Presentation on theme: "End of Life Care Education Case Scenario 1 End of Life Care Webinar MODULE 1."— Presentation transcript:
End of Life Care Education Case Scenario 1 End of Life Care Webinar MODULE 1
Case: A 78-year old male; good prior health; admitted with acute SDH; GCS 7 Started on mechanical ventilation peri-op. with expected wean by 2-4 days Poor response to Rx, no GCS Δ ; VAP; respiratory failure worsens; BP drops; kidney fails; antibiotic resistant infection; still very sick on day 12 F Doctor feels ongoing treatment is unlikely to help F Family friend who knows you requests cessation of all Rx
What is your outlook?
A Case for Limiting Treatment Death from serious illness is not inevitable; technology can save lives (!) Medical intervention is given to all patients, in order to save a few lives In situations where support is unlikely to benefit the patient: Offering ongoing treatment is deceit May strain limited societal resources
Decision Making: The Ethical Basis Autonomy – The patient’s decisions are supreme – The family as surrogate decision makers Beneficence Non-malficence – Do no harm; “ Primum non nocere” Justice – Individual vs. distributive
Ideal Approach to the Case: Agree to stop treatment after family (appropriate surrogates) consensus is established because you are professionally obliged not to continue non-beneficial treatments Ideal Ethically correct Physician takes responsibility Effective palliative measures can be administered
Misguided Alternative Approach 1: Refuse to stop treatment because you do believe that “euthanasia” is morally unacceptable Naïve justification Limiting therapy is ethical: Honest approach to failing Rx Minimizes patient discomfort Guarantees distributive justice Death is not an intended goal The morality of euthanasia?: Its goal is to end life
Euthanasia Opinions of Indian Doctors There is some confusion about the “intent” of treatment limitation: – 54% equated withholding therapy with “mercy killing” – 64% equated withdrawal with it Is euthanasia immoral? – 42% considered it a valid option in an advanced cancer scenario – We are unaware if these doctors would assist patients’ suicide
Self-Centered Approach 2: Refuse to limit life-support measures because you are concerned about the legal ramifications of withdrawal / withholding Self interest (fear of litigation) primary Cost of continued care may be high ? False promise Scope for abuse………
Approach 2: Does not help the “Public Image” of the Profession, does it?
Approach 3: Refuse to stop treatment; but ‘suggest’ the family “take the patient home” “against medical advice” The Ethics(?) of LAMA (Leaving “Against Medical Advice”): It is treatment withdrawal in an atmosphere of uncertainty (legal / social) Coercive (patient takes the ‘blame’) Paternalistic Provokes distrust of the profession Huge scope for abuse
Case B Mr. A, 65 yr old came with a pacemaker inserted 8 weeks ago in another hospital. He had fever and was found to have an infected pacemaker and lead. Started antibiotics and took out pacemaker and reinserted external pacemaker by Cardiologist Developed an RV puncture, took for surgery and an epicardial lead was inserted Could not wean off ventilator post op Transferred to MICU. During the next few days, found diaphragmatic paralysis (? External pacing) – removed and internal lead placed medial wall of RV No improvement in weaning – EMG / NCV – Critical Illness Polyneuropathy Tracheostomy done – prognosis explained to family; they want to go home; no more money for Rx; patients wants therapy discontinued. Clinical Ethics Committee meeting called
Case B - contd Clinical Ethics Committee decision : Continue all Rx, no additional cost Family went home as they could not stay on Psychiatric evaluation – Patient depressed, started antidepressants and psychotherapy, visits by layperson Continued Rx – next 6 weeks, gradually improved both physically and emotionally Weaned off at 8 weeks Transferred back to Cardiology