end of life decision ( EOLD)

7/30/2019 end of life decision ( EOLD)

1/32

END OF LIFE DECESION

Ubaidur Rahaman

Senior Resident, CCM, SGPGIMS

Lucknow, India


2/32


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


3/32


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


4/32


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 End of life support care in ICU: treatment provided when life support was or was not withdrawn.Chest 2000;118:1424-30-End of life decisions in Indian intensive care unit.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


5/32


Why ???

BENEFISCENCE

NONMALEFISCENCE

AUTONOMY

JUSTICE

MEDICAL ETHICS


6/32

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


7/32

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


8/32

END OF LIFE DECESIONWHO WILL DECIDE

MEDICAL PATERNALISM

PATIENT AUTONOMY

SHARED DECESION MAKING


9/32

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)


10/32

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


11/32


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)


12/32

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 judgment can not be used to interpret all acts of withdrawl and withholding of life support asSuicide and therefore illegal


13/32

END OF LIFE DECESIONPATIENT AUTONOMY- RIGHT TO REFUSE TREATMENT

EOLD

VS

Euthanasia and physician assisted suicide

FACILITATING

VS

HASTENING THE NATURAL PROCESS OF DYING


14/32


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)


15/32

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


DOCUMENTATION


16/32


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


17/32

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


18/32


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


19/32


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.


20/32


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


21/32

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%)


22/32

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


23/32

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


24/32


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)


25/32


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


26/32

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


27/32

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


28/32

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


29/32


30/32

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.


31/32

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.


32/32

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

Documents

end of life decision ( EOLD)