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

Health & Medicine Spiritual

DNR: OUTSTANDING ETHICO-
LEGAL-FIQHI ISSUES

Dr Omar Hasan Kasule Sr
Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City

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

3.0 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

4.0 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

5.0 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

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

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

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

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

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

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

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

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

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

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The application of ‘CPR-for-all’ is the ultimate evidence drift. A treatment that is completely appropriate for dropping dead whilst running a marathon has almost no place in acute healthcare facilities where chronic irreversible complex co-morbidities abound. 90% of doctors would not choose CPR for themselves, yet 100% are trained in how to administer it to patients. Defaulting to ‘CPR-for-all’ removes a patients’ ability to provide informed consent for assault whilst they die from another disease. Remember - 2 weeks in ICU can spare you 5 minutes of difficult conversation. vs. Across the globe, patients are assumed to be full code to allow for prompt resuscitation, until code status can be discussed and clarified. There are numerous excellent reasons for this. Can you imagine if our systems decreed that DNR was the default? “Let’s not shock that VF, until we can clarify his code status.” Or, “let’s not resuscitate that child, after all, DNR is the default and her mother isn’t here yet!” Making DNR the default is not a good solution to ICU or hospital over-crowding. Let’s not mandate DNR, let’s mandate having reasonable code discussions early and often.

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