1. Ethics in terminally ill patient II
BMS 234
Medical Ethics

2. Outline: Euthanasia ( mercy killing ). Brain stem death.
Withholding futile life support.
Withdrawing futile life support.

3. Euthanasia Active Passive Euthanasia ( mercy killing ):
Measures that lead to the death of a terminal patient to spare patient from further pain and suffering.
Euthanasia
Active
Passive

4. Active euthanasia: is an act of commission in which the physician takes an action that results in the death of the patient.
Passive euthanasia: is an act of omission in which the physician fails to take action necessary to sustain the life of the terminal patient.

5. Case Study
A 70-year-old man with advanced cancer with severe pain was not responsive to morphia, and asked the doctor to kill him and save him from suffering. The doctor refused, claiming that he could not commit illegal homicide. The doctor also refused to give the patient any advice about suicide. On the patient's insistence, the doctor agreed to stop hydration and nutrition to enable slow death.

7. Both Active and passive euthanasia are illegal

8. Euthanasia at the request of the patient and with his informed consent is still considered illegal.

9. Death Definition:
Irreversible cessation of circulatory and respiratory functions and of all functions of the entire brain, including the brain stem.

10. Brain stem death Cessation of all functions of the brain stem.
The brain stem is responsible for regulating most of the body's automatic functions that are essential for life. These include:
Respiratory rate
heartbeat
blood pressure
Level of consciousness.

11. After brain death, it's not possible for someone to remain conscious
After brain death, it's not possible for someone to remain conscious. Combined with the inability to breathe or maintain bodily functions, this constitutes the death of a person.

12. Legal criteria of brain death:
Core temperature is higher than 34oC.
No sedative or muscle relaxant.
Two doctors but must be not from the transplant team and one of them at least must be a consultant.
 The tests must be repeated after a short period of time.

13. Definitive criteria of brainstem death are:
Fixed pupils.
No corneal reflex.
Absent oculo vestibular reflexes: no eye movements following the slow injection of at least 50ml of ice-cold water into each ear in turn (the caloric reflex test).
No response to supra-orbital pressure.
No Gag reflex.
No observed respiratory effort in response to disconnection of the ventilator for long enough to ensure elevation of the arterial partial pressure of carbon dioxide. 

14. VIP
The tests are repeated after about hours to be sure from brain stem death.

15. Withholding futile life support

16. Withholding futile life support:
The decision to withhold life support is made when the patient is found already brain-dead or when there is clear evidence that such support will be medically futile.

17. The doctor will find it emotionally difficult to withhold life support that in his better judgment is futile.
Many doctors therefore play safe by starting life support; however, this creates the new problem of when to terminate it, another emotion difficult decision that families normally resist.

18. Case study
A car accident victim in severe shock was wheeled into the Emergency Room with unrecordable blood pressure or pulse. ECG showed low amplitude slow waves. The doctor did not declare death, but ,against the insistence of family members, doctor refused to start life support because he reasoned there was no hope. The patient was declared dead one hour later. The family threatened to sue the doctor.

19. Withdrawing futile life support

20. Life support theoretically should be stopped as soon as the patient is brain-dead, or when it is clearly futile.
Withdrawal decisions can be affected by bed availability in the intensive care unit. In cases of bed shortage, there are more aggressive and frequent efforts to test for brain stem death.

21. Case study
A 90-year-old with multi-organ failure and clinical signs of brain stem death was on life support. He was occupying the last available bed in the ICU because the doctors were afraid to tell the family about the death, which had many vocal and angry members. However, when 50 survivors from an air crash site were brought in, the doctors decided to withdraw life support from the old man to free up at least one ICU bed.

22. So What is the difference between withholding life support and withdrawal of life support?

23. Withholding of life support: Not to perform artificial life support.
Withdrawal of life support: Stop life support after you have started.

24. Reference:
Professionalism and ethics . Handbook for residents.