1. 5. Ethics in terminally ill patient BMS 234 Dr. Maha Al Sedik Dr. Noha Al Said Medical Ethics

2. Why we need to know about end of life issues? ( objectives ) 1 Physicians meet terminally ill patients daily and need to know the ethical guidelines in dealing with them. 2 Artificial Life support has created more ethical and practical problems.

3. Outline Terminally ill patient. Ethical issues in geriatric care. Difference between proxy and substitute decision maker. Ethical issues in palliative care.

5. Terminal illness Is an illness from which recovery is not expected. (the point of no return) The definition of terminal illness is not always accurate; some patients who were told they were going to die have lived for years, but such cases are few in actual practice.

6. Needs of terminally ill patients Medical supportPsychological support reminded about their religious duties

7. Decisions for the terminally ill Aggressive treatment that has no benefit. Resuscitation in case of cardio- respiratory arrest ( CPR ). Artificial life support. When to stop and when to continue?

8. Geriatric care

9. Ethical issues in geriatric care Geriatrics or geriatric medicine: is a specialty that focuses on health care of elderly people. The most serious is the mental deterioration that impairs the ability to make informed decisions.

10. Who will be the decision maker? It is better if the patient decided the proxy decision maker at an earlier point. If not, a family member can be the substitute decision maker. If not, the health care workers will be the substitute decision maker.

11. 3. Substitute decision maker One of the health care workers 2. Substitute decision maker A family member according to law 1. Proxy decision maker chosen by the patient himself Who will be the decision maker?

12. What is the difference between proxy decision maker and substitute decision maker?

13. Proxy decision maker : Person chosen by the patient himself in earlier years of life to take decisions instead of the patient if he is unable to take the decision. Substitute decision maker : Person not chosen by the patient to take decisions instead of the patient if he is unable to take the decision ( may be one of family member or doctor ).

14. Case study A 30-year-old patient with multiple sclerosis and choose 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 married another woman 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.

15. Ethical issues in palliative care

16. Case study : Palliative vs. curative care 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 hospital that provided palliative care at great expense.

17. Palliation Consists of measures taken to make the remaining life of a terminal patient as comfortable as possible.

18. Palliation AnalgesicsAnesthesiapalliative surgerypalliative radiotherapy

19. Pain control: is considered great problem because: 1.some analgesics such as morphia may cause respiratory depression. Pain control in palliative care:

20. Patient has to choose Semiconscious without pain Full conscious with pain 2. Level of Anesthesia

21. 3. Palliative surgery: An operation performed on an incurable cancer, that are not expected to cure the cancer but to control symptoms and improve the quality of life. 4. palliative radiotherapy: It is radiotherapy performed on an incurable cancer that are not expected to cure the cancer but to control symptoms and improve the quality of life.

22. DNR

23. Case scenario Doctors wrote a Do Not Resuscitate (DNR) order for 80 years old grandmother with disseminated untreatable ovarian cancer. Her family objected when told of this decision. 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.

24. Do Not Resuscitate (DNR) (DNR) Do not resuscitate: Advance medical decision not to perform artificial life support measures.

25. Made by three physicians, including a disease specialist and the patient's primary doctor. The family must be informed (without seeking their involvement in the decision). The order should specify which procedures are included: intubation and ventilation, chest compressions, ionotropic drugs, gas mask, etc. Conditions must be fulfilled in DNR:

26. DNR is a physician, not a family, decision.

27. Case study 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, which had been in his shirt pocket, decided not to resuscitate him, but his wife insisted that he be resuscitated.

28. Reference: Professionalism and ethics. Handbook for residents.

29. Dr. Maha Al Sedik …… Dr. Noha Al Said