Code of Ethics
Our Common Values
In the service of our patients and of the community, EPCA management and staff seek to maintain the highest standards of home and community-based palliative care in accordance with the Hippocratic-Christian tradition. In addition to the general principles of common morality and healthcare ethics (beneficence and non-maleficence, truth telling, promise keeping, personal responsibility for health and healthcare, and so on), there are principles of particular importance for palliative care which we seek to describe here. The purpose of this present code is to articulate for ourselves and others the basic principles upon which EPCA operates.
All members of EPCA including the Committee of Management and members of the Ethics Committee are required to be committed to this Code; the CEO undertakes to ensure that the code is implemented by staff and volunteers, and to report annually to the Committee of Management upon implementation of this Code throughout the service; the Committee of Management will in turn report on this matter to the Annual General Meeting; the management and staff agree to abide by this Code as a condition of their employment; and the management in conjunction with the Ethics Committee will provide orientation and ongoing professional formation for management and staff which focuses not only on technical competency but also on these ethical guidelines.
As a partnership of religious and community based organisations, EPCA is committed to the following core values: respect for the dignity of the human person; compassion for those who are suffering and dying, and for those around them; justice, excellence and unity in our care. In all their activities our management and staff should act accordingly to the highest ethical and professional standards.
Respect And Compassion For The Human Person
EPCA upholds the dignity and inestimable worth of every individual in our care, including those who are terminally ill, suffering gravely or otherwise at a low ebb. Human dignity can never be lost. We therefore reject the notion that any person can be judged ‘unworthy’ of our care whether because of sickness or short life expectancy, their personal beliefs status or views, their low ‘quality of life’, or considerations of economic efficiency. We devote ourselves to supplying medical, nursing, allied health and volunteer services to those in our region living with a life-threatening or life-shortening illness, and to those around them. We aim to provide integrated services focussed on their particular needs.
Care For The Whole Person
When a person’s life is nearing its end and ‘therapeutic’ treatments are no longer of any avail or are too burdensome, the goal of our care is properly palliative. While many forms of treatment will be inappropriate in such circumstances, other forms of care will be indicated in so far as they sustain patients in their living and dying. By providing physical, psychological, social and spiritual support we seek to help our patients make the most of what remains of their lives, not only alleviating suffering but also enhancing their personal dignity and the quality of their lives. We seek to relieve not only physical symptoms (such as pain and discomfort) but also psychological symptoms (such as anxiety, fear, distress) and spiritual symptoms (crises of faith, hope and love).
EPCA staff therefore seek to establish a relationship of trust, compassion and confidence with all those entrusted to our care.
Reverence For Human Life
Inviolability Or Sacredness Of Human Life
EPCA, in keeping with the Hippocratic and Christian traditions, the principles of palliative care as widely practised in Australia, upholds the inviolability (‘sacredness’) of human life and rejects the practices of assisted suicide and euthanasia, however well-motivated such activities may sometimes seem.1 By euthanasia we mean any action or omission which of itself and by intention causes death with the purpose of eliminating all suffering. It must be distinguished from other care decisions which sometimes risk or have the effect of shortening life but which are not intended to hasten death (e.g. giving of appropriate pain relief, withdrawal of burdensome treatments).
The Hippocratic Oath: “I will never use my art to injure or wrong my patient. I shall give no deadly drug to anybody even if asked for it, nor will I make a suggestion to this effect.” Florence Nightingale’s Path for Nurses: “I will abstain from whatever is deleterious and mischievous, and will not take or knowingly administer any harmful drug.” The World Health Organization includes in its definition of Palliative Care the following statements that Palliative Care: “affirms life and regards dying as a normal process” and “intends neither to hasten or postpone death” (WHO website) For an example of Christian ethics supporting these common values see Code of Ethical Standards for Catholic Health and Aged Care in Australia (CHA 2001)
Examples of euthanasia which must be rejected include administering deliberate overdoses of otherwise appropriate medications, and withholding or withdrawing life-sustaining forms of care that can easily be administered without causing undue burden. Adequate sustenance, antibiotics, and simple remedies to clear blocked airways, will normally be provided unless these would cause undue distress or physiologically overload systems that are failing.
Trust And Creative Responses To Suffering
The relationship between patient and health professionals depends crucially upon the trust that health-workers will always be guardians and servants of the life and health of their patients. In no circumstances will staff initiate or co-operate in a course of action or calculated omissions intended to hasten a patient’s death. Vulnerable patients will be protected from pressures which lower their self-esteem or encourage self-abandonment.
The Voluntary Assisted Dying Act 2017 (Vic) came into force on 19 June 2019. The practice Voluntary Assisted Dying (VAD) is inconsistent with the values of EPCA and this Code of Ethics. Section 7 of the Act permits a right of conscientious objection for registered Health Practitioners. EPCA has chosen not to participate in, offer or support the provision of VAD services. By its public commitment to its clients, carers and their families EPCA embraces the principle of non-abandonment and will provide all of our clients, carers and families with the care, support and respect to which EPCA is committed whether or not they choose to explore or access VAD.
Euthanasia diverts attention and resources away from more positive responses such as holistic provision for the physical, emotional and spiritual comfort of those who are ill, and for their families and carers. EPCA is committed to developing and promoting such creative responses to suffering and dying.
The control of pain may in some cases lead to side effects like loss of energy and reduced activity, loss of lucidity and consciousness, or shortening of life. EPCA is committed to providing the best of pain management in these circumstances while avoiding side-effects of pain medication where possible.
Respect For The Patient
The primary source of EPCA’s right to treat is the patient who approaches us seeking our care. EPCA staff will demonstrate respect for the freedom of conscience and religious and other beliefs of our patients, especially concerning suffering, treatment, dying and death. Even when our patients’ beliefs differ significantly from our own, every support will be made available for them to find meaning in their dying in a way that coheres with their own deepest convictions.
EPCA is likewise committed to ensuring that patients can make their own informed choices about their care, including the type and site of care. Competent patients who are properly informed may consent or refuse consent to treatments they judge to be too burdensome. Accordingly, in so far as the circumstances of illness permit, EPCA staff are responsible for giving patients accurate information about their conditions and prognosis, the range of palliative care options, and the likely and possible effects of these care options. Staff are likewise responsible for ensuring that the patient is, as far as is possible in the circumstances, not only informed but also competent and free when making such decisions.
EPCA acknowledges also the role of the legal representatives of the patient in situations where the patient is not competent to make his or her own decisions. A legally appointed guardian, power of attorney, or medical decision maker appointed under the Medical Treatment Planning and Decisions Act, 2016 (Vic) or, if there is none, the medical practitioner responsible for the patient’s care, (where the provisions of the Act apply will refer the matter to the Public Advocate or) will have to judge whether particular treatments are appropriate or are excessively burdensome or intrusive and should be discontinued.
When treatments are withheld or withdrawn because they are judged medically futile or too burdensome, other care such as appropriate feeding and hydration, hygiene, pressure and comfort care will continue.
Home-based palliative care affects many intimate aspects of people’s lives and the palliative care team often has access to confidential information about patients. A person’s right to privacy must always be respected and confidences kept appropriately.
Respect For The Deceased, For Families And Care-Givers
After death has occurred, the body of the deceased is to be tended with care, reverence and in accordance with the religious beliefs and expressed desires of the deceased.
For Christians, the hope of the resurrection transforms the mystery of death, and the dying Christian person is encouraged to place his or her trust in Christ who, through His life, death and resurrection, has given a new meaning to all human existence and to suffering and death in particular.
The relatives and ‘significant others’ of the dying person are our special concern and are to be given every consideration. Their knowledge of the patient’s wishes and their own views should be taken into account when the patient is incompetent to express his or her own view. EPCA undertakes to provide appropriate professional services and support not only to patients, but also to their families, care givers and others. This includes support through the period of dying, grief and bereavement.
Respect For Staff
EPCA seeks to establish and maintain a relationship of mutual trust and support between management and staff, whether paid or volunteers. We undertake to train, supervise and support our staff appropriately.
While the ultimate responsibility for decision about a patient’s treatment usually lies with the patient and his or her medical practitioner, all members of the palliative care team must make their own professional contribution to palliative care decisions and are accountable for their own practice. Members of the team therefore have a right to know the rationale for providing a particular intervention they are asked to perform, or for withholding or withdrawing a particular form of care they are asked to withhold or withdraw, and an obligation to provide the medical practitioner and other members of the care team with relevant information.
The integrity of all members of the palliative care team must be respected. Staff have the right to object on conscientious grounds to taking part in a course of action they judge to be unethical.
Respect For Justice, Community And Law
Justice And Charity For All
EPCA seeks to enact justice and charity in all its activities. We recognise and seek to answer the basic human right to palliative care in life-threatening or life-shortening illness, and we accept responsibility for stewardship over the material resources and personnel we have for providing such care. We recognise that resources and personnel must be used responsibly and distributed fairly among those who need them.
Accountability To The Community
We also recognise that the Victorian community provides us with resources and opportunities to perform our particular service. We are therefore accountable to government and the community for our use of those resources and opportunities. We are also accountable to the members of our Sponsoring Bodies, to our benefactors and friends, and acknowledge a particular debt of gratitude to them and our need for their continuing support.
EPCA staff will respect all legal and moral requirements with respect to the inviolability of human life, the provision of due care, consent to and refusal of treatment, guardianship and power of attorney, fulfilment of contractual promises to the Department of Health and Human Services (Victoria), corporations, charities and other appropriate laws. With respect to the last of these EPCA has agreed to provide services that are integrated, equally accessible and evenly available throughout the Eastern region of greater Melbourne.
Research And Education
While all procedures undertaken by EPCA will be directed primarily to the good of patients, we recognise that much valuable research and education depends on the generous involvement of patients and others in procedures which are not necessarily of immediate benefit to them but which advance knowledge of palliative care or the education of palliative care professionals. We will undertake and participate in such research and education and the broader role of informing and educating the community regarding palliative care. All research requires the consent of the research subject and the approval of the appropriate research ethics committee.
Role Of The Ethics Committee
This code contains norms for sound ethical decision-making in palliative care. EPCA looks to its Ethics Committee to advise on the application of this code and more general principles to the care of our patients, to advise on ethical issues relating to the employment and deployment of staff, and to assist in the orientation and ongoing professional formation of management and staff.
Adopted as at 10th November, 2020