Ethics in Critical Care

1. 2nd CME ON CRITICAL CARE MEDICINE Ethics in Critical Care Prathap Tharyan MD, MRCPsych Professor and Head, Department of Psychiatry Christian Medical College, Vellore

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. CONFLICTING PRINCIPLES? • Not hierarchical • Autonomy 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

17. 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

18. The Multi Layered Approach Patient Preferences Contextual features: legal, social, family, economic societal Medical Goals Quality of life issues Foundational Principles, Type of Ethical Problem

19. Lets also remember • Medicine is about : “Can we?” • Ethics is about: “Should we?” The ethicist as a hedge

20. Case history Helping patients and their families through difficult times is never easy Prathap Tharyan MD, MRCPsych Professor and Head, Department of Psychiatry On behalf of the CMC Vellore Clinical Ethics Committee

21. 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

22. 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 respirator • Opinion backed by evidence that further attempts would be futile Surely there is a lesson to be learned in this?

23. 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

24. 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

25. 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 issues The ethical dilemma

26. What would you do? THE BUCK STOPS HERE

27. 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 situation Clinical ethics committee meets

28. 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

29. 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

30. 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

31. Independent medical review and Neuro-ICU efforts • Confirmed diagnosis, prognosis • Attempts at weaning off respirator not proving successful Follow up of action plan

32. Conversations with Mr. P • Knew of his prognosis • Wished to live • Agreed to the tracheostomy • Agreed to try hard to get off the ventilator • Soon realized this was not possible • Began 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

33. Further conversations with Mr. P • Asked to be sent home to die surrounded by his family • Not possible • I suggested his family be brought here • List of 15 names of 90 family members produced Truth telling is never easy

34. 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

35. The final ethical review • The family met ethics committee • All issues reviewed, documented • My goodbye • The sedative • Withdrawal of life support • Mr. P, in your death, you taught us about the sanctity of life Wednesday

36. 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 situations Ethical dilemmas at the end of life

37. Lets also remember • Medicine is about : “Can we?” • Ethics is about: “Should we?” The ethicist as a hedge

38. Thank you Did we do the ‘right’ thing?