Tuesday, December 10, 2013
Sunday, December 8, 2013
ETHICAL ISSUES IN CRITICAL CARE.
Withholding a treatment is not starting a treatment that has a disproportionate burden without achieving reasonable clinical goals. For example, a patient with overwhelming sepsis and an MI; we would not offer a heart transplant as that would not be medically beneficial. We would technically be withholding a treatment. However we decided medically that it would not benefit the patient. As a consequence, heart transplantation would not be offered the patient or the patient’s family.
Medical ethics refers
chiefly to the rules of etiquette adopted by the medical
profession to regulate professional conduct with each other, but also towards their individual patients
and towards
society, and includes considerations of
the motives behind that conduct
PRINCIPLES
OF CRITICAL CARE
1.Early Diagnosis
and Identification of the Problem
2. Anticipation of possible events and complications
3.The
Holistic Approach
4.Appropriate Use of
Technology
5.Primum
non nocere
6.Evidence Based Medicine
7.Recognition of Limits
of Critical Care
Beneficence:
This refers to the
tradition of acting always in the patients’ best interest to maximise benefits
and minimise harm.
Non-malfeasance:
This principle
ensures that treatment or research ought not to produce harm
Negligence
Misconduct
RIGHT OR WRONG
What is more
right ?
What is more wrong?
Prioritizing ?
Ethical Quandary: You can make decision but cannot decide.
Autonomy of Patient:
It is the respect for an individual’s autonomy or
ability to make decisions for him/herself
includes respect for their privacy and confidentiality need to provide sufficient information for them to make
informed choices truth telling protection of persons with diminished or
impaired autonomy.
Distributive justice
Means that patients in similar circumstances should receive similar care. Physicians need to have a socially responsible behavior, which makes it their duty to make optimal use of the material, financial and human resources under their control. The physician may thus provide treatment and resources to one with a potentially curable condition over another for whom treatment will be futile.
Means that patients in similar circumstances should receive similar care. Physicians need to have a socially responsible behavior, which makes it their duty to make optimal use of the material, financial and human resources under their control. The physician may thus provide treatment and resources to one with a potentially curable condition over another for whom treatment will be futile.
Non-medically
Beneficial Treatment
(Futile Care)
(Futile Care)
•It
is well established in medical ethics and law that it is appropriate to
withhold medical intervention when such interventions provide no reasonable
likelihood of benefit to the patient.
DO NOT RESUSCITATE ORDERS
“DNR
orders only preclude resuscitative efforts in the event of cardiopulmonary
arrest and should not influence other therapeutic interventions that may be
appropriate for the patient.
WITHDRAWAL OF TREATMENT:
Withdraw
of treatment is treatment that has been started, such as mechanical ventilation
or dialysis or artificial nutrition and hydration. WD is discontinuing a
therapy that has a disproportionate burden without achieving reasonable
clinical goals. It is NOT hastening death. The goal is to stop nonmedically beneficial treatment
and to relieve suffering. Intent matters.
WITHHOLDING OF TREATMENT :
Withholding a treatment is not starting a treatment that has a disproportionate burden without achieving reasonable clinical goals. For example, a patient with overwhelming sepsis and an MI; we would not offer a heart transplant as that would not be medically beneficial. We would technically be withholding a treatment. However we decided medically that it would not benefit the patient. As a consequence, heart transplantation would not be offered the patient or the patient’s family.
Guidelines for limiting life-prolonging
interventions and providing palliative care towards the end of life in Indian Intensive
care units (Source ISCCM Website):
1. The physician has a moral obligation to inform the
capable patient/family, with honesty and clarity, the poor prognostic status of the
patient when
further aggressive support appears non-beneficial. The
physician is expected
to initiate
discussions on the treatment options available including the option of no specific treatment
2.When the fully informed capable patient/family desires to
consider comfort care, the physician
should explicitly communicate the available modalities of limiting life-prolonging interventions.
3. The physician must discuss the implications of
forgoing aggressive interventions
through formal
counseling sessions with the capable patient/family, and work towards a shared decision-making process.
Thus,
he accepts patient’s autonomy in making an informed
choice of therapy, while
he fulfils his
obligation of providing beneficent care.
4.Pending consensus decisions or in the event of conflicts between
the physician’s approach and the family’s wishes, all existing
supportive interventions should continue. The physician however, is not morally obliged to institute new therapies against his better clinical
judgment.
5. The proceedings of the counseling sessions, the
decision-making process, and
the final decision
should be clearly documented in the case records, to ensure transparency
and to avoid future misunderstandings.
6. The overall responsibility for the decision rests
with the attending physician
/intensivist of the patient, who
must ensure that all members of the caregiver team including the medical and nursing staff
represent the same approach to the care of the patient.
7. If the capable patient/family
consistently desires that life support be withdrawn, in situations in which the physician
considers aggressive treatment non-beneficial,
the treating team is ethically bound to consider withdrawal within the limits of existing laws.
8. In the event of withdrawal or
withholding of support, it is the physician’s obligation to provide compassionate and effective
palliative care to the patient as well as attend to the emotional
needs of the family.
The 196 th
Draft Bill of the Law Commission of India
In a landmark development, the Indian Law Commission published a draft bill on "Medical treatment of terminally ill patients (for the protection of patients and medical practitioners)" in 2006.
In a landmark development, the Indian Law Commission published a draft bill on "Medical treatment of terminally ill patients (for the protection of patients and medical practitioners)" in 2006.
It reviewed the
case laws and legal guidelines from several countries and made some notable
observations :
Euthanasia and physician-assisted suicide remain
criminal offences, but are clearly distinct from withholding and withdrawal of
life support
Adult patients' right to self determination and right to
refuse treatment is binding on doctors if based on informed choice
The State's interest in protecting life is not absolute
The obligation of the physician is to act in the
"best interests" of the patient
Refusal to accept medical treatment does not amount to
"attempt to commit suicide" and endorsement of FLST by the physician
does not constitute "abetment of suicide"
Withholding & withdrawal is viewed as an
"omission to struggle" on the part of the physician that will not be
unlawful unless there is a breach of duty towards the patient
Applying invasive therapies contrary to patient's will
amounts to battery or in some cases to culpable homicide
Saturday, November 30, 2013
Normal Laboratory Values
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