DNR outstanding ethico legal-fiqhi issues

DNR: OUTSTANDING ETHICO-LEGAL-FIQHI ISSUES

Dr Omar Hasan Kasule SrOmar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City

2.0 UNCERTAINTIES (qa’idat al yaqiin)

• Definition of terminal illness, maradh al mawt

• Death process: point z - prolongation of life vs prolongation of death

• Peri-operational DNR

• Pre-hospital DNR

Dr Omar Hasan Kasule SrOmar Hasan K Kasule Sr Department of Bioethics

King Fahad Medical City

3.0 PROTECTION OF LIFE (maqsad hifdh al nafs) VS EXCLUDING FUTILITY

• Artificial life support vis a vis allowing natural death (AND)

• Do not resuscitate orders (DNR)• Do not treat orders (DNT)• DNR as Passive Euthanasia (EU) – al umuur bi

maqasidiha



4.0 PROTECTION OF THE PATIENT FROM POTENTIAL HARM (qa’idat al dharar)

• Paternalism• Patient consent for CPR• Patient consent for DNR• Family assent to DNR• Age discrimination



5.0 PROTECTION/CONSERVATION OF RESOURCES (maqsad hifdh al maal)

• Over and/or inappropriate utilization of ICU resources

• Synonyms for ICU:– Intensive Monitoring Unit (IMU)– Futile Care Unit (FCU)– Wasteful Care Unit (WCU)– Extremist Care Unit (ECU)– Mortuary Care Unit (MCU)– Hospice Care Unit (HCU)



5.0 PROTECTION/CONSERVATION OF RESOURCES (maqsad hifdh al maal)

• Use of palliative instead of intensive care• KPI: ICU mortality/discharge a reflection of

admission and not intervention



6.0 IMPLEMENTATION ISSUES

• DNR policies and guidelines• Knowledge of physicians regarding DNR• Practices of physicians regarding DNR• Mistaken Identification of DNR patients



7.0 CRITERIA FOR DNR (hifdh al nafs vs hifdh al maal)

• DNR: an established death process beyond Young’s z point

• DNT: terminal conditions not yet in an established death process.

• DNR & DNT: admit to palliative care where hi-tech is not available



8.0 The KFMC CPP No 1430-60 6 EXAMPLES FOR DNR

• Advanced incurable malignancy• advanced multi-organ failure• irreversible, severe, and documented brain

damage • advanced cardiac, hepatic, or pulmonary disease • inoperable, life threatening congenital heart

disease, fatal chromosomal or neuromuscular disease

• Irreversible, severe, mental and physical incapacity.



9.0 The SAMSO MSP 7 EXAMPLES FOR DNR:

• Advanced incurable, end-stage malignancy • End-stage organ failure • Advanced irreversible brain damage • End-stage renal disease if renal replacement therapy

is not feasible • Inoperable congenital anomalies incompatible with life • Fatal chromosomal abnormalities • Brain death.



10.0 COMPONENTS OF A DNR ORDER

• Cardiopulmonary resuscitation involving chest compressions and oxygenation

• Endotracheal intubation• Mechanical ventilation• Defibrillation• Vaso-active/ionotropic medication



11.0 MAY/MAY NOT: NON-CARDIO-RESPIRATORY LIFE SUPPORT

• Renal dialysis• Blood transfusion• Parenteral nutrition• Pulmonary hygiene• Normal treatment eg antibiotics



12.0 SUPPORTIVE CARE FOR ALL DNR PATIENTS

• Clearance of secretions (oral, throat, etc)• Hydration and nutrition• Pain management, antipyretics, and sedation• Supplemental oxygen• Anti emetics and relieve of constipation• Relief of urinary retention• Relief of dypnea and cough)



13.0 RECOMMENDATIONS

• Develop palliative care as an alternative to ICU for DNR and DNT cases

• Training workshops on the ethical issues of EOL• DNR orders to specify interventions

intended/prohibited• Respecting the autonomy of physicians who have

conscientious objections to DNR• More psycho-social support for DNR families• More empirical research on the DNR process• Regular audits of DNR decisions and outcomes.



Thank you

Health & Medicine

DNR outstanding ethico legal-fiqhi issues