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Presentation at a medical ethics course held at the
Security Forces Hospital Riyadh May 14, 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 &
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
& 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
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
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.
Case 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
·
Over-view
§
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
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.