1. Case scenario – Ethical & legal aspects ISCCM/IAPC

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 Δ ; 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

3. What is your outlook?

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

6. Decision Making: The Ethical Basis Autonomy – The patient’s decisions are supreme – The family as surrogate decision makers Beneficence Non-malficence – Do no harm; “ Primum non nocere” Justice – Individual vs. distributive

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

8. Misguided Alternative Approach 1: Refuse to stop treatment because you do believe that “euthanasia” is morally unacceptable Naïve 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

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

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………

11. Approach 2: Does not help the “Public Image” of the Profession, does it?

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