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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.
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?
Ethical
issues in palliative care:
·
Deficient
decision making capacity
·
Decisions on
interventions: nutrition, hydration, pain control, infection treatment
·
Double effect
of analgesics
·
Balance between
pain control and social life
Ethical
issues in disability care:
·
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
DNR orders:
·
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 1
·
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 2
·
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.
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:
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.
Case scenario 6:
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.
Case scenario 7:
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.