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WITHDRAWAL OF THERAPY

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withdrawal of therapy by j.a.al-ata consultant & assistant professor of pediatric cardiology chairman, bio-ethics committee kfsh-rc jed. definition withdrawal of ... – PowerPoint PPT presentation

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Title: WITHDRAWAL OF THERAPY


1
WITHDRAWAL OF THERAPY
  • By J.A.AL-ATA
  • CONSULTANT ASSISTANT PROFESSOR OF PEDIATRIC
    CARDIOLOGY
  • CHAIRMAN, BIO-ETHICS COMMITTEE KFSH-RC JED.

2
DEFINITION
  • Withdrawal of advanced life support (e.g.
    mechanical ventilation) when continued ICU care
    becomes futile or when
    brain death is established.
  • However, a narrow definition of futility in this
    situation is the key, since the concept of
    futility could lead to inappropriate decisions.
  • It is best to consider a situation futile when
    the patient is terminally ill, the condition is
    irreversible, and death is imminent.

3
IMPORTANT POINTS
  • The patient is always the key source of authority
    in these decisions.

4
CONT
  • The most important ingredient in end-of-life
    decision making is effective communication.

5
CONT
  • It is important to try to ascertain what the
    patient thought about quality-of-life values
    before surrogate decisions can be made on the
    patient's behalf.

6
CONT
  • The concepts of
  • beneficence, nonmaleficence, autonomy, and
    justice are the foundation of ethical decision
    making.
  • Treatment is not mandatory.

7
IMPLICATIONS OF AUTONOMY
  • Competent ( MENTAL , AGE , AUTONOMY , INFORMED )
    patients have the right to refuse treatment
  • Patient guardian does not have the right to
    refuse treatment in non-futile situation in which
    refusal of treatment will significantly harm the
    patient.

8
CONT
  • Studies showed poor agreement between patients
    and surrogates suggesting that substituted
    judgment is not an accurate tool to make
    end-of-life decisions.
  • Islamically and probably in other faiths a
    patient is encouraged to seek and accept
    treatment leading to cure or substantial
    improvement or preventing significant harm.

9
THE WITHDRAWAL PROCESS
  • Establishing the futile situation and/ or brain
    death.

10
BRAIN DEATH CRIETERIA
  • Deep coma with cessation of respiration.
  • Irreversible diagnosed brain or brain stem injury
    for which there is no cure or palliation.
  • No cause for transient coma (e.g. hypoglycemia or
    hypothermia or sedative drugs----etc.
  • Evidence of no brain stem function
  • Enough time
  • Confirmatory tests

11
CONT
  • OR , a confirmed futile state judged at least by
    two consultant physicians.

12
CONT
  • Proper communication between treating physicians,
    nursing, bio-ethics to gather information about
    the medical,social,religious
    cultural,emotional, and legal situation.

13
CONT
  • Meeting the concerned family members or
    guardians
  • Showing empathy,concern.
  • Aiming at explaining the state till well
    understood at reaching a gradual thoughtful
    decision with them.
  • Give NEEDED time
  • Act truly as the patient and family advocate.

14
CONT
  • If the decision is made, document in the chart
    and implement in a timely manner.
  • If there is opposition allow time for
    reconsideration.
  • explore your alternatives
  • Avoid confrontation and do not wave with
    legislative empowerment you have early.

15
CONT
  • Support the family and attend to their wishes and
    needs
  • Direct them (if ok) to spend more time with the
    patient and attend to his or her non-medical
    current needs
  • Involve the Imam or chaplan

16
CONT
  • Better to wean from the vent. rapidly than to
    stop it at once
  • Comfort,comfort,
  • NO pain (avoid over sedation)
  • Oxygen
  • Hydration
  • Maintaining blood glucose not necessarily
    nutrition
  • Quiet , private environment.

17
CONT
  • DONT FALL IN THE TRAP OF EUTHANASIA, ASSISTED
    SUICIDE
  • MODIFY PLANS AS CHANGES COME.

18
TIPS TO SUCCESSFUL THERAPY WITHDRAWAL
  • Discuss issues early with the patient and get to
    his or her wishes.
  • Have good rapport with patient and family.
  • Evaluate your patient properly before embarking
    on a heroic management plan.

19
Situations in which CPR should be performed
  • People likely to benefit from CPR should be given
    this treatment if the need arises, unless they
    have specifically rejected it.
  • People for whom the benefit of CPR is uncertain
    or unlikely should be given this treatment if the
    need arises, unless they have specifically
    rejected it. CPR should be initiated until the
    patient's condition has been assessed.

20
Situations in which CPR should not be performed
  • People who have rejected CPR and those who almost
    certainly will not benefit from it should not be
    given this treatment if an arrest occurs.

21
Review of CPR decisions
  • In the following circumstances review of
    decisions should be undertaken immediately
  • If a competent person (or proxy) changes his or
    her decision about resuscitation.
  • If there is a significant, unexpected change in a
    person's condition.

22
CONT
  • A decision not to initiate CPR does not imply the
    withholding or withdrawing of any other treatment
    or intervention.
  • A person who does not receive CPR should receive
    all other appropriate treatments, including
    palliative care, for his or her physical, mental
    and spiritual comfort.

23
THANK YOU
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