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Presentation at a medical ethics course held at Madina
October 29, 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 - 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.