Case scenario – Ethical & legal aspects ISCCM/IAPC.
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Case scenario Ethical & legal aspects ISCCM/IAPC Slide 2 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 ; 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 Slide 3 What is your outlook? Slide 4 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 Slide 5 Slide 6 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 Slide 7 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 Slide 8 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 Slide 9 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 Slide 10 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 Slide 11 Approach 2: Does not help the Public Image of the Profession, does it? Slide 12 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