end of life_decesion

END OF LIFE END OF LIFE END OF LIFE END OF LIFE

DECESIONDECESIONDECESIONDECESION

Ubaidur RahamanUbaidur RahamanUbaidur RahamanUbaidur Rahaman

Senior Resident, CCM, Senior Resident, CCM, Senior Resident, CCM, Senior Resident, CCM,

SGPGIMSSGPGIMSSGPGIMSSGPGIMS

Lucknow, IndiaLucknow, IndiaLucknow, IndiaLucknow, India

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND 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,and to refuse to treat those who are overmastered by their disease,

realizing that in such cases medicine is powerless.”

— The Hippocratic Corpus


Why ???

Aggressive treatment of critically ill patients with hopeless prognosis

Patient dying in ICU surrounded by mechanical supports

Need of

Advent of LIFE SUPPORT TECHNOLOGY

Drawing a line not to artificially prolong natural process of dying

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 choose

for themselves,” support trial JAMA 1995


Why ???

MORE INTERVENTIONS: invasive procedures

Escalation/ changes of drugs

Diagnostic tests

Patients dying with full resuscitation Receive

-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 End of life support care in ICU: treatment provided when life support was or was not withdrawn.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

In the last few days of life


Why ???

BENEFISCENCE

NONMALEFISCENCE

MEDICAL ETHICS

NONMALEFISCENCE

AUTONOMY

JUSTICE

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONJUSTICE-ALLOCATION OF RESOURCES

Limitation and withdrawl of intensive therapy at the end of life practices in intensive care units

in Mumbai, India. F. Kapadia, J. Divatia, F. E. Udwadia, Dilip R. Karnad, Crit Care Med 2005;33:1272-1275

Heath care cost

government- DDDDDDD 17.8% in India vs 44.3% in USA

Insurance and social security-DDvirtually 0 in India vs 33.7% in USA

Patient-++... 82.2% in IndiaPatient-++... 82.2% in India

81% of outpatient care and 56% inpatient care provided by private hospitals

Majority of ICU beds are in private hospitals

Relatively few beds in public hospital are in constantly high demand

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONJUSTICE- ALLOCATION OF RESOURCES

I naively assumed that the case studies my Indian colleagues would provide for discussion in our

sessions 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 to

us in the United Statesus in the United States,

that is, the disclosure of patient information to a patient or to a family member, establishing who

is 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 Supportive

Voice Vol. 11 No. 1 Winter 2006 Bridget Carney, PhD, RN

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONWHO WILL DECIDE

MEDICAL PATERNALISM

SHARED DECESION MAKING

PATIENT AUTONOMY

SHARED DECESION MAKING


PATIENT AUTONOMY

RIGHT TO REFUSE TREATMENT

YES

LEGAL PROVISION

Where treatment in question affects individual or his family only

Does this right extends to

Refusal 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)

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND 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 court

Case of Rathiram vs Union of India 1994Case 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 court

Gian Kaur vs State of Punjab 1996

Right to live can not be interpreted to include the right to die an unnatural death

curtailing the natural process


PATIENT AUTONOMY- RIGHT TO REFUSE TREATMENT

Supreme court

case 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 such

a right up to the end of natural lifea 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 dignified

procedure 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





Supreme court

case of Gian Kaur vs State of Punjab-1996

RIGHT TO LIFE includes the RIGHT OF A DYING MAN TO ALSO DIE WITH DIGNITY

Thus according to supreme court

RIGHT TO LIFE includes the RIGHT OF A DYING MAN TO ALSO DIE WITH DIGNITY

When his life is ebbing out



The judgment can not be used to interpret all acts of withdrawl and withholding of life support as

Suicide and therefore illegal



EOLD

VS

Euthanasia and physician assisted suicide

FACILITATING

VS

HASTENING THE NATURAL PROCESS OF DYING


is morally permissible if the action

EOLD vs Euthanasia and physician assisted suicide

RU

LE

OF

DO

UB

LE

EF

FE

CT An action with two possible consequences, one good and one bad

USE OF SEDATIVES/ NARCOTICS- relieving pain or causing death

is morally permissible if the action

RU

LE

OF

DO

UB

LE

EF

FE

CT

•Is not in itself immoral

•Is undertaken only with the intention of achieving the possible good effect, without

intending 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

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)

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND 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 DOCTORAMPLE SCOPE TO PROTECT THE WELL MEANING DOCTOR

GOOD INTENTIONBENEFISCENCE, NON MALEFISCENCE



DO

CU

ME

NTA

TIO

N


ISCCM POSITION

LIMITING LIFE PROLONGING INTERVENTIONS AND PROVIDING PALLIATIVE CARE

TOWARDS THE END OF LIFE IN INDIAN INTENSIVE CARE UNITSMani 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•When to initiate EOL discussions

•Checklist for initiating EOL discussions

•Rationale

•Recommendation for limiting life support interventions

LIMITATION OF LIFE SUPPORT

ISCCM POSITION RECOMMENDATION 2

•DNI/ DNR

•TREATMENT WITHHOLDING

FULL RESUSCITATION

•TREATMENT WITHHOLDING

•TREATMENT WITHDRAWING

PALLIATIVE CARE

EUTHANASIA AND PATIENT ASSISTED SUICIDE- illegal in India


ISCCM POSITION

Pending consensus decisions or in the event of conflicts between the physician’s recommendations

and family’s wishes, all existing supportive interventions should continue.

The physician however, is not morally obliged to institute new therapies against his/ her

better clinical judgment.

RECOMMENDATION 4

The discussions leading up to the decision to withhold life supporting therapies should be clearly

documented in the case records, to ensure transparency and to avoid future misunderstanding.

Such documentation should mention the persons who participated in the decision making process

and the treatment withhold or withdrawn.

The committee does not regard the signature of a family representative to be a mandatory requirement.

RECOMMENDATION 5


ISCCM POSITION

if the capable patient or family consistently desires that life support be withdrawn, in situation in which

the 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 the

use of opiates and the indication for their use.

The optimal dose of opiates is determined by increasing the dose until the patient’s comfort is ensured,

There is no maximal dose recommended.


ICU DATA

Paucity of empirical data on the frequency and manner of foregoing life support in Indian ICUPaucity of empirical data on the frequency and manner of foregoing life support in Indian ICU

•UNAWARENESS OF ETHICAL ISSUES

•CULTURE OF FIGHTING TILL THE END

•ABLE TO SAY THAT ONE HAS DONE EVERYTHING

•LACK OF PALLIATIVE CARE ORIENTATION

•LEGAL AND ADMINISTRATIVE PREJUDICES


ICU 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;158:1163–1167.

prospectively collected data from icu trainee residents from 131 ICUs at 110 institutions in 38 states of USA

over a period of 1year (1994-1995)

Total ICU admissions -++74,502

Total ICU deaths-++++ 6,303 (8.5%)

Brain deaths-+++++... 393 (6.2%)

Full resuscitation-+. 1,544 (26%)

end-of-life decisions -5,910 (73%)

DNI - ++++++..+1,430 (24%)

Withholding -+++...797 (14%)

Withdrawal -++++ 2,139 (36%)


ICU 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 from

January 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.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 hours

Withholding +89% died within 14.3 hours

11% of patients survived

REASONS-AGE, POOR PROGNOSIS, POOR PREDICTED QUALITY OF LIFE

Greatest frequency of limitation occurred in acute neurological disease

Substantial intercountry variability – religion and culture rooted


ICU DATA- INDIA

Limitation of life support in the ICU: ethical issues relating to end of life care

Mani R.K., IJCCM 2003;7:112-117

Single centre survey from tertiary care Indian Hospital March- Dec 2002

Total admissions- ++..852

Total deaths-+++...+ 238 ( 27%)

Full resuscitation-++. 186 (78%)

EOLD- ++48 (22%)

DNR-+++ 4 (8%)

Withhold-+. 4 (8%)

LAMA- ++.38 (79%)

Brain dead-.. 4 ( 8%)

Reasons - financial

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONICU DATA- INDIA

Limitation and withdrawl of intensive therapy at the end of life practices in intensive care units

in 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

Hinduja hosp

(Private)

Breach Candy

(Private)

TMH

(Public private)

KEM HOP

(Public)TOTAL

Total death in

hospital87 24 88 846 1045

Death in ICU 59 10 12 62 143

EOL decision 24 (41%) 4 (40%) 6 (50%) 15 (19%) 49 (34%)

-DNI 8 (13.6%) 2 (20%) 2 (17%) 0 12 (25%)

-Withhold 14 (24%) 0 4 (33%) 15 (24%) 33 (67%)

-Withdrawn 2 (3%) 2 (20%) 0 0 4 (8%)

END OF LIFE DECESIONEND OF LIFE DECESIONEND OF LIFE DECESIONEND 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 India

admitted between May 2006 to Dec 2007

Reasons- advanced chronic diseaseEOLD- ++++43 (48%)

Patients admitted- 830

Death-+++++ 88 (10.6%)

Full resuscitation- 45 ( 57%)

Reasons- advanced chronic disease

unresponsive to treatment

Advanced age

Family unwilling to continue treatmentPREHOSPITAL 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


DATA- CAREGIVERS APPROACH- INDIA

Physician belief and practices regarding end of life care in India

V.Theodore Barnett, V.K. Aurora, IJCCM, July-Sep, 2008, 12(3)

Response to questionnaires at NAPCON 2002 at Jaipur, India

Joint 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 guidelines

Culture and religion was not perceived as barrier

Fators considered important-•Age

•Economy

•Duration of disease

•HIV status


DATA- CAREGIVERS APPROACH-ISRAEL

Forgoing Life-Sustaining Treatments: Comparison of Attitudes between Israeli and

North 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 during

1992-1994

DNR orders both (incidence and reason) were similar to that in USA

Approach was paternalistic compared to USA

An 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


DATA- CAREGIVERS APPROACH- EUROPE

Forgoing life support in western European intensive care units: The results of an

ethical questionnaireVincent, Jean-Louis MD, PhD, FCCM, Crit Care Med;1999;27(8):1626-33

Intensive care unit ------------------------limitation of beds

admissions with no hope of survival--70%

shortening of death------------------------40%

differences between action and belief of physicians

DEFINITIONS ISCCM POSITIONS

FULL SUPPORT: the provision of all measures needed to support hemodynamics, ventilation

and metabolism.

FULL RESUSCITATION( CPR): aggressive ICU management up to and including

resuscitative attempts, in the event that cardio respiratory arrest occurs.

DNI/ DNR: aggressive ICU management up to , but not including endotracheal intubation ( 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 escalate

existing treatments for life support, ( including, but not limited to, intubation, ionotropes,

vasopressors, mechanical ventilation, dialysis, antibiotics, intravenous fluids, enteral or

parenteral nutrition) with the understanding that the treatment has a higher potential to cause

pain and suffering than resolution of organ failure.

DEFINITIONS ISCCM POSITIONS

WITHDRAWING OF LIFE SUPPORT: the cessation or removal of an ongoing life supporting

treatment while not substituting an equivalent alternative treatment, with the

understanding that the treatment in question is causing pain and suffering and serves no

purpose other than delaying death. It is anticipated that the patient will die following the

change 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 underlying with no further attempt at resuscitation or providing organ support, when the underlying

disease process is presumed to have reached a point of no return.

Futility- a life sustaining intervention is futile if reasoning and experience indicates that

the intervention would be highly unlikely to result in a meaningful survival for that

patient.

Def of American Thoracic Society

end of life_decesion

Education