Ethics in Critical Care

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Ethics in Critical Care
2nd CME ON CRITICAL CARE MEDICINE

• Prathap Tharyan MD, MRCPsych
• Professor and Head,
• Department of Psychiatry
• Christian Medical College, Vellore

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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
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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
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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
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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?
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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 1960s
• 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
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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
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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
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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
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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
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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
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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
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ETHICAL PRINCIPLES

• Autonomy Respect for an individuals 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
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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
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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
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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
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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

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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
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Lets also remember

• Medicine is about Can we?
• Ethics is about Should we?

The ethicist as a hedge
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Helping patients and their families through
difficult times is never easy
Case history

• Prathap Tharyan MD, MRCPsych
• Professor and Head,
• Department of Psychiatry
• On behalf of the CMC Vellore Clinical Ethics
  Committee

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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
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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?
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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 familys wish
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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. Ps wish
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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
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What would you do?
THE BUCK STOPS HERE
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The ethics committees 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
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Conversations with the family

• Wife very distressed by Mr. Ps 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. Ps wife
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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. Ps son
• Did not see any other practical solution
• Pleaded for help

Mr. Ps son-in-law the lawyer
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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
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Independent medical review and Neuro-ICU efforts

• Confirmed diagnosis, prognosis
• Attempts at weaning off respirator not proving
  successful

Follow up of action plan
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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
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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
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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
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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
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The aftermath

• Mr. Ps 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
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Lets also remember

• Medicine is about Can we?
• Ethics is about Should we?

The ethicist as a hedge
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Thank you

• Did we do the right thing?