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Presentation at a Course on the Application of Ethical Principles to Clinical Practice held at the Faculty of Medicine, King Fahad Medical City 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.
Terminally
Incurable Diseases & EOL Decisions
} 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
§ Withhold/withdraw
of 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.
Case
Scenario - 5
} A car accident
victim in severe shock was wheeled into the emergency room with unrecordable
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 and 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, 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
} Overview
§ 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.