religious differences in beliefs and values.

In this situation, there are several ethical considerations that need to be taken into account. One of the primary considerations is respecting Mrs. Khan’s autonomy and right to make decisions about her own healthcare. However, her family’s cultural and religious beliefs may conflict with this principle, as they may feel responsible for making decisions on her behalf.

Another ethical consideration is the principle of non-maleficence, or the duty to do no harm. In this case, the healthcare team may argue that continuing life support is causing unnecessary harm to Mrs. Khan, as it is prolonging her suffering and may not result in a positive outcome.

A third ethical consideration is the principle of beneficence, or the duty to do what is in the patient’s best interest. The healthcare team may argue that transitioning to comfort care is in Mrs. Khan’s best interest, as it will provide her with pain relief and improve her quality of life in her final days.

 

How would you resolve this?

In order to resolve this ethical challenge, the healthcare team will need to work closely with Mrs. Khan’s family to address their concerns and help them understand the reasoning behind the recommendation to withdraw life support. It may be helpful to involve a religious leader or counsellor to facilitate the conversation and help the family come to a decision that is in line with their religious and cultural values, while also respecting Mrs. Khan’s autonomy and providing her with the best possible care. Ultimately, the decision to withdraw life support should be made with the input and agreement of all parties involved, including Mrs. Khan, if possible.

 

Provision of End-of-life care in LMICs

The provision of end-of-life care exists in low and middle-income countries (LMICs). However, there are significant variations in the availability and quality of care depending on the specific country and region. In many LMICs, access to palliative care and end-of-life services is limited due to a lack of resources, inadequate training of healthcare professionals, and cultural and religious barriers.

Despite these challenges, there have been efforts to improve end-of-life care in LMICs in recent years. For example, the World Health Organisation (WHO) has developed guidelines for palliative care in low-resource settings, and many countries have established palliative care programs and initiatives to improve access to care.

In some LMICs, community-based programs have been developed to provide end-of-life care to patients in their homes, often with the support of trained volunteers. These programs may also provide education and training to families and caregivers on how to care for patients in their final stages of life.

There are also a number of non-governmental organisations (NGOs) working to improve end-of-life care in LMICs. These organisations may provide funding, training, and support for local healthcare providers and may work to raise awareness about the importance of palliative care.

While there is still much work to be done to improve access to end-of-life care in LMICs, there are signs of progress and a growing recognition of the need to prioritise palliative care as an essential component of healthcare.

Written by

Jahanara Miah