Ethical Decision-Making in End-of-Life Care

Authored by: Asha Gandreti

Art by: Eileen Cho

The end of life is a period of overwhelming uncertainty, where an abundance of unanswered questions may arise from patient, family, and provider perspectives; is there truly a correct course of action to take when a loved one is diagnosed with a terminal disease? While there may not be one straightforward answer to this question, it is undeniable that it carries a heavy weight on providers and families who must make pressing decisions on a patient’s health. 

When one considers medicine and medical decision-making as a whole, it is easy to think primarily of preventative and curative care. Healthcare, however, encompasses a much wider scope of patient services, including hospice and palliative care. End-of-life care is the process of providing physical comfort and tending to the mental, emotional, and spiritual needs of those who are actively dying; it is an essential, yet oftentimes overlooked, component of health care. 

This article outlines several ethical factors that must be considered to make informed and value-aligned decisions during a patient’s final days of life. Choices revolving around end-of-life care ultimately should be guided not just by medical judgment, but by respect for patient autonomy and the moral principles surrounding dignity in life’s final stages. 

To begin, the concept of autonomy–a patient’s right to self-determination–must be emphasized. Autonomy lays the foundation of medical ethics, a framework that guides medical professionals in their prioritizing of patients’ well-being [1]. An essential tool that builds on this idea of autonomy and medical ethics is the advance directive (AD): oral or written instructions on medical decision-making in the event that a patient loses the ability to communicate decisions for themselves [2]. In a study published by the National Library of Medicine, approximately 80% of patients who had died from advanced cancer completed ADs, and about half were reported to have helped guide care. It was also noted that the majority of patients passed away in their location of choice [3]. 

Additionally, the appointment of a healthcare proxy–also known as a health care agent or power of attorney–can further ensure that a patient’s values and wishes are respected after the patient has lost their ability to make decisions. The sequence of decision-making authority typically follows this order: the patient retains ultimate control while competent; if their decision-making capacity is lost, the AD serves as the guide. Next in line is the designated health care proxy, and when neither an AD nor proxy is in place, decision-making falls to family members, and finally, to the treating physician [4]. 

When physicians become the primary decision-makers, it is of utmost importance that they act with both beneficence and non-maleficence in mind. Beneficence refers to the physician's obligation to promote the patient’s well-being and act for their benefit. Non-maleficence, on the other hand, is a physician's duty to avoid doing harm on their patient [5]. Applying these two principles can aid in determining when curative measures are no longer in alignment with the patient’s values or overall quality of life. 

 As a result, these ethical considerations play a vital role in examining and determining whether a patient should receive curative or palliative care. The National Cancer Institute defines curative therapy as treatment meant to cure an illness (with the goal of a full recovery), while palliative care is provided to improve quality of life and reduce pain in those suffering from life-threatening illnesses. Fully understanding these options allows families and health care proxies to make decisions that appropriately mirror patients’ values. 

Here at Cornell University, various student organizations work to bridge gaps between public knowledge and the vast realm of healthcare. GlobeMed–a chapter organization providing experiential learning opportunities for students interested in global health–educates its members weekly on current events while simultaneously enhancing the visibility of smaller, often unnoticed healthcare issues. Additionally, the STEMinist Movement at Cornell directs educational outreach to elementary and middle schools in the greater Ithaca area, strengthening youth awareness on topics such as health, science, and engineering. These organizations’ commitments can be mirrored to increase public knowledge on end-of-life care considerations, whether it be through health organizations at Cornell, or larger global movements towards health ethics literacy. 

References

1. Young, M., & Wagner, A. (2025). Medical ethics. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK535361/

2. House, S. A., Schoo, C., & Ogilvie, W. A. (2025). Advance directives. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK459133/

3. Bakitas, M., Ahles, T. A., Skalla, K., Brokaw, F. C., Byock, I., Hanscom, B., Lyons, K. D., & Hegel, M. T. (2008). Proxy perspectives about end-of-life care for person’s with cancer. Cancer, 112(8), 1854–1861. https://doi.org/10.1002/cncr.23381

4. Akdeniz, Melahat, et al. “Ethical Considerations at the End-of-Life.” SAGE Open Medicine, vol. 9, Mar. 2021, p. 20503121211000918. PubMed Central, https://doi.org/10.1177/20503121211000918.

5. Varkey, Basil. “Principles of Clinical Ethics and Their Application to Practice.” Medical Principles and Practice, vol. 30, no. 1, Feb. 2021, pp. 17–28. PubMed Central, https://doi.org/10.1159/000509119.