1. End-of-life Issues in the ICU
Dr. Nehad Nabeel Al-Shirawi
MRCP(UK), EDIC, Saudi Fellowship in ICU
Intensivist / Pulmonologist

2. بسم الله الرحمن الرحيم
‘And whosoever saves a life, it is as if they have saved the whole of humankind’
{مِنْ أَجْلِ ذَلِكَ كَتَبْنَا عَلَى بَنِي إِسْرَائِيلَ أَنَّهُ مَن قَتَلَ نَفْسًا بِغَيْرِ نَفْسٍ أَوْ فَسَادٍ فِي الأَرْضِ فَكَأَنَّمَا قَتَلَ النَّاسَ جَمِيعًا وَمَنْ أَحْيَاهَا فَكَأَنَّمَا أَحْيَا النَّاسَ جَمِيعًا وَلَقَدْ جَاءتْهُمْ رُسُلُنَا بِالبَيِّنَاتِ ثُمَّ إِنَّ كَثِيراً مِّنْهُم بَعْدَ ذَلِكَ فِي الأَرْضِ لَمُسْرِفُونَ}
Qur’an 5:32

3. Presentation Outline Problems with DNR decision in our societies
Definitions
When to consider DNR
Islamic Point View of DNR
My Study
Conclusions

4. Problems with DNR Decisions in Our Societies

5. Problem # 1
Ignorance
Many people are so ignorant to understand the meaning of “DNR” and futility of treatment.

6. Misconceptions Regarding Death
Problem # 2
Misconceptions Regarding Death
Misconceptions among most of the population leading to lack of understanding and acceptance of “DEATH”.
(يحي العظام وهي رميم ) !!!!!!!!

7. Problem # 3 Misconceptions Regarding Role of HCP
Confusion about our role as health care providers (save lives at any cost)
(احنا عملنا إلّي علينا والباقي علي الله)

8. DNR Guideline: How Much of Islamic Point-View
Guidelines are necessary to identify the key ethical and legal issues that govern DNR decisions
The guidelines provide a framework to support physician in
Making DNR decisions
Communicating them effectively
Islamic point-view should be considered ALL the time

9. Definitions

10. DNR
Instructions that the patient should not receive cardiopulmonary resuscitation (CPR) in the event that he / she suffers a cardiac arrest, usually in the hospital
Do not intubate, do not defibrillate, no medications

11. Life – Prolonging Measures
Intravenous Fluids
Nasogastric tube feeding
Dialysis
Vasopressors
Mechanical ventilation

12. Medical Futility
When CPR and other critical care efforts have no reasonable chance of prolonging life or providing benefit to the patient – i.e. they are futile
Discharge to home intact
Pain / symptom free life
Full awareness of the surroundings

13. Euthanasia
Euthanasia: comes from the Greek “Eu-thanatos” which means “ an easy or good death”
Killing the patient for their own benefit

14. Death Death has several consequences
Medical
Legal
Religious
Socioeconomic
Death = body – spirit (خروج الروح من الجسد)
قال الله تعالى: ( قل يتوفاكم ملك الموت الذي وكّل بكم ثم إلى ربكم ترجعون ) السجدة 11
( ويسألونك عن الروح قل الروح من أمر ربي وما أوتيتم من العلم إلا قليلا) الاسراء 58

15. Death
Medical Definition: The irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart, respiration, and brain activity
In many countries : Brain Death = Death
In Islamic countries – disagreement

16. When to Consider DNR ?

17. When to Consider DNR ? CPR is unlikely to useful (Futile)
CPR is not in accord with a valid advance directive
CPR is not in accord with a competent patient’s recorded and sustained wishes
Resuscitation is likely to be followed by a length and quality of life that would not be in the best interest of the patient (pain, lack of awareness)

18. Emergency Situations
In emergencies, there will rarely be time to make a proper assessment of the patient’s condition and the likely outcome of CPR and so attempting CPR will usually be appropriate
Health professionals will make all reasonable efforts to attempt to revive the patient in the event of cardiac or respiratory arrest

19. It is Important to Explain that:
No CPR does not mean no other treatment
No CPR does not mean withdrawal of mechanical ventilator, etc
No CPR does not mean “Mercy Killing”

20. Islamic Point-View

21. What’s Unique about Ethics in Islam
What is Moral in Islam is Always Legal (Halal)

22. Human Life
But if one saves a life, it shall be as if he saved all mankind.”
Qur’an 5:32.
“Every soul shall taste death”
Qur’an 3:185.

23. Death: International Collective Of Islamic Jurists And OIC
Death: International Collective Of Islamic Jurists And OIC. Amman, Jordan 1986
Declaration of death:
Heart and breath have stopped and the condition is irreversible OR
Mental function has ceased and the condition is irreversible
Responsibility of the physician
القرار رقم ( ٥) الصادرعن مجلس مجمع الفقه الإسلامي المنعقد في دورة مؤتمره الثالث بعمان من ٨- ١٣ صفر ١٤٠٧ ه/ ١١ -١٦ أكتوبر / تشرين الأول ١٩٨٦ ، وقراره رقم ( ١) د ٤/ ٠٨ / ٨٨ في دورة مؤ تمره الرابع بجدة في السعودية من ١٨ - ٢٣ جمادى الآخرة ١٤٠٨ ه/ الموافق ٦- ١١ فبراير/ شباط ١٩٨٨

24. Time of Death
Time of Death = Complete cardiopulmonary arrest after withdrawal
المريض الذي ركبت على جسمه أجهزة الإنعاش يجوز رفعها إذا تعطلت جميع وظائف دماغه تعطلاً نهائياً وقررت لجنة من ثلاثة أطباء اختصاصيين خبراء أن التعطل لا رجعة فيه، وإن كان القلب والتنفس لا يزالان يعملان بفعل الأجهزة المركبة، لكن لا يحكم بموته شرعاً إلا إذا توقف التنفس والقلب تاماُ بعد رفع الأجهزة
في قرار المجمع الفقهي الإسلامي التابع لرابطة العالم الإسلامي في دورته العاشرة المنعقدة في مكة المكرمة 1408هـ

25. 4 Ethical Principles

26. 4 Ethical Principles in Islam
Principle of maslahah (Self and public interest) is to address the needs of humankind and confers the welfare of most people.
The principle of la darar wa la dirar (a person must not harm himself or someone else) – prohibited to cause a loss to another person

27. The Major Islamic Ruling Principles

28. The Sharia Law System Category Arabic Do it Not do it Obligatory
(Prescribed)
Fard
Wajeb
Reward
Punishment
Recommended
(Desirable)
MustahabMandub
No Punishment
Permitted
(Allowed)
Mubah
Halal
No Reward
Discouraged
(Disliked)
Makruh
Manboth
Forbidden
(Prohibited)
Haraam
Mahd’ur 28

29. Is Medical Treatment Necessary?
Definite:
The desired results are achieved without fail
e.g. stop bleeding to sustain life
Mandatory (واجب)
Probable/Expected:
The desired results are often achieved but not always
e.g. many medical treatments
Sunnah (سنه)
Imagined:
The desired results are not a realistic expectation
e.g. some medical treatments
Permissible (مباح)

30. Resuscitation In Islam
Two opinions
Recommended (مندوب)= حكم التداوي
Obligatory (فرض كفاية) = إنقاذ الروح
Most people agree on second opinion because
المريض لا اختيار له في هذه الحال فلا يمكن إجراء حكم التداوي على مسألة الإنعاش
المريض في في حالة خطرة وحاجته لأجهزة الإنعاش أصبحت أمراً ضرورياً كحاجته للطعام والشراب بحيث لو تركه فقد عرض نفسه للهلاك

31. Fatwa # (12086) Dated (1989) by the Saudi Committee for Fatwa & Islamic Affairs

32. Fatwa # (12086) Dated (1989) by the Saudi Committee for Fatwa & Islamic Affairs

33. Permitted (Mubah)
Do Not Resuscitate order: when the treatment becomes futile.
Withdrawal or withheld therapy is permitted in brain death.

34. Forbidden (Haraam) Active Euthanasia:
Passive Euthanasia: Patient should be provided with food, drink, nursing, and relief from pain until death.
Suicide
Murder. "take not life which Allah has made sacred" Qur’an 6:151.

35. What About Withdrawal ?
In patients with deep coma/persistent vegetative state –forbidden (Haram) by most authorities
In Brain Death – many authorities said is allowed (Halal)
مجمع الفقه الإسلامي الثالث التابع لمنظمة المؤتمر الإسلامي المنعقد في عمان بالأردن عام ١٩٨٧، وفتوى المجلس الفقهي التابع لرابطة العالم الإسلامي في دورته العاشرة في ٢٤ / ٢/ ١٤٠٨ ه

36. [ قرار هيئة كبار العلماء) رقم ( 190 ) وتاريخ 6 /4 /1419 هـ
What About Withdrawal ?
 إذا قرر ثلاثة أطباء متخصصون فأكثر رفع أجهزة الإنعاش عن المريض الموضحة حالته في السؤال الأول (حالة عجز شديد - مثل : الشلل الدماغي ، ومصاب بتخلف عقلي شديد) - فإنه يجوز اعتماد ما يقررونه من رفع أجهزة الإنعاش ، ولكن لا يجوز الحكم بموته حتى يعلم ذلك بالعلامات الظاهرة الدالة على موته ، أما موت الدماغ فلا يعتمد عليه في الحكم بموته
 إذا قرر الأطباء المختصون رفع الأجهزة في الحالة المذكورة في السؤال الأول ، فإنه لا يلتفت إلى معارضة الأهل
إذا غلب على ظن الطبيب المختص أن الدواء ينفع المريض ولا يضره أو أن نفعه أكثر من ضرره ، فإنه يشرع له مواصلة علاجه ، ولو كان تأثير العلاج مؤقتا؛ لأن الله سبحانه قد ينفعه بالعلاج نفعا مستمرا خلاف ما يتوقعه الأطباء .
[ قرار هيئة كبار العلماء) رقم ( 190 ) وتاريخ 6 /4 /1419 هـ

37. My Study

38. My Study Questionnaire-based study
12-questions questionnaire distributed to physicians at SMC
Total sample size 152 physicians

39. Basic Characteristics
Number
Percent
Age < 40 years
103/144
71.5
Age ≥ 40 years
41/144
28.5
Male
109/152
71.7
Female
43/152
28.3
Muslims
140/150
93.3
Other Religions
10/150
6.7

40. Sub-specialty
Total Number = 135
51.1%
25.9%
17.7%
5.3 %

41. Professional Level

42. Answer to Questions
DNR Policy

43. Do you Feel Comfortable or at Ease when Talking to Relatives about DNR??

44. Do you Feel Comfortable or at Ease when Talking to Relatives about DNR??
Majority of females don’t feel comfortable (P value < 0.05)

45. Withdrawal in Brain Dead
There is a significant number of physicians
Who said NO !!!!

46. Why not Withdrawing in Brain Dead ?

47. Persons Involved in DNR Decision
The main persons involved in DNR decisions are the
Caring Team and consultant

48. Reasons for Making DNR

49. Conclusions

50. Conclusions
There are many misconceptions concerning DNR decisions among health care professionals
In the era of resource utilization and scares ICU beds, making DNR decisions might seem necessary if the treatment is futile
A clear Law is needed to regulate this matter