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Challenging decisions in the area of end of life care in the ICU


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Title: Challenging decisions in the area of end of life care in the ICU

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Challenging decisions in the area of end of life
care In the Intensive Care Unit
  • By
  • Amr Saad Zidan Hassan
  • MB.B.CH.
  • Faculty of medicine
  • Cairo University

Supervised by
  • Professor Dr/ Magdy Mohammed Hussien Nafie
  • Professor of anesthesia intensive care
  • Faculty of medicine Ain shams University
  • Professor Dr/ Noha Sayed Hussien
  • Assistant Professor of anesthesia intensive
  • Faculty of medicine Ain shams University
  • Dr/ Wael Sayed Abd El Ghaffar
  • Lecturer of anesthesia intensive care
  • Faculty of medicine Ain shams University

  • First and foremost , thanks to ALLAH , the most
    merciful and the greatest beneficent for giving
    me the strength and health to finish this work
    until the end

  • I am particularly grateful to
  • Magdy Mohammed Hussien Nafie
  • For his continuous support , patience and
    valuable supervision of this work.

  • Also I want to thank
  • Dr /Noha Sayed Hussien
  • For her support and great help during the
    accomplishment of this work
  • And finally, my thanks to
  • Dr / Wael Sayed Abd El Ghaffar
  • For his sincere guidance throughout the work

Aim of the work
  • This study is prepared to help intensivists
    easily take definite decisions towards critical
    issues concerning end of life care in the ICU.

  • Introduction
  • Treatment, nutrition and transition to
  • Cardiopulmonary resuscitation (CPR)
  • Diagnosis of death and organ donation
  • Ethical , legal, cultural and religious issues

  • Death previously was a private, usually spiritual
    event involving family and friends, it is today
    by contrast often public and technological.
  • The goal of end of life decision making is to
    meet patient's wishes and needs by choosing
    appropriate treatments.
  • End of life care is care that helps all those
    with advanced, progressive, incurable illness to
    live as well as possible until they die. It
    enables the supportive and palliative care needs
    .It includes management of pain and other
    symptoms and provision of psychological, social,
    spiritual and practical support.

Treatment, nutrition and transition to
  • In situations where full treatment has been
    judged to be inappropriate, some treatment
    modalities may be limited, withheld or withdrawn.

Treatment, nutrition and transition to palliation
  • Definitions
  • Limitation of treatment means a treatment, which
    might be beneficial is continued to a
    predetermined upper limit, dose or time period
  • Withholding treatment means a treatment, which
    might be beneficial in a different scenario is
    not initiated .
  • Withdrawal of treatment means a treatment, which
    might be beneficial in a different scenario is
    reduced and stopped

Treatment, nutrition and transition to palliation
  • Medical and legal analyses have emphasized that
    clinicians should make no distinction between
    decisions to withhold or to withdraw. This is
    because whether any therapy is initiated or
    continued should be based solely on an assessment
    of its benefits versus burdens and the
    preferences of the patient.
  • Furthermore, in many cases the value of an
    intervention can only be determined after a trial
    of therapy for example

Treatment, nutrition and transition to palliation
  • Kidney dialysis
  • The ethical challenges for dialysis withdrawal
    arise when stopping dialysis becomes an option
    patients want to consider.
  • Shared decision making between the patient and
    physician must occur, and if the patient lacks
    decision-making capacity, the health care agent
    should be involved.
  • Physicians should provide patients with all
    available information including available
    treatment options, consequences of dialysis
    withdrawal, and other end of life care options
    like hospice and palliative care.

Nutrition and hydration
  • Clinically, the American Medical Association does
    not distinguish between nutrition and hydration
    and other life sustaining treatments
  • Others argue that nutrition and hydration
    treatments are palliative care that fulfill a
    basic human need and should not be denied to
    patients at the end of life
  • In practice Instead of hydrating the patient,
    water can cause bloating and swelling and
    nutrition may cause intestinal problems that can
    add to a patients discomfort .

Cardiopulmonary resuscitation (CPR)
  • History of (CPR)
  • Modern CPR has been developed in the late 1950s .
  • Later in 1960s mouth-to-mouth ventilation and
    chest compression were combined to form CPR
    similar to the way it is practiced today.

Cardiopulmonary resuscitation (CPR)
  • Many algorithms have been established and updated
    to summaries and simplify the steps of recent CPR

Cardiopulmonary resuscitation (CPR)
  • CPR guidelines were updated to discuss several
    new aspects of care like
  • CPR techniques
  • Electrical therapies
  • Post-cardiac arrest syndrome
  • Post-cardiac arrest care
  • Neurological outcome after cardiac arrest

Cardiopulmonary resuscitation (CPR)
  • Do Not Attempt Resuscitation (DNAR)
  • All pediatric and adult patients who suffer
    cardiac arrest in the hospital setting should
    have resuscitative attempts initiated unless the
    patient has a valid DNAR order.
  • DNAR decision does not override clinical judgment
    in the unlikely event of a reversible cause of
    the patients respiratory or cardiac arrest .
  • DNAR decisions apply only to CPR and not to any
    other aspects of treatment.
  • In some cases, the decision not to attempt CPR is
    a straightforward clinical decision. So If the
    clinical team believes that CPR will not restart
    the heart ,it should not be offered or attempted

Diagnosis of death and organ donation
  • Definition and Diagnosis of death
  • In past eras, human death was much easier to
    define than it is now With advances in life
    support, the line between who is alive and who is
    dead has become blurred.
  • Life support technologies have produced a new
    kind of patient, one whose brain does not
    function, but whose heart and lungs continue to

Diagnosis of death and organ donation
  • In the USA they are defining death according to
    Uniform Determination of Death Act (UDDA) as
  • Either irreversible cessation of circulatory and
    respiratory function or irreversible cessation of
    all functions of the entire brain, including the

Diagnosis of death and organ donation
  • In Egypt this definition faced a great opposition
    considering that there is no medical or
    scientific evidence validating either the
    neurological or circulatory criterion of death
    being synonymous with true biological death.

Diagnosis of death and organ donation
  • Brain death criteria and clinical diagnosis of
    brain death
  • Irreversible well defined etiology of
  • Exclusion of hypothermia.
  • Sufficient observation period (at least 6 hours)
    between two brain death examinations .
  • No clinical evidence of cerebral function.
  • No clinical evidence of brainstem function(
    pupillary reflex..).
  • Positive apnea test.

Diagnosis of death and organ donation
  • Pitfalls in clinical brain death testing
  • Hypothermia.
  • Intoxication or drug overdose.
  • Neuromuscular and sedative drugs.
  • Pupillary fixation caused by anticholinergic
    drugs (e.g. atropine).
  • Absent corneal reflexes due to overlooked
    contact lenses.
  • Oculovestibular reflexes diminished after prior
    use of ototoxic drugs (e.g. aminoglycosides) or
    due to pre-existing disease.

Diagnosis of death and organ donation
  • Organ donation
  • Determination of death can be further complicated
    by the process of organ donation.
  • Donors are classified in to
  • A. Brain dead deceased donors.
  • B. Donation after cardiac death (DCD) donors.

Diagnosis of death and organ donation
  • Inadequate brain-dead donor management may result
    in loss of transplantable organs or even (in up
    to 15) loss of the organ donor altogether.
  • So Critical care professionals are responsible
    for the integrity of the organ donation process
    in collaboration with the organ procurement team,
    so they have to be up to date with the recent
    principles regulating organ donation and dealing
    with its complications (e.g. rejection,
    infection,malignancy ..).

Ethical , legal, cultural and religious issues
  • Islamic viewpoint on brain death and organ
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  • Death is a process rather than an event. The
    determination and certification of death indicate
    that an irrevocable point in the dying process
    has been reached, not that the process has ended.
  • Determination of death by any means does not
    guarantee that all bodily functions and cellular
    activity, including that of brain cells, have
    ceased. Several tissues can be retrieved for
    transplantation long after death has been
    determined by cessation of circulation and brain
    stem functions.

Ethical , legal, cultural and religious issues
  • Acceptance of brain stem death donation in some
    Islamic countries
  • The subject of BSD was discussed at the 3rd
    international conference of Islamic Jurists held
    in Amman-Jordan, in 1986, The religious scholars
    have passed a fatwa permitting BSD

Ethical , legal, cultural and religious issues
  • Opposition of BSD donation in Egypt
  • In Egypt this definition of death was opposed by
    Foundation of Dar Al iftaa Al masriyyah (FDAA)
    which stated in the fatwa number 1880 for the
    year 2003 discussing postmortem transplantation
  • The donor's death must be ascertained in
    accordance with the Islamic legal definition of
    death i.e. complete loss of function of all body
    organs such that life cannot be restored.
  • Since certainty cannot be removed by doubt, if it
    is not possible through medical technology to
    transplant an organ from a person whose death has
    been ascertained and this is only possible from
    one who is brain dead, then this procedure is
    prohibited and is tantamount to killing a soul
    without right which Allah has prohibited.

Ethical , legal, cultural and religious issues
  • There has been also legal opposition to the
    recognition of brain-death as legal death and
    organs are not legally or routinely procured from
    heart-beating brain-dead patients as they are
  • In May 2009, the Egyptian People's Assembly
    started reviewing a draft law to oversee and
    regulate organ transplant operations, it
    advocates the use of the conventional medical
    position that death occurs upon the irreversible
    cessation of all brain activity.
  • On December, 2009 the Shoura passed a bill that
    contained most of the provisions of the original
    law that was proposed in the lower house version
    (People's Assembly)

Ethical , legal, cultural and religious issues
  • The current bill does not define death but would
    refer cases of organ donation from deceased
    persons to a panel of 3 experts who must reach
    consensus on whether the donor is dead. The
    Higher Committee for Organ Transplants would
    appoint the experts in conjunction with the
    Ministry of Health
  • According to the law, any decision to remove
    organs before the panel's approval would be
    considered first-degree murder and punishable by
  • The new law also penalizes physicians who perform
    illegal organ transplant procedures, subjecting
    them to a maximum sentence of 15 years in jail.
    Hospitals and medical facilities allowing illegal
    operations will also be fined up to 1 million
    Egyptian pounds and can be shut down altogether

Ethical , legal, cultural and religious issues
  • The law also contains many other conditions most
    of them were taken from the fatwa of Dar Al iftaa
    published in 2003 , regulating the deceased organ
    donation in Egypt.

  • For intensivists, managing death in the
    critically ill has become a key professional
    skill. Intensivists must be thoroughly familiar
    with the ethical framework that guides
    end-of-life decision making.
  • Usage of Any therapy should based solely on its
    benefits versus burdens .
  • A combination of rational thinking, empathy, and
    patience will almost always foster effective
    decision making and exceptional end of life care.