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