case scenario – ethical & legal aspects isccm/iapc
Post on 01-Apr-2015
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Case scenario – Ethical & legal aspects
ISCCM/IAPC
Case:• 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 helpF 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
MisguidedAlternative 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 RxMinimizes patient discomfortGuarantees distributive justiceDeath is not an intended goal
The morality of euthanasia?:Its goal is to end life
EuthanasiaOpinions 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-CenteredApproach 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 helpthe
“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
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