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DNR: OUTSTANDING ETHICO-               LEGAL-FIQHI ISSUES                    Dr Omar Hasan Kasule SrOmar Hasan K Kasule Sr...
2.0 UNCERTAINTIES           (qa’idat al yaqiin)• Definition of terminal illness, maradh al mawt• Death process: point z - ...
3.0 PROTECTION OF LIFE(maqsad hifdh al nafs) VS EXCLUDING FUTILITY• Artificial life support vis a vis allowing natural dea...
4.0 PROTECTION OF THE PATIENT FROM   POTENTIAL HARM (qa’idat al dharar) •   Paternalism •   Patient consent for CPR •   Pa...
5.0 PROTECTION/CONSERVATION OF      RESOURCES (maqsad hifdh al maal)• Over and/or inappropriate utilization of  ICU resour...
5.0 PROTECTION/CONSERVATION OF   RESOURCES (maqsad hifdh al maal)• Use of palliative instead of intensive care• KPI: ICU m...
6.0 IMPLEMENTATION ISSUES•   DNR policies and guidelines•   Knowledge of physicians regarding DNR•   Practices of physicia...
7.0 CRITERIA FOR DNR      (hifdh al nafs vs hifdh al maal)• DNR: an established death process beyond  Young’s z point• DNT...
8.0 The KFMC CPP No 1430-60 6          EXAMPLES FOR DNR• Advanced incurable malignancy• advanced multi-organ failure• irre...
9.0 The SAMSO MSP 7 EXAMPLES FOR                  DNR:• Advanced incurable, end-stage malignancy• End-stage organ failure•...
10.0 COMPONENTS OF A DNR ORDER• Cardiopulmonary resuscitation involving  chest compressions and oxygenation• Endotracheal ...
11.0 MAY/MAY NOT: NON-CARDIO-        RESPIRATORY LIFE SUPPORT•   Renal dialysis•   Blood transfusion•   Parenteral nutriti...
12.0 SUPPORTIVE CARE FOR ALL DNR                PATIENTS•   Clearance of secretions (oral, throat, etc)•   Hydration and n...
13.0 RECOMMENDATIONS• Develop palliative care as an alternative to ICU for  DNR and DNT cases• Training workshops on the e...
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DNR outstanding ethico legal-fiqhi issues

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Cases on End of Life Issues presented and discussed by Prof. Omar H. Kasule for the medical students of FOM-KFMC on Monday 23rd of April, 2012

Published in: Health & Medicine, Spiritual
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Transcript of "DNR outstanding ethico legal-fiqhi issues"

  1. 1. DNR: OUTSTANDING ETHICO- LEGAL-FIQHI ISSUES Dr Omar Hasan Kasule SrOmar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  2. 2. 2.0 UNCERTAINTIES (qa’idat al yaqiin)• Definition of terminal illness, maradh al mawt• Death process: point z - prolongation of life vs prolongation of death• Peri-operational DNR• Pre-hospital DNR Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  3. 3. 3.0 PROTECTION OF LIFE(maqsad hifdh al nafs) VS EXCLUDING FUTILITY• Artificial life support vis a vis allowing natural death (AND)• Do not resuscitate orders (DNR)• Do not treat orders (DNT)• DNR as Passive Euthanasia (EU) – al umuur bi maqasidiha Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  4. 4. 4.0 PROTECTION OF THE PATIENT FROM POTENTIAL HARM (qa’idat al dharar) • Paternalism • Patient consent for CPR • Patient consent for DNR • Family assent to DNR • Age discrimination Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  5. 5. 5.0 PROTECTION/CONSERVATION OF RESOURCES (maqsad hifdh al maal)• Over and/or inappropriate utilization of ICU resources• Synonyms for ICU: – Intensive Monitoring Unit (IMU) – Futile Care Unit (FCU) – Wasteful Care Unit (WCU) – Extremist Care Unit (ECU) – Mortuary Care Unit (MCU) – Hospice Care Unit (HCU) Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  6. 6. 5.0 PROTECTION/CONSERVATION OF RESOURCES (maqsad hifdh al maal)• Use of palliative instead of intensive care• KPI: ICU mortality/discharge a reflection of admission and not intervention Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  7. 7. 6.0 IMPLEMENTATION ISSUES• DNR policies and guidelines• Knowledge of physicians regarding DNR• Practices of physicians regarding DNR• Mistaken Identification of DNR patients Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  8. 8. 7.0 CRITERIA FOR DNR (hifdh al nafs vs hifdh al maal)• DNR: an established death process beyond Young’s z point• DNT: terminal conditions not yet in an established death process.• DNR & DNT: admit to palliative care where hi-tech is not available Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  9. 9. 8.0 The KFMC CPP No 1430-60 6 EXAMPLES FOR DNR• Advanced incurable malignancy• advanced multi-organ failure• irreversible, severe, and documented brain damage• advanced cardiac, hepatic, or pulmonary disease• inoperable, life threatening congenital heart disease, fatal chromosomal or neuromuscular disease• Irreversible, severe, mental and physical incapacity. Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  10. 10. 9.0 The SAMSO MSP 7 EXAMPLES FOR DNR:• Advanced incurable, end-stage malignancy• End-stage organ failure• Advanced irreversible brain damage• End-stage renal disease if renal replacement therapy is not feasible• Inoperable congenital anomalies incompatible with life• Fatal chromosomal abnormalities• Brain death. Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  11. 11. 10.0 COMPONENTS OF A DNR ORDER• Cardiopulmonary resuscitation involving chest compressions and oxygenation• Endotracheal intubation• Mechanical ventilation• Defibrillation• Vaso-active/ionotropic medication Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  12. 12. 11.0 MAY/MAY NOT: NON-CARDIO- RESPIRATORY LIFE SUPPORT• Renal dialysis• Blood transfusion• Parenteral nutrition• Pulmonary hygiene• Normal treatment eg antibiotics Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  13. 13. 12.0 SUPPORTIVE CARE FOR ALL DNR PATIENTS• Clearance of secretions (oral, throat, etc)• Hydration and nutrition• Pain management, antipyretics, and sedation• Supplemental oxygen• Anti emetics and relieve of constipation• Relief of urinary retention• Relief of dypnea and cough) Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  14. 14. 13.0 RECOMMENDATIONS• Develop palliative care as an alternative to ICU for DNR and DNT cases• Training workshops on the ethical issues of EOL• DNR orders to specify interventions intended/prohibited• Respecting the autonomy of physicians who have conscientious objections to DNR• More psycho-social support for DNR families• More empirical research on the DNR process• Regular audits of DNR decisions and outcomes. Dr Omar Hasan Kasule Sr Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City
  15. 15. Thank you
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