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

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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
  care
• Faculty of medicine Ain shams University
• Dr/ Wael Sayed Abd El Ghaffar
• Lecturer of anesthesia intensive care
• Faculty of medicine Ain shams University

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Acknowledgment

• 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

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Acknowledgment

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

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Acknowledgment

• 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

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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.

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contents

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

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Introduction

• 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.

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Treatment, nutrition and transition to
palliation

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  modalities may be limited, withheld or withdrawn.

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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

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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

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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.

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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 .

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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.

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Cardiopulmonary resuscitation (CPR)

• Many algorithms have been established and updated
  to summaries and simplify the steps of recent CPR
  guidelines

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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

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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

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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
  work.

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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
  brainstem.

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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.

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Diagnosis of death and organ donation

• Brain death criteria and clinical diagnosis of
  brain death
• Irreversible well defined etiology of
  unconsciousness.
• 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.

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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.

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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.

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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 ..).

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Ethical , legal, cultural and religious issues

• Islamic viewpoint on brain death and organ
  donation
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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.

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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
  transplantation.

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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
  that
• 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.

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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
  elsewhere.
• 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)

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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
  death
• 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

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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.

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Summary

• 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.

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• THANK YOU