Transcript of End of Life Care Education Case Scenario 1 End of Life Care Webinar MODULE 1.
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- End of Life Care Education Case Scenario 1 End of Life Care
Webinar MODULE 1
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- 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
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- What is your outlook?
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- 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
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- Decision Making: The Ethical Basis Autonomy The patients
decisions are supreme The family as surrogate decision makers
Beneficence Non-malficence Do no harm; Primum non nocere Justice
Individual vs. distributive
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- 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
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- Misguided Alternative Approach 1: Refuse to stop treatment
because you do believe that euthanasia is morally unacceptable Nave
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
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- 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
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- 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
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- Approach 2: Does not help the Public Image of the Profession,
does it?
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- 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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- 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
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- 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
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- 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