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DILEMMASETHICAL

K.S. ChewSchool of Medical Sciences

Universiti Sains Malaysia

General Concepts of Biomedical Ethics

Four Basic Biomedical Principles

Five Essential Elements of a Valid Informed Consent

Five Things To Be Explained To the Patient in an Informed Consent

Three Groups of Incompetent Patients to Give Informed

Consent

Emergency Procedures Without Written Consent - The Doctrine of Necessity

Bolam Test

Bolitho Test

Proving Medical Negligence

Shapes for Colorand Masking

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Four Basic

Principles Of Ethics

Principle #1 AutonomyDoes my action impinge on an individual's personal autonomy?Do all relevant parties consent to my action?Do I acknowledge and respect that others may choose differently?

Principle #2 BeneficenceWho benefits from my action and in what way?

Principle #3: Non-maleficene

Which parties may be harmed by my action?What steps can I take to minimise this harm?Have I communicated risks involved in a truthful and open manner?

Principle #4: Justice

Is my proposed action equitable? How can I make it more equitable?

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Beauchamp TL, Childress JF. Principles of biomedical Ethics. 4th ed. Oxford: Oxford University Press, 1994.

Ethical Issues In Cardiopulmonary

Resuscitation

Biomedical Ethics in Resuscitation

Successful v Unsuccessful (70 - 95%)

Prolonging Suffering

Patient’s right to die in dignityDecisions in matter of

seconds!

Persistent Vegetative State

A whole of gamut of complicated dilemma

Case Scenario 1

You are rushing to catch your flight in another 30 minutes. As you are heading to your departing gate, you witness a crowd of people, and one of them actually recognizes you as a doctor and says that a man has just collapsed and they need your help in the resuscitation.

However, two things are going on in your mind - you have not been performing CPR for a long time since your ACLS course 5 years ago and you have a plane to catch. What would you do? If you do not help out in the resuscitation process, would you be liable for medical negligence in the future?

Case Scenario 2

A building has collapsed. You are called in to help out with the disaster. At the disaster site, a man has stopped breathing at a distance not far from where you are standing. The relatives over there are shouting for you to come over and help. However, you realize that some rocks are still falling from where the man is trapped. Would be liable to be sued if you do not?

Case Scenario 3

A 80-year old man with history of frequent exacerbation of COPD is diagnosed with acute pulmonary edema, currently complicated with respiratory failure Type 2. All other treatment modalities fail to prevent his deterioration. You know that his prognosis is not good but he needs mechanical ventilation to support his worsening respiratory effort.

1. Would you have intubated him?

2. If the relatives insist on you to actively resuscitate him but you do not, would you be liable to be sued?

Case Scenario 4

A 50-year old, previously healthy and active sportsman, is admitted for sudden onset of chest pain. He collapses while being treated in the emergency department. You start CPR and defibrillation promptly. Realizing what you are doing, the wife intervenes and insists that you stop the resuscitation process. She says that he has verbally stated his wish that he does not want to be actively resuscitated and a prolonged suffering the moment he dies.

What would you do?

Case Scenario 5

A 40-year old, previously healthy, army is involved in a serious car accident. On arrival to the emergency department, his GCS is 7/15. He is mechanically ventilated. His vital signs are good. A CT scan brain is done - showing a massive intraparenchymal bleeding over the right hemisphere with midline shift and generalized cerebral edema. Clinical re-assessment 30 minutes later shows that the patient is manifesting signs of increased ICP and transtentorial herniation. In view that his prognosis may not be good and that the ward resources are limited, the managing team decides to withdraw his support system in A&E. What do you think?

Cardiopulmonary Resuscitation: Ethical Issues

Resuscitation Decisions for in-hospital settings

1. to initiate resuscitation2. NOT to initiate resuscitation3. to terminate resuscitation4. to withdraw life support system (rarely)

Resuscitation Decisions for out-of- hospital

settings

1. to initiate resuscitation

2. NOT to initiate resuscitation

3. to terminate resuscitation

GENERAL PRINCIPLES GOVERNING RESUSCITATION DECISION

Is governed by two important principles:

A. The Principle of Patient Autonomy

Advanced directives (DNAR) If patient preferences uncertain, emergency conditions should be treated until those preferences are known

GENERAL PRINCIPLES GOVERNING RESUSCITATION DECISION

B. The Principle of Futility

Definition: If the purpose of a medical treatment cannot be achieved, the treatment is considered futile.

The key determinants - duration remaining in cardiac arrest, length and quality of life expected

“Physicians are NOT obliged to provide care when there is

scientific and social consensus that the treatment is

ineffective.” - American Heart Association

“Whereas patients have a right to refuse treatment, they do not have automatic right to

demand treatment; they cannot insist that

resuscitation must be attempted in any circumstances”

- European Resuscitation Council

“It is wise for a doctor to seek a second opinion in

making a momentous decision to with-hold

resuscitation for fear of the doctor’s own personal

values, or the questions of available resources might

influence his/her decision.”

- European Resuscitation Council

“Most doctors will err on the side of intervention in children for emotional reasons, even though the overall prognosis is often worse in children than in adults.”

- European Resuscitation Council

Doctor’s Personal Factors Influencing Resuscitation Decision

DNAR order means just that - in the event of cardiopulmonary arrest, CPR should not be attempted at all.

Other treatment should be continued; e.g. pain relief, sedation on required basis in terminal illnesses.

DO NOT ATTEMPT RESUSCITATION (DNAR) ORDER

Criteria For NOT to Start CPR for In-Hospital Setting# 3 No

physiological benefit expected (futility)

#2 Patient with signs of irreversible death (rigor

mortis, decapitation, decomposition, dependent

lividity)

#1 Patient with DNAR

order

“If something is worth doing, it is worth doing it

well”

“If the resuscitation process is worth doing, it is worth doing it well”

Treat the resuscitation process seriously. Respect the solemn moment for the patient and

relatives

Do not laugh or joke when resuscitation is going on

“not merely about drawing the curtain.....”

Criteria To STOP CPR For In-Hospital Setting

Extra panel

#1 Patients

with DNAR Order

In general, resuscitation should be continued as long as VF persists.

And resuscitation should be terminated when ongoing asystole for more than 20 minutes in the absence

of a reversible cause, and with all measures of BLS and ACLS in place

#2 On Grounds of

futility*

Paramedics are trained to start CPR at the very first instance upon a victim in cardiac arrest with the exception of:

1. A person with obvious clinical signs of irreversible death (e.g. rigor mortis, dependent lividity, decapitation, decomposition)2. A person with clear DNAR order3. Attempts to perform CPR would place the rescuer at risk of danger/physical injuries

Criteria For NOT Starting CPR In Out-of-Hospital Setting

1. Restoration of effective, spontaneous circulation and ventilation2. Care is transferred to a more senior-level emergency medical professional3. The rescuer is unable to continue because of exhaustion4. Reliable criteria indicating irreversible death5. A valid DNAR order is presented

Criteria To STOP CPR In Out-of-Hospital Setting

1. Not usually done in A&E department2. Often in intensive care units for clinical brain death patients3. Patient in deep coma for >24 hrs, after ruling out potentially reversible causes4. Done by two specialists (usually anesthesiologists, neurologists, neurosurgeons) on two assessments (6hrs apart)5. Detailed criteria can be found in MMC Brain death Guidelines

Withdrawing Life Support

If you or your team have made the decision to withdraw a life support system in emergency department, you should also be responsible to document

and sign your decisions and to answer any doubts from the family. Do not push the job to

another team.

1. Spouse2. Adult child3. Parent4. Any relative5. Person nominated as the person caring for the incapacitated patient6. Specialized care professionals

Must act in best interest of patient

SURROGATE DECISION MAKERS (IN ORDER OF PRIORITY)

Conclusion

Decision making in cardiopulmonary resuscitation can be very complex due to the diversity of the cases

It may have to be made in matters of seconds!

If in doubt, always err on for the patient’s benefit

Always treat the patient with dignity and respect

If you do not want this to be done to your own family member, you do not want it to be done on your patient