Medical futility DNR

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This is the presentation part of the recently held Medical Ethics workshop (2011) for the residents.

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Medical futility DNR

  1. 1. 11 20 12 Medical Futility 8 /2 & R N Resuscitation (DNR) y &D ilit Dr. Sreedharan V. Koliyadan. MS; DNB; FRCS ut Consultant; Department of Surgery Sultan Qaboos University F sreesurgery@gmail.com e/ re r.S D28-12-2011 Sree/Futility&DNR 1
  2. 2. 11 First I will define what I conceive medicine 20 to be. In general terms, it is to do away with 812 the sufferings of the sick, to lessen the /2 R violence of their diseases, and to refuse to N treat those who are overmastered by their &D disease, realizing that in such cases y ilit medicine is powerless. ut — The Hippocratic Corpus F e/ re r.S D28-12-2011 Sree/Futility&DNR 2
  3. 3. Medical Futility & Do-Not-Resuscitate 11 Medical Futility: 20 Definition 12 Types 8 Purposes /2 Limitations R Estimation N Process &D Do-Not-Resuscitate Orders: Definition y ilit Purpose ut Limitations F Process e/ Policies: RH/SQUH re DNR: Islamic perspectives : r.S D28-12-2011 Sree/Futility&DNR 3
  4. 4. Futility 11 20 12Definition: 8Futile (adj): incapable of producing any /2useful result; pointless (Oxford dictionary) RFutility (noun): pointlessness or N &Duselessness:Medical Futility: a judgment that y ilitfurther medical treatment of a patient utwould have no useful result. F e/Origin: Futili (Latin) from Greek re r.S D 28-12-2011 Sree/Futility&DNR 4
  5. 5. 11 Futility: Types 20 12 Quantitative: likelihood of survival 8 /2 Qualitative: likelihood of quality of life after R survival N y &D ilit F ut e/ reTrotter G. Editorial Introduction : Futility in the 21 st Century. HEC Forum. 2007;19:1–12. r.SChwang E. Futility clarified. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics [Internet]. 2009 Jan;37(3):487–95,396 D 28-12-2011 Sree/Futility&DNR 5
  6. 6. 11 Futility: Types 20 12 1. Physiological 8 /2 2. Imminent demise R N 3. Lethal condition 4. Qualitative y &D ilit F ut e/ re r.SSlosar JP. Medical Futility in the Post-Modern Context. HEC Forum. 2007;19(1):67–82. D 28-12-2011 Sree/Futility&DNR 6
  7. 7. Futility: Purpose 11 20 Decide Interventions 12 Reasons for the concept of medical futility: 8 /2 1. Absence of beneficence R 2. Creation of harm N &D 3. Respect for autonomy of patient/ surrogate 4. Distributive justice y ilit 5. Autonomy of physician F ut e/ re r.SJoseph R. Hospital policy on medical futility - does it help in conflict resolution and ensuring good end-of-life care? Annals of the Academy of Medicine, Singapore[Internet]. 2011 Jan;40(1):19–7.Baily MA. Futility, Autonomy, and Cost in End-of-Life Care. Journal of Law , Medicine and Ethics. 1989;00:172–82. D 28-12-2011 Sree/Futility&DNR 7
  8. 8. Futility: Estimation 11 20 812 /2 R N &D y ilit ut F e/ re r.S D28-12-2011 Sree/Futility&DNR 8
  9. 9. Futility: Estimation 11 20:1. The AHA Guidelines for CPR and Emergency 12Cardiac Care: 8 "no survivors after CPR have been reported /2under the circumstances in well-designed studies." R2. Schneiderman(1990): N &D Intervention is futile if it has failed the last 100times it has been attempted y ilit3. The American Thoracic Society ut " intervention futile if it is highly unlikely to Fresult in meaningful survival" e/ re [Editorial]. W hen Is CPR Futile ? Journal Of The American Medical Association. 1995;273(2):156–8. r.S D28-12-2011 Sree/Futility&DNR 9
  10. 10. Futility: Estimation 11 Overall survival to home after CPR: 18% 20 Futility: Quantitative criteria: 12 <1/100 < 13% Survival 8 /2 <5% survival R Futility: Individual diseases: N Hypotension: survival 2% &D Renal failure: 3% AIDS: 2% y ilit >70yrs: 4% ut Other Scales: F APACHE II e/ ASA re r.SEhlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo R a, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly.The New England journal of medicine [Internet]. 2009 Jul 2;361(1):22–31.Lawson a. Futility. Current Anaesthesia & Critical Care [Internet]. 2004 Aug [cited 2011 Dec 23];15(3):219–23. D 28-12-2011 Sree/Futility&DNR 10
  11. 11. 11 Futility: Limitations 20 12 Futility of Physician vs. Futility of 8 /2 patient/SDM R N Estimation of Quantitative Futility &D Estimation of Qualitative Futility (Values) ilit y F ut e/ re r.SLuce J. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists. Critical Care. 1995;23(4):760–6. D 28-12-2011 Sree/Futility&DNR 11
  12. 12. Unilateral vs Bilateral Decisions 11 20 “Physicians are NOT obliged to provide care when there is scientific and social consensus that the treatment is 12 ineffective.” 8 American Heart Association /2 R “Physicians are under no ethical obligation to render N treatments that they judge have no realistic likelihood of &D medical benefit to the patient” American College of Emergency Physician, 1998 y ilit ut CPR maybe withheld even if requested by the patients F “when efforts to resuscitate a patient are judged by e/ the treating physician to be futile” re AMA Council on Ethical and Judicial Affairs, 1991 r.S D28-12-2011 Sree/Futility&DNR 12
  13. 13. “Whereas patients have a right to refuse treatment, they do not have 11automatic right to demand treatment; they cannot insist that resuscitation 20must be attempted in any circumstances” European Resuscitation Council, Resuscitation Guidelines 2005 12…“futility is a professional judgment that takes precedence over patient 8 /2autonomy and permits physicians to withhold or withdraw care deemed Rto be inappropriate without subjecting such a decision to patient Napproval.” &DSchneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning andethical implications. Ann Intern Med. 1990 Jun 15;112(12):949-54. y ilitIf general medical opinion considers a particular treatment futile (not utaltering the patient’s immediate survival nor offering any advantage overalternative treatments), then this alternative need not be performed or F e/even discussed with the patient and/or his surrogate (1990, p. 952). reAmerican College of Chest Physicians and the Society ofCritical Care Medicine’s Consensus Panel published “Guidelines for the r.SInitiation, Continuation, and Withdrawal of Intensive Care.” D 28-12-2011 Sree/Futility&DNR 13
  14. 14. 11 20 Unilaterally taking the treatment option off 12 the table for discussion or unilaterally 8 refusing to provide it— when there are real /2 potential value conflicts at stake—can no R N longer be an acceptable answer. y &D ilit F ut e/ Rubin SB. If We Think It ’ s Futile , Can ’ t We Just Say No ? HEC Forum. 2007;19:45–65. re r.S D28-12-2011 Sree/Futility&DNR 14
  15. 15. 11 20 812 /2 R N &D y ilit ut F e/ re r.S D28-12-2011 Sree/Futility&DNR 15
  16. 16. Futility: Fair Process Approach 11 20 8 12 /2 R N y &D ilit F ut e/ re r.S D[Council on Ethical and Judicial Affairs A medical A. Medical Futility in End-of-Life Care: Report of the Council on Ethical and Judicial Affairs. JAMA: The Journal of the 28-12-2011American Medical Association. 1999;281(10):937–41. Sree/Futility&DNR 16
  17. 17. 11 Do-Not-Resuscitate Order (DNR) 20 12 Definition: 8 /2 Alternative terms: DNAR; AND R N y &D ilit F ut e/ re r.SBishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. The American journal of bioethics : AJOB [Internet]. 2010 Jan [cited 2011Dec 23];10(1):61–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20077345 D 28-12-2011 Sree/Futility&DNR 17
  18. 18. 11 DNR: Policy 20 12 Purpose: 8 /2 Limit unnecessary CPR based on Futility R In-hospital survival: 13% N &D Out of Hospital survival: 1% y ilit Protect physician ut Withholding treatment F e/ Instituting treatment re r.STomlinson T, Czlonka D. Futility and hospital policy. Hastings Center Report. 1995;25(3):28–35. DEwy GA. Cardiac Resuscitation — When Is Enough Enough ? New England Journal of Medicine. 2006;355(5):510–2. 28-12-2011 Sree/Futility&DNR 18
  19. 19. 11 DNR Policy: Limitations 20 12CPR if no DNR order 8 /2Communication on End-of-Life issues R NEstimation of Futility &DAssessment of Values & Goals y ilitPaternalism vs Autonomy F ut e/ re r.SHackler C. It ’ s Bigger Than CPR and Futility : Withholding Medically Inappropriate Care It ’ s Bigger Than CPR and Futility : Withholding MedicallyInappropriate. The American Journal of Bioethics. 2010;10:70–1. D 28-12-2011 Sree/Futility&DNR 19
  20. 20. 11 DNR : Process 20 12 8 S= Subjective values of the patient / SDM /2 R O=Objective data gathered by physician N &D A= Assessment putting the S & O together P=Plan of intervene or not. y ilit F ut e/ re r.SRubin SB. If We Think It ’ s Futile , Can ’ t We Just Say No ? HEC Forum. 2007;19:45–65 . D 28-12-2011 Sree/Futility&DNR 20
  21. 21. 11 DNR Policy: Process 20 121. Education of patient/SDM: 8 /22. Estimate success of CPR in that patient R N3. Evaluate potential QOL after successful CPR &D4. Problems of instituting CPR y ilit5. Time for reflections F ut e/ re r.SKind V. Case Study CPR and DNR Decision Making. Age in Action. 2010;:1–5. D 28-12-2011 Sree/Futility&DNR 21
  22. 22. 11 DNR Policy 20 8 12 “Slow code” /2 R “DNR without Consent” N &D “Futile DNR” y ilit F ut e/ re r.SDavid P Eisenman. DNR orders and Medical Futility. Journal Of The American Medical Association. 1995;274(4):299–300.Luce JM. Clinical Commentary Making Decisions About the Forgoing of Life-sustaining Therapy. Critical Care Medicine. 1993;:1–4.Truog RD. Is it always wrong to perform Futile CPR? New England Journal of Medicine. 2010;362(6):477–9. D 28-12-2011 Sree/Futility&DNR 22
  23. 23. 11 DNR: Islamic perspectives 20 812 /2 "Anyone who has saved a life, it is as R N if he has saved the life of whole &D mankind" (5:32). y ilit Fut e/ re r.S D28-12-2011 Sree/Futility&DNR 23
  24. 24. 11 DNR: Islamic Perspectives 20 12Purposes of Law: 8 /2 R1. Certainty of Futility: N &D2. Preservation of life (ḥifẓ al-nafs): y ilit3. Consent: F ut4. Abuse: e/ re r.SKasule OH. DNR: An Islamic Formulation. Journal of Islamic Medical Association. 2010;42(March):36–7. D28-12-2011 Sree/Futility&DNR 24
  25. 25. DNR: Islamic perspectives 11 20 12 The Presidency of the Administration of Islamic 8 Research and Ifta, Riyadh, Kingdom of Saudi /2 Arabia (KSA): Fatwa No. 12086 R N y &D ilit F ut e/ re r.STakrouri MSM, Halwani TM. An Islamic Medical and Legal Prospective Of Do Not Resuscitate Order In Critical Care Medicine. The Internet Journal of Health.2008;7(1).Saleem Saiyad. Do Not Resuscitate: A case study from islamic view point. Journal of Islamic Medical Association [Internet]. 2009 Jan;41:109–13 D 28-12-2011 Sree/Futility&DNR 25
  26. 26. 11 DNR: Islamic perspectives 20 8 12 Out of 659 neonatal admissions in /2 R Oman (RH), 39 (6%) parents N consented for DNR. y &D ilit F ut e/ re r.Sda Costa DE, Ghazal H, Al Khusaiby S. Do Not Resuscitate orders and ethical decisions in a neonatal intensive care unit in a Muslim community. Archives of diseasein childhood. Fetal and neonatal edition [Internet]. 2002 Mar;86(2):F115–9. D 28-12-2011 Sree/Futility&DNR 26
  27. 27. 11 DNR Policy: RH 20 812 /2 R N &D y ilit ut F e/ re r.S D28-12-2011 Sree/Futility&DNR 27
  28. 28. 11 20 812 /2 R N &D y ilit ut F e/ re r.S D28-12-2011 Sree/Futility&DNR 28
  29. 29. 11 20 812 /2 R N &D y ilit ut F e/ re r.S D28-12-2011 Sree/Futility&DNR 29
  30. 30. Medical Futility & Do-Not-Resuscitate 11 Medical Futility: 20 Definition 12 Types 8 Purposes /2 Limitations R Estimation N Process &D Do-Not-Resuscitate Orders: Definition y ilit Purpose ut Limitations F Process e/ Plicies: RH/SQUH re DNR: Islamic perspectives : r.S D28-12-2011 Sree/Futility&DNR 30

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