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Presentation at a training program for
family medicine resident s at the National Guard Madina 9-10 November 2014 by
Professor Omar Hasan Kasule Sr. MB ChB (MUK). M{H (Harvard), DrPH (Harvard)
Chairman of the Ethics Committee King Fahad Medical City
Concepts
- Terminal illness
- Do Not Resuscitate (DNR)
- Withholding of life support
- Withdrawal of life support
- Brain death
Ethical issues in geriatric care:
- Impaired ability to make informed decisions.
- Advance statements
- Proxy decision makers
- In the absence of relatives?
- Deficient decision making capacity
- Decisions on interventions: nutrition, hydration, pain control, infection treatment
- Double effect of analgesics
- Balance between pain control and social life
- Discrimination
- Special services
- Sensitivity training for health care workers
Decisions
for the terminally ill:
- Withhold or withdraw aggressive treatment that has no nett benefit lasting for a reasonable time.
- DNR: Withhold resuscitation in case of cardio-respiratory arrest for patients who cannot get a net benefit from CPR and who will succumb again and have to undergo resuscitation.
- Withdrawal of life support for brainstem dead patients
- Withdrawal of life support from patients in irreversible coma: ? futility ? quality of life
- Decision to donate organs
Issues in decision making
- Capacity for decision making:
- Substitute / proxy decision makers:
- Advance directives
- A do-not-resuscitate (DNR) order is a decision made by three physicians including a disease specialist and the primary doctor of the patient. The family must be informed of the decision but they cannot intervene in the decision.
- The DNR order is made essentially for situations in which resuscitation is futile and not necessarily for terminal disease per se.
- The order should specify which procedures are included in the order: intubation and ventilation, chest compressions, ionotropic drugs, gas mask etc. A do not treat (DNT) order relates to treatment of the primary disease condition like cancer when that treatment is considered futile.
- Euthanasia literally ‘good death’ is causing the death of a terminal patient to save him/her from further pain and suffering.
- Active euthanasia is an act of commission in which the physician takes an action that results in the death of the patient.
- Passive euthanasia is an act of omission in which the physician fails to take action necessary to sustain the life of the terminal patient.
- Both active and passive euthanasia are illegal and healthcare workers who engage in them can be sued for homicide.
- Euthanasia at the request of the patient and with his informed consent is still considered illegal.
- The distinguishing feature of euthanasia is the intention behind the action, sparing the patient further suffering.
- An action than can be considered euthanasia can be deemed legal of the intention behind it is different.
- Withholding a treatment because it is futile is acceptable but withholding it to hasten the death of the patient to avoid further suffering is passive euthanasia.