Webinar Case Scenario 1

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End of Life Care Education
MODULE 1
Case Scenario 1
End of Life Care Webinar
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 ; 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.
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
THANK YOU
This education program is a joint initiative of Indian Society of Critical Care
Medicine and Indian Association of Palliative Care. 2014
© All rights reserved
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