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Presentation
at a training program ‘Applying the Principles of Ethics to Clinical
Practice:’ held at Aramco Dhahran April 6, 2015 by Professor Omar Hasan
Kasule Sr. MB ChB (MUK). MPH (Harvard), DrPH (Harvard) Chairman of the Ethics
Committee King Fahad Medical City.
Case 1: Palliative vs curative care
Scenario 1: A 90-year old in ICU with stage 4
widely metastasized cancer and multi-organ failure was told by the doctors that
there was nothing they could do to reverse the course of the disease and that
they could only provide symptomatic treatment. He asked to be discharged to die
at home. His children objected saying that he needed complex nursing that they
could not provide at home. He was finally admitted to a private hospice that
provided palliative care at great expense.
Hint: importance of palliation
Case 2: Capacity for decision making
Scenario: The thoracic surgeon wanted to carry out a de-bulking operation
to decrease lung cancer mass to enable the patient breathe easier and he told
the patient of the high risk of death from hemorrhage. The patient 85-year old
patient was drowsy because of medication and was suspected of suffering from
dementia. The doctor was not sure whether the patient was capable of
understanding the explanations given and making serious decisions about the
operation and he had no relatives nearby.
Hint: impaired decision making capacity requiring competence testing
Case 3: Advance directive proxy vs father
Scenario: A 30-year old patient of multiple sclerosis had 5 years before
while in good health designated her husband as the decision maker. When she
lost consciousness the doctors needed a decision whether to put her on life
support. The husband who had by that remarried and lived in a separate house
decided against life support because it would prolong her suffering. Her father
intervened and decided for life support because that would be in her best
interests.
Hint: need for a policy to select the family proxy decision maker
Case 4: Advance directive: anticipated vs real circumstances
Scenario: A university professor with previous episodes of transient stroke
had written a directive and had it witnessed that if he lost consciousness he
would not like to be resuscitated. Years later he was brought to the hospital
unconscious from head injuries sustained in a car accident. The doctors reading
his directive in his shirt pocket decided not to resuscitate him but his wife
insisted that he be resuscitated.
Hint: problem of advance directives being applied to unanticipated
situations
Case 5: DNR physicians vs family
Scenario: Doctors wrote a Do-not-resuscitate (DNR) order for an 80-year old
grandmother with disseminated untreatable ovarian cancer. Her family objected
vehemently when told of this decision and sought its reversal. Before the
dispute was resolved the patient collapsed after an episode of acute pneumonia
unrelated to her original condition. The nurses following the DNR order did not
call the resuscitation team.
Hint: DNR is a physician and not a family decision
Case 6: Euthanasia
Scenario: A 70-year old man with advanced
cancer with severe pain not responsive to morphia asked the doctor to kill him
and save him from suffering. The doctor refused claiming that he could not
commit illegal homicide. The doctor also refused to give the patient any advice
about suicide. On the patient’s insistence the doctor agreed to stop hydration
and nutrition to enable slow death.
Hint: passive euthanasia by withholding food and hydration is illegal
Case 7: Withholding futile life support
Scenario: A car accident victim in severe shock was wheeled into the
emergency room with un-recordable blood pressure or pulse. ECG showed low
amplitude slow waves. The doctor did not declare death but against the
insistence of family members refused to institute life support because he
reasoned there was no hope. The patient was declared dead 1 hour later. The
family threatened to sue the doctor.
Hint: doctor judgment vs family emotions
Case 8: Life support with brain stem death
Scenario: A 90-year old with multi organ failure and clinical signs of
brain stem death was on life support was occupying the last available bed in
the ICU because the doctors were afraid to disclose death to the family that
had many vocal and angry members. However when 50 survivors from an air crash
site were brought it, the doctors decided to withdraw life support from the old
man to free up at least one ICU bed.
Hint: Unnecessary life support at family insistence
Case 9: Ventilation for purposes of organ harvesting
Scenario: An ICU doctor kept a brain stem dead patient on artificial life
support to maintain the vitality of his organs until the arrival of the
transplant team to harvest the heart and lungs donated by the patient while
still conscious in favor of his cousin who was born with severe congenital
abnormalities and would die without the transplantation.
Hint: Delay of death determination for other interests
Case 10: Post mortem family vs police
Scenario: A police man died suddenly during a fight with criminals who were
later arrested. The police authorities wanted to carry out a post mortem to
determine the cause of death in order to charge and punish the criminals with
homicide. Some members of the family objected to the post mortem on the grounds
that it was against the shari’at. Other members supported the post
mortem because of insurance compensation purposes.
Hint: balance of benefits and harms of post mortem exam