170411P - END OF LIFE ISSUES

Presentation at a Grand Round, King Abdullah Medical City held at Makkah AlMukarramah, Saudi Arabia on 11 April 2017 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.
• The 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.

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 on 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 to claim 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 in, the doctors decided to withdraw life support from the old man to free up at least one ICU bed.

CASE SCENARIO - 7

• A policeman 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'ah. 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.