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Exploring the role that autonomy plays in achieving a good death: a case study

02 January 2016
Volume 8 · Issue 1


Currently patients at the end of life, for numerous reasons, often dial 999 when they experience many symptoms that can impact upon their current quality of life, such as pain and breathlessness. These calls regularly elicit a high priority paramedic response, which when taken in context, may be inappropriate, and can often lead to transportation to hospital, which itself can be inappropriate, and or delay in the most appropriate care required. This is worsened somewhat by sporadic or non-existent community palliative care coverage in various areas.

The concept of autonomy is key to patient care, but arguably more so at the end of life. This article will review the available literature and recent evidence in the context of an anonymised case study, to highlight how patient and family autonomy can guide and support the decisions made by paramedics in these cases, and the benefits and challenges this autonomy brings, in the current social context of health care.

This case study aims to didactically explore the concept of an autonomous good death through an anonymised example from practice. In doing so, it will explore the surrounding concepts of advanced decision making, do not actively resuscitate orders, mental capacity, a good death, and a good-enough-death, and how autonomy guides all of these areas of care. In doing so paramedics may be better able to respond to some of the challenges they face in clinical practice, while attempting to provide the most appropriate care at the most appropriate time to those at the end of life.

‘You matter because you are you, and you matter to the end of your life’

It is this end of life to which leading 20th century hospice campaigner Dame Cicely Saunders refers, that has become increasingly prominent within health and social care policy and practice in recent years.

With the general United Kingdom (UK) population continuing to grow, those living longer often do so with chronic/long-term and life-limiting conditions (NHS England, 2014). This is partly due to the West's perceived continued medical and technological propensity to postpone death (Komaromy, 2001; Clark, 2002). As a result, there is an increasing need for high-quality palliative and end-of-life care (EoLC), for which the aim is to ultimately achieve a good death for the service user and the family.

Multiple authors argue that paramedics play a significant role in achieving this aim (Munday et al, 2011; Nelson and French, 2012; Brady, 2013; 2014). However, despite this, recent studies have indicated that EoLC education for paramedics is sporadic, with feelings of confusion, complexity, and uncertainty often surrounding decision making, especially when addressing legal and ethical issues (Munday et al, 2011; Taghavi et al, 2012), such as autonomy.

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