Home 
Contact 
Profile 
Videos 
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.
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.