ethics in critical care
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Ethics in Critical CarePrathap Tharyan MD, MRCPsych
Professor and Head,Department of Psychiatry
Christian Medical College, Vellore
2nd CME ON CRITICAL CARE MEDICINE
CMC Vellore
Ethics in Critical Care
WHAT IS MEDICAL ETHICS?
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.
Need for medical ethics
CMC Vellore
Ethics in Critical Care
What is the need for medical ethics?
The practice of medicine and the practice of ethics are inseparable.
Every clinical decision invokes an ethical decision as well.
In many instances, the ethical issue may not be readily apparent.
In others conflicts arise between ethical principles and medical decisions, which require the clinician to be well versed with the former in order to guide the latter. Need for
medical ethics
CMC Vellore
Ethics in Critical Care
What is the need for medical ethics?
The problems of health systems are in the last analysis ethical:– Who will live?– Who will die?– Who will get what treatment?– Who will decide?– And how?
Need for medical ethics
CMC Vellore
Ethics in Critical Care
What is the need to discuss medical ethics now?
The foundational principals of ethical health care are under siege– Hippocratic tradition challenged as
being:• paternalistic • anachronistic • absolutist• no focus on primary prevention
What about Hippocrates?
CMC Vellore
Ethics in Critical Care
What is the need to discuss medical ethics now?
Shifts in the traditional moral grounds of society in general:– Social and moral upheaval of the 1960’s– Changing expectations of a better educated and
more affluent public– The rise of feminism, consumer activism, civil
rights and participatory democracy– The primacy of individual autonomy over shared
communal values A distrust of technology, authority, and
institutions (corrosion of fiduciary relationship)
Society has changed
CMC Vellore
Ethics in Critical Care
What is the need to discuss medical ethics now?
Shifts in the traditional moral grounds of medicine:– Specialisation, fragmentation,
commercialisation, institutionalisation and depersonalisation of heath care.
– Commercialisation of medical education
– Unethical medical practices Consumer protection act (COPRA) 1986 THE INDIAN MEDICAL COUNCIL ACT (102
of 1956)Need for medical ethics
CMC Vellore
Ethics in Critical Care
A new ethical code for health care in the 21st century?
While I continue to keep this Oath unviolated, may it be granted to me to enjoy life and the practice of the Art, respected by all men, in all times. But should I trespass and violate this Oath, may the reverse be my lot.”
(The Hippocratic Oath, 5th century B.C)
In a world of health care economics, consumers, clients and service providers, health care has to be based on sound ethical principles that reflect the reality and needs of contemporary society
Need for medical ethics
CMC Vellore
Ethics in Critical Care
The philosophical underpinnings of medical ethics
ETHICAL THEORIES DEONTOLOGY (Deon = duty)
– Springs from moral obligations– Actions determined by rightness or
wrongness ( virtue ethics)– The outcome of action is not
important
The philosophical underpinnings of medical ethics
CMC Vellore
Ethics in Critical Care
ETHICAL THEORIES
TELEOLOGY (Telos = goal)– Actions determined by their
consequences– Motives less important than the
outcome– Greatest good for the greatest
number – Actions will vary depending on the
situation ( situational ethics)The philosophical underpinnings of medical ethics
CMC Vellore
Ethics in Critical Care
PROBLEMS WITH THESE MODELS
Deontology– Values are not universally shared– Do not consequences matter?
Teleology– Greatest good for the greatest
number does not protect minority rights
– Not always possible to predict consequences accurately
– Your values may conflict with the action needed
The philosophical underpinnings of medical ethics
CMC Vellore
Ethics in Critical Care
RECONCILING THE TWO
SEQUENTIAL MODEL– What is the right thing to do in this
instance? – What would be the consequences?
Additional ethical principles
Motives- Action-Consequences-Situation
CMC Vellore
Ethics in Critical Care
ETHICAL PRINCIPLES
Autonomy: 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. The Principles of medical ethics: Autonomy
CMC Vellore
Ethics in Critical Care
ETHICAL PRINCIPLES
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
The Principles of medical ethics:
Do good
Do no harm
CMC Vellore
Ethics in Critical Care
ETHICAL PRINCIPLES Justice: This refers to the need to treat all
people equally and fairly Society uses a variety of factors as a criteria
for distributive justice, including the following: – to each person an equal share – to each person according to need – to each person according to effort – to each person according to contribution – to each person according to merit – to each person according to free-market exchanges
We should strive to provide some decent minimum level of health care for all citizens, regardless of ability to pay
The Principles of medical ethics:
Distributive justice
CMC Vellore
Ethics in Critical Care
CONFLICTING PRINCIPLES?
Not hierarchicalAutonomy can conflict with
beneficence In India many people do not know how
to deal with autonomy– Wishes of relatives also important
Autonomy/beneficence can conflict with justice
Need to balance beneficence with non-malfeasance
The Principles of medical ethics
CMC Vellore
Ethics in Critical Care
THE RELATION BETWEEN LAW AND ETHICS Ethical values have often been
influenced by and influenced legal doctrine and legal principles are closely related to ethical principles.
Ethical obligations exceed legal duties
Law serves to demarcate the limits of individual autonomy in the interests of society. It also protects the rights of individuals
CMC Vellore
Ethics in Critical Care
The Multi Layered Approach
Patient Preferences
Medical Goals
Foundational Principles, Type of Ethical Problem
Contextual features: legal, social, family, economicsocietal Quality of
life issues
CMC Vellore
Ethics in Critical Care
Lets also remember
Medicine is about : “Can we?” Ethics is about: “Should we?”
The ethicist as a hedge
Helping patients and their families through difficult times is never easy
Prathap Tharyan MD, MRCPsychProfessor and Head,
Department of Psychiatry
On behalf of the CMC Vellore Clinical Ethics Committee
Case history
CMC Vellore
Ethics in Critical Care
The case of Mr. P
A 65 year old retired man was diagnosed to have motor neuron disease 4 years prior to retirement and had become progressively worse
Seen in various ‘corporate’ speciality hospitals- poor prognosis conveyed
Sent to CMC Hospital for a feeding gastrostomy- difficulty swallowing
Bed ridden, could not talk, communicated by writing; fully alert and compos mentis
The makings of an ethical dilemma
CMC Vellore
Ethics in Critical Care
Encounters in CMC
During the procedure he developed respiratory arrest and was put on life support
3 months later the ICU head called for a clinical ethics committee meeting
Failed attempts to wean off respiratorOpinion backed by evidence that
further attempts would be futileSurely there is a lesson to be learned in this?
CMC Vellore
Ethics in Critical Care
The ethical dilemma begins
His family had spent more than 8 lakhs and wanted to remove him off the respirator
They knew of the prognosis They had no more money to spend. They owed money for treatment at CMC He had a wife, one grown up son, one married
daughter whose husband is a lawyer and two other smaller children who were studying.
All shared the same opinion about what they wish to do.
They did not express the wish to take him home
The family’s wish
CMC Vellore
Ethics in Critical Care
Intensive dilemma in intensive care
He has heard of home respirators and wished to have one.
Did not wish to die The family and Mr. P had not discussed
these issues with each other
Mr. P’s wish
CMC Vellore
Ethics in Critical Care
Not just another day at the office The ICU doctors know treatment is futile There is no longer any money to pay for
expensive treatments; the family wish to take Mr. P off life support
Mr. P wishes to live; wants a home ventilator Where does this come from? Mr. P did not want a tracheostomy There are limited ICU beds and many
potentially treatable people who need these beds
This is a Christian institution with certain values
Conflicting ethical principles: every one of them
Legal issuesThe ethical dilemma
CMC Vellore
Ethics in Critical Care
What would you do?
THE BUCK STOPS HERE
CMC Vellore
Ethics in Critical Care
The ethics committee’s recommendations
Independent review of medical notes and physical condition
Transfer to Neuro-ICU: try to wean off respirator
Hospital bears further costs Try to get money from ex-employers Explore issue of home respirator Talk with patient and family Meet in one month to review situationClinical
ethics committee meets
CMC Vellore
Ethics in Critical Care
Conversations with the family Wife very distressed by Mr. P’s condition and
prognosis; fears having to deal with him on her own if he worsened
Distressed about lack of adequate medical care in her village in Jharkhand
Would rather kill herself than take him home to manage on her own
Did not want to sacrifice her younger children's’ futures in futile treatments
Rational; distressed; not clinically depressed
Mr. P’s wife
CMC Vellore
Ethics in Critical Care
Conversations with the family
Very supportive of mother in law and his own wife
Fully aware of legal issues Was in communication with family
back home, including Mr. P’s son Did not see any other practical
solution Pleaded for help
Mr. P’s son-in-law: the lawyer
CMC Vellore
Ethics in Critical Care
The elusive home ventilator
Costs 2,00,000 Rs Needs uninterrupted power supply,
technical support Family live in a village in Jharkhand Wife not willing to try nursing him on a
ventilator at home Transport home by rail or air not
possible Ambulance journey to Jharkhand also
not feasible Money from employer not forthcoming
Other developments
CMC Vellore
Ethics in Critical Care
Independent medical review and Neuro-ICU efforts
Confirmed diagnosis, prognosis Attempts at weaning off
respirator not proving successful
Follow up of action plan
CMC Vellore
Ethics in Critical Care
Conversations with Mr. P
Knew of his prognosisWished to liveAgreed to the tracheostomyAgreed to try hard to get off the
ventilatorSoon realized this was not possibleBegan to accept that
– his illness would progress; – that a home respirator was not possible – even if it were, his QOL would be poor
A brave and forthright man
CMC Vellore
Ethics in Critical Care
Further conversations with Mr. PAsked to be sent home to die
surrounded by his familyNot possible I suggested his family be brought
hereList of 15 names of 90 family
members produced
Truth telling is never easy
CMC Vellore
Ethics in Critical Care
Of death and dying Acknowledged a good life Felt at peace with his maker Feared the moment of death: “ did not want to
choke to death’’ Promise that this would not happen Much more at peace about dying after that Wrote that he was willing to be taken off life
support after his family came Family came on a Monday with return tickets
booked for the following Friday Shifted to a private room with technical support Family finalized many issues, said their goodbyes
Confronting ones fears of death
CMC Vellore
Ethics in Critical Care
The final ethical review
The family met ethics committeeAll issues reviewed, documentedMy goodbyeThe sedativeWithdrawal of life supportMr. P, in your death, you taught
us about the sanctity of life
Wednesday
CMC Vellore
Ethics in Critical Care
The aftermath
Mr. P’s death affected everyone involved
Contrast with the situation 25 years ago Happens everyday without any ethical
review Withdrawal of life support not the central
issue: was it a good death? Should we publish this and call for
discussion, legal guidance? Guidelines for procedures in similar
situationsEthical dilemmas at the end of life
CMC Vellore
Ethics in Critical Care
Lets also remember
Medicine is about : “Can we?” Ethics is about: “Should we?”
The ethicist as a hedge
Did we do the ‘right’ thing?
Thank you
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