1. End of Life Care Education Case Scenario 1 End of Life Care Webinar MODULE 1

2. Case: A  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

13. Case B  Mr. A, 65 yr old came with a pacemaker inserted 8 weeks ago in another hospital. He had fever and was found to have an infected pacemaker and lead.  Started antibiotics and took out pacemaker and reinserted external pacemaker by Cardiologist  Developed an RV puncture, took for surgery and an epicardial lead was inserted  Could not wean off ventilator post op  Transferred to MICU. During the next few days, found diaphragmatic paralysis (? External pacing) – removed and internal lead placed medial wall of RV  No improvement in weaning – EMG / NCV – Critical Illness Polyneuropathy  Tracheostomy done – prognosis explained to family; they want to go home; no more money for Rx; patients wants therapy discontinued.  Clinical Ethics Committee meeting called

14. Case B - contd  Clinical Ethics Committee decision : Continue all Rx, no additional cost  Family went home as they could not stay on  Psychiatric evaluation – Patient depressed, started antidepressants and psychotherapy, visits by layperson  Continued Rx – next 6 weeks, gradually improved both physically and emotionally  Weaned off at 8 weeks  Transferred back to Cardiology

16. THANK YOU This education program is a joint initiative of Indian Society of Critical Care Medicine and Indian Association of Palliative Care. 2014 © All rights reserved