end of life decision ( eold)
TRANSCRIPT
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END OF LIFE DECESION
Ubaidur Rahaman
Senior Resident, CCM, SGPGIMS
Lucknow, India
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END OF LIFE DECESION
First I will define what I conceive medicine to be.In general terms, it is to do away with the sufferings of the sick,
to lessen the violence of their diseases,
and to refuse to treat those who are overmastered by their disease,realizing that in such cases medicine is powerless.
The Hippocratic Corpus
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END OF LIFE DECESION
Why ???
Aggressive treatment of critically ill patients with hopeless prognosisPatient dying in ICU surrounded by mechanical supports
Drawing a line not to artificially prolong natural process of dying
Need of
As the consequences are
physical, emotional and financial suffering on the part of patients and relations
Allocation of scarce resources-Potentially salvageable patients denied bed
physicians . . . provide more extensive treatment to seriously ill patients than they would choosefor themselves, support trial JAMA 1995
Advent of LIFE SUPPORT TECHNOLOGY
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END OF LIFE DECESION
Why ???
MORE INTERVENTIONS: invasive procedures
Escalation/ changes of drugsDiagnostic tests
-Hall R I, Rocker GM. End of life support care in ICU: treatment provided when life support was or was not withdrawn.Chest 2000;118:1424-30-End of life decisions in Indian intensive care unit. Mani R.K., Mandal A.K.;Intensive Care Med 2009,35:1713-1719
Increased pain and financial burden
Patients dying with full resuscitationReceive
In the last few days of life
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END OF LIFE DECESION
Why ???
BENEFISCENCE
NONMALEFISCENCE
AUTONOMY
JUSTICE
MEDICAL ETHICS
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END OF LIFE DECESIONJUSTICE-ALLOCATION OF RESOURCES
Limitation and withdrawl of intensive therapy at the end of life practices in intensive care unitsin Mumbai, India. F. Kapadia, J. Divatia, F. E. Udwadia, Dilip R. Karnad, Crit Care Med 2005;33:1272-1275
Heath care costgovernment- 17.8% in India vs 44.3% in USA
Insurance and social security-virtually 0 in India vs 33.7% in USAPatient-... 82.2% in India
81% of outpatient care and 56% inpatient care provided by private hospitals
Majority of ICU beds are in private hospitalsRelatively few beds in public hospital are in constantly high demand
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END OF LIFE DECESIONJUSTICE- ALLOCATION OF RESOURCES
I naively assumed that the case studies my Indian colleagues would provide for discussion in oursessions would be focused on the
problems of justice and the allocation of limited resources.
However, these daily challenges did not present irresolvable ethical dilemmas.
Rather, the ethical dilemmas used in our discussions centered on issues very familiar tous in the United States,
that is, the disclosure of patient information to a patient or to a family member, establishing whois the decision-maker, patient autonomy, withdrawal of treatment, and provision of end-of-life
care/hospice
Ethical Challenges in End-of-Life Care Delivery in India SupportiveVoice Vol. 11 No. 1 Winter 2006 Bridget Carney, PhD, RN
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END OF LIFE DECESIONWHO WILL DECIDE
MEDICAL PATERNALISM
PATIENT AUTONOMY
SHARED DECESION MAKING
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END OF LIFE DECESIONPATIENT AUTONOMY
RIGHT TO REFUSE TREATMENT
YES
LEGAL PROVISION
Where treatment in question affects individual or his family only
Does this right extends toRefusal or removal of life supportive system
but
Where does this right enters into forbidden zone of suicide
and
the constitutional and legal provisions in Indian law for limiting life support. S.Balakrishnan, R.K. Mani.ISCCM Position, IJCCM, April June 2005;9(2)
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END OF LIFE DECESIONPATIENT AUTONOMY-RIGHT TO REFUSE TREATMENT
Opinion of professional body must therefore precede the evolution of legal provisions
Indian law has no clearly stated position on any of these issues
Very few relevant case laws exist in our country
Supreme courtCase of Rathiram vs Union of India 1994
a person can not be forced to enjoy the right to life to his detriment, disadvantage or dislike
Supreme courtGian Kaur vs State of Punjab 1996
Right to live can not be interpreted to include the right to die an unnatural deathcurtailing the natural process
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PATIENT AUTONOMY- RIGHT TO REFUSE TREATMENT
Supreme courtcase of Gian Kaur vs State of Punjab-1996
Distinction between suicide and dignified procedure of death
the right to life including the right to live with human dignity would mean the existence of sucha right up to the end of natural life
This also includes the right to a dignified life up to the point of death including a dignifiedprocedure of death
In other words, this may include the right of a dying man to also die with dignity when his life is ebbing out
But the right to die with dignity at the end of life is not to be confused or equated with the right to die an
unnatural death curtailing the natural span of life
the constitutional and legal provisions in Indian law for limiting life support. S.Balakrishnan, R.K. Mani.
ISCCM Position, IJCCM, April June 2005;9(2)
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END OF LIFE DECESIONPATIENT AUTONOMY- RIGHT TO REFUSE TREATMENT
Supreme courtcase of Gian Kaur vs State of Punjab-1996
RIGHT TO LIFE includes the RIGHT OF A DYING MAN TO ALSO DIE WITH DIGNITY
When his life is ebbing out
Thus according to supreme court
the constitutional and legal provisions in Indian law for limiting life support. S.Balakrishnan, R.K. Mani.ISCCM Position, IJCCM, April June 2005;9(2)
The judgment can not be used to interpret all acts of withdrawl and withholding of life support asSuicide and therefore illegal
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END OF LIFE DECESIONPATIENT AUTONOMY- RIGHT TO REFUSE TREATMENT
EOLD
VS
Euthanasia and physician assisted suicide
FACILITATING
VS
HASTENING THE NATURAL PROCESS OF DYING
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END OF LIFE DECESION
is morally permissible if the action
EOLD vs Euthanasia and physician assisted suicide
RULE
OFDOUBLE
EFFECT An action with two possible consequences, one good and one bad
Is not in itself immoral
Is undertaken only with the intention of achieving the possible good effect, withoutintending the possible bad effect, even though the bad effect may be foreseen
The action does not bring about the good effect solely by means of the bad effect
Is undertaken for a proportionately grave reason
USE OF SEDATIVES/ NARCOTICS- relieving pain or causing death
Recommendation 8, ISCCM Position, Limiting life-prolonging interventions and providing palliative care towards
the end of life in Indian intensive care units. IJCCM, April- June 2005, 9(2)
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END OF LIFE DECESIONLEGAL ISSUES RELATED TO TREATING DOCTOR
IPC SECTION 76, 81 AND 88
DEFENCES AVAILABLE TO DOCTOR UNDER IPC
AMPLE SCOPE TO PROTECT THE WELL MEANING DOCTOR
GOOD INTENTIONBENEFISCENCE, NON MALEFISCENCE
the constitutional and legal provisions in Indian law for limiting life support. S.Balakrishnan, R.K. Mani.ISCCM Position, IJCCM, April June 2005;9(2)
DOCUMENTATION
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ISCCM POSITION
LIMITING LIFE PROLONGING INTERVENTIONS AND PROVIDING PALLIATIVE CARETOWARDS THE END OF LIFE IN INDIAN INTENSIVE CARE UNITS
Mani R.K., Chawla R., Divatia J.V., Kapadia F. Rajgopalan R, Balakrishnan S., Todi S.K.; IJCCM April-June2005,9(2)
When to initiate EOL discussions
Checklist for initiating EOL discussions
Rationale
Recommendation for limiting life support interventions
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LIMITATION OF LIFE SUPPORTISCCM POSITION
RECOMMENDATION 2
DNI/ DNR
TREATMENT WITHHOLDING
TREATMENT WITHDRAWING
PALLIATIVE CARE
FULL RESUSCITATION
EUTHANASIA AND PATIENT ASSISTED SUICIDE- illegal in India
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LIMITATION OF LIFE SUPPORTISCCM POSITION
Pending consensus decisions or in the event of conflicts between the physicians recommendationsand familys wishes, all existing supportive interventions should continue.
The physician however, is not morally obliged to institute new therapies against his/ herbetter clinical judgment.
RECOMMENDATION 4
The discussions leading up to the decision to withhold life supporting therapies should be clearlydocumented in the case records, to ensure transparency and to avoid future misunderstanding.
Such documentation should mention the persons who participated in the decision making processand the treatment withhold or withdrawn.
The committee does not regard the signature of a family representative to be a mandatory requirement.
RECOMMENDATION 5
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LIMITATION OF LIFE SUPPORTISCCM POSITION
if the capable patient or family consistently desires that life support be withdrawn, in situation in whichthe physician considers aggressive treatment nonbeneficial, the treating team is ethically bound to
consider withdrawl within the limits of existing laws.
RECOMMENDATION 7
RECOMMENDATION 8
Rule of double effect since court can not recognize intentions, we should take care to document theuse of opiates and the indication for their use.
The optimal dose of opiates is determined by increasing the dose until the patients comfort is ensured,
There is no maximal dose recommended.
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END OF LIFE DECESION
ICU DATA
Paucity of empirical data on the frequency and manner of foregoing life support in Indian ICU
UNAWARENESS OF ETHICAL ISSUES
CULTURE OF FIGHTING TILL THE ENDABLE TO SAY THAT ONE HAS DONE EVERYTHING
LACK OF PALLIATIVE CARE ORIENTATION
LEGAL AND ADMINISTRATIVE PREJUDICES
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END OF LIFE DECESIONICU DATA- USA
A National Survey of End-of-life Care for Critically Ill PatientsTHOMAS J. PRENDERGAST, MICHAEL T. CLAESSENS, and JOHN M. LUCE; AM J RESPIR CRIT CARE MED 1998;158:11631167.
Total ICU admissions -74,502Total ICU deaths- 6,303 (8.5%)Brain deaths-... 393 (6.2%)
prospectively collected data from icu trainee residents from 131 ICUs at 110 institutions in 38 states of USAover a period of 1year (1994-1995)
Full resuscitation-. 1,544 (26%)
end-of-life decisions -5,910 (73%)DNI - ..1,430 (24%)Withholding -...797 (14%)Withdrawal - 2,139 (36%)
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END OF LIFE DECESIONICU DATA- EUROPE
End-of-Life Practices in European Intensive Care UnitsThe Ethicus Study
Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied fromJanuary 1, 1999, to June 30, 2000.
To determine the frequency and types of actual end-of-life practices in
European intensive care units (ICUs) and to analyze the similarities and differences.
Full resuscitation ...-20%EOL decision-80%withholding -.-38%withdrawing -.... -33%shortening of the dying process -2%.
withdrawal - 99% died within 4 hoursWithholding 89% died within 14.3 hours11% of patients survived
REASONS-AGE, POOR PROGNOSIS, POOR PREDICTED QUALITY OF LIFEGreatest frequency of limitation occurred in acute neurological disease
Substantial intercountry variability religion and culture rooted
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END OF LIFE DECESIONICU DATA- INDIA
Limitation of life support in the ICU: ethical issues relating to end of life careMani R.K., IJCCM 2003;7:112-117
Total admissions- ..852Total deaths-... 238 ( 27%)Full resuscitation-. 186 (78%)
Single centre survey from tertiary care Indian Hospital March- Dec 2002
EOLD- 48 (22%)DNR- 4 (8%)Withhold-. 4 (8%)LAMA- .38 (79%)Brain dead-.. 4 ( 8%)
Reasons - financial
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END OF LIFE DECESIONICU DATA- INDIA
Limitation and withdrawl of intensive therapy at the end of life practices in intensive care unitsin Mumbai, India. F. Kapadia, J. Divatia, F. E. Udwadia, Dilip R. Karnad, Crit Care Med 2005;33:1272-1275
Review of prospectively collected data from ICU of 4 major hospitals from Oct -Dec 2002
0
15 (24%)
0
15 (19%)
62
846
KEM HOP
(Public)
4 (8%)02 (20%)2 (3%)-Withdrawn
33 (67%)4 (33%)014 (24%)-Withhold
12 (25%)2 (17%)2 (20%)8 (13.6%)-DNI
49 (34%)6 (50%)4 (40%)24 (41%)EOL decision
143121059Death in ICU
1045882487Total death inhospital
TOTALTMH
(Public private)
Breach Candy
(Private)
Hinduja hosp
(Private)
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END OF LIFE DECESIONICU DATA- INDIA
End of life decisions in Indian intensive care unit.Mani R.K., Mandal A.K.; Intensive Care Med 2009,35:1713-1719
Retrospective analysis of patients died in 12 bed ICU of tertiary care private hospital in Indiaadmitted between May 2006 to Dec 2007
Patients admitted- 830Death- 88 (10.6%)Full resuscitation- 45 ( 57%)
Reasons- advanced chronic diseaseunresponsive to treatment
Advanced ageFamily unwilling to continue treatment
PREHOSPITAL FULLY DEPENDENDENT STATUS
self paying . full resuscitation
Insurance beneficiaries- equally represented
REASONABLE LEVELS OF LIMITATION ARE ACHEIVABLE IN INDIA DESPITE PERCEIVED BARRIERS
EOLD- 43 (48%)DNR- .............15 (35%)Withhold-.. 25 (58%)Withdrawl-... .3 (7%)
Escalation of treatment in last 3 days of life more frequent in full resuscitation group
FINANCIAL BURDEN
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END OF LIFE DECESIONDATA- CAREGIVERS APPROACH- INDIA
Physician belief and practices regarding end of life care in IndiaV.Theodore Barnett, V.K. Aurora, IJCCM, July-Sep, 2008, 12(3)
Response to questionnaires at NAPCON 2002 at Jaipur, IndiaJoint conference of National college of chest physicians and Indian chest society
46% answered withdrawl was practiced(almost 75% of hospitals in India did not allow this practice)
Barriers-Legal and administrative, lack of guidelinesCulture and religion was not perceived as barrier
Fators considered important-Age
EconomyDuration of disease
HIV status
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END OF LIFE DECESIONDATA- CAREGIVERS APPROACH-ISRAEL
Forgoing Life-Sustaining Treatments: Comparison of Attitudes between Israeli andNorth American Intensive Care Healthcare ProfessionalsEthan Soudry , Charles L. Sprung , Phillip D. Levin, IMAJ 2003;5:770-774
A survey among members of Israeli society of critical care medicine using a questionnaire during1992-1994
DNR orders both (incidence and reason) were similar to that in USAApproach was paternalistic compared to USAAn almost similar percent of physicians apply DNR orders in their intensive care units,but much less (28% vs 95%) actually discuss these orders with the families of their patients
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END OF LIFE DECESIONDATA- CAREGIVERS APPROACH- EUROPE
Forgoing life support in western European intensive care units: The results of anethical questionnaire
Vincent, Jean-Louis MD, PhD, FCCM, Crit Care Med;1999;27(8):1626-33
Intensive care unit ------------------------limitation of bedsadmissions with no hope of survival--70%shortening of death------------------------40%differences between action and belief of physicians
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DEFINITIONS ISCCM POSITIONS
FULL SUPPORT: the provision of all measures needed to support hemodynamics, ventilationand metabolism.
FULL RESUSCITATION( CPR): aggressive ICU management up to and includingresuscitative attempts, in the event that cardio respiratory arrest occurs.
DNI/ DNR: aggressive ICU management up to , but not including endotracheal intubation (DNI) or attempts at CPR ( DNR).
WITHHOLDING OF LIFE SUPPORT: not to institute new treatment or to escalateexisting treatments for life support, ( including, but not limited to, intubation, ionotropes,vasopressors, mechanical ventilation, dialysis, antibiotics, intravenous fluids, enteral orparenteral nutrition) with the understanding that the treatment has a higher potential to causepain and suffering than resolution of organ failure.
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DEFINITIONS ISCCM POSITIONS
WITHDRAWING OF LIFE SUPPORT: the cessation or removal of an ongoing life supportingtreatment while not substituting an equivalent alternative treatment, with theunderstanding that the treatment in question is causing pain and suffering and serves nopurpose other than delaying death. It is anticipated that the patient will die following thechange in therapy because of the natural progression of underlying disease conditions.
PALLIATIVE CARE: provisions of active measures aimed at only alleviating pain and suffering,
with no further attempt at resuscitation or providing organ support, when the underlyingdisease process is presumed to have reached a point of no return.
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Futility- a life sustaining intervention is futile if reasoning and experience indicates thatthe intervention would be highly unlikely to result in a meaningful survival for thatpatient.
Def of American Thoracic Society