Home 
Contact 
Profile 
Videos 
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.
Palliative care 1:
overview
·
Why palliative care
·
The concept of pleasant death
·
Noble human qualities
·
The hereafter
·
Guiding principles on terminal care
Palliative care 2: overview
·
Development of palliative care
·
Resources for terminal care
·
Site of palliative care
·
Palliative care team
·
Modalities of care: pain control, spiritual,
emotional, psychological, communication, symptom management, nutritional
support
Palliative care: ethical and legal issues
·
Deficient decision making capacity: Advance
statements, Proxy decision makers, If the patient is not competent to make
decisions, his guardian, wali, will make decisions that the caregivers are
bound to respect, In the absence of relatives?
·
Decisions on interventions: nutrition,
hydration, pain control, infection treatment
·
Balance between pain control and social life,
Double effect of analgesics
·
Requests for assisted death should be refused.
·
Telling the whole truth to the patient requires
judgment and balancing benefits and harm.
·
Privacy and confidentiality have to be maintained.
·
Caregivers must respect the patient’s autonomy
as long as he is competent.
Case
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.
TERMINALLY
INCURABLE DISEASES AND EOL DECISIONS:
Over-view
·
Concepts: Terminal illness, Do Not Resuscitate
(DNR), Withholding of life support, Withdrawal of life support, Brain death,
euthanasia, assisted suicide
·
Decisions for the terminally ill:
withhold/withdraw of life support/nutrition & hydration
Case
scenario 1
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.
Case
scenario 2:
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.
Case
scenario 3:
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.
Case
scenario 4:
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
scenario 5:
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.
Case
scenario 6:
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.
Scenario
7:
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.
SOLID
ORGAN TRANSPLANTATION AND DONATION:
Overview
·
Legal rulings about
transplantation; qa’idat al mashaqqat, qa’idat al dharar, qa’idat al qasd
·
Informed consent Abuses:
selling organs, kidnap
·
Indications, side
effects, and complications
·
Procuring and harvesting
organs
Case
scenario 1:
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.