Dr. Nehad Nabeel Al-Shirawi MRCP(UK), EDIC, Saudi Fellowship in ICU Intensivist / Pulmonologist...
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Transcript of Dr. Nehad Nabeel Al-Shirawi MRCP(UK), EDIC, Saudi Fellowship in ICU Intensivist / Pulmonologist...
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Dr. Nehad Nabeel Al-Shirawi MRCP(UK), EDIC, Saudi Fellowship in ICU
Intensivist / Pulmonologist
End-of-life Issues in the ICU
End-of-life Issues in the ICU
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‘And whosoever saves a life, it is as if they have saved the whole of humankind’
�ن�ه�} أ ائيل� ر� إس ب�ني ع�ل�ى ك�ت�ب ن�ا ذ�لك� ل أ�ج منفي اد! ف�س� و
أ� ن�ف س! بغ�ي ر ا س) ن�ف ت�ل� ق� م�نيع)ا م ج� الن�اس� ت�ل� ق� ا ك�أ�ن�م� ف� ض ر
ن األ� و�م�يع)ا م ج� الن�اس� ي�ا أ�ح ا �ن�م� ك�أ ف� ا ي�اه� د أ�ح ل�ق� و�
ن ه�م م8 ك�ثيرا) إن� ث�م� بالب�ي8ن�ات ل�ن�ا س� ر� م اءت ه� ج�} ون� رف� ل�م�س ض ر
األ� في ذ�لك� ب�ع د�
Qur’an 5:32
الرحمن الله بسمالرحيم
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Presentation Outline
• Problems with DNR decision in our societies • Definitions • When to consider DNR • Islamic Point View of DNR• My Study • Conclusions
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Problems with DNR Decisions in Our Societies
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Problem # 1 Ignorance
Many people are so ignorant to understand the meaning of “DNR” and
futility of treatment.
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Problem # 2 Misconceptions Regarding Death
Misconceptions among most of the population leading to lack of
understanding and acceptance of “DEATH”.
( رميم وهي العظام !!!!!!!! ( يحي
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Problem # 3 Misconceptions Regarding Role of HCP
Confusion about our role as health care providers (save lives at any cost)
إلDي ) عملنا احناوالباقي علينا
الله (علي
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• Guidelines are necessary to identify the key ethical and legal issues that govern DNR decisions
• The guidelines provide a framework to support physician in 1. Making DNR decisions 2. Communicating them effectively
• Islamic point-view should be considered ALL the time
DNR Guideline: How Much of Islamic Point-View
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Definitions
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• Instructions that the patient should not receive cardiopulmonary resuscitation (CPR) in the event that he / she suffers a cardiac arrest, usually in the hospital
• Do not intubate, do not defibrillate, no medications
DNR
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• Intravenous Fluids• Nasogastric tube feeding• Dialysis • Vasopressors • Mechanical ventilation
Life – Prolonging Measures
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• When CPR and other critical care efforts have no reasonable chance of prolonging life or providing benefit to the patient – i.e. they are futile– Discharge to home intact– Pain / symptom free life– Full awareness of the surroundings
Medical Futility
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• Euthanasia: comes from the Greek “Eu-thanatos” which means “ an easy or good death”
• Killing the patient for their own benefit
Euthanasia
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• Death has several consequences1. Medical 2. Legal3. Religious 4. Socioeconomic
• Death = body – spirit ( الجسد من الروح (خروج• ( : الذي الموت ملك يتوفاكم قل تعالى الله قال
ترجعون ( ربكم إلى ثم بكم *ل 11السجدة وك
وما) • ربي أمر من الروح قل الروح عن ويسألونك) قليال إال العلم من 58االسراء أوتيتم
Death
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• Medical Definition: The irreversible cessation of all vital functions especially as indicated by permanent stoppage of the heart, respiration, and brain activity
• In many countries : Brain Death = Death
• In Islamic countries – disagreement
Death
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When to Consider DNR ?
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1. CPR is unlikely to useful (Futile)
2. CPR is not in accord with a valid advance directive
3. CPR is not in accord with a competent patient’s recorded and sustained wishes
4. Resuscitation is likely to be followed by a length and quality of life that would not be in the best interest of the patient (pain, lack of awareness)
When to Consider DNR ?
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Emergency Situations
• In emergencies, there will rarely be time to make a proper assessment of the patient’s condition and the likely outcome of CPR and so attempting CPR will usually be appropriate
• Health professionals will make all reasonable efforts to attempt to revive the patient in the event of cardiac or respiratory arrest
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• No CPR does not mean no other treatment
• No CPR does not mean withdrawal of mechanical ventilator, etc
• No CPR does not mean “Mercy Killing”
It is Important to Explain that:
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Islamic Point-View
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What’s Unique about Ethics in Islam
What is Moral in Islam is Always Legal (Halal)
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But if one saves a life, it shall be as if he
saved all mankind.”Qur’an 5:32.
Human Life
“Every soul shall taste death” Qur’an 3:185.
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Death: International Collective Of Islamic Jurists And
OIC. Amman, Jordan 1986
• Declaration of death:
– Heart and breath have stopped and the condition is irreversible OR
– Mental function has ceased and the condition is irreversible
– Responsibility of the physician
رقم ) مؤتمره( ٥القرار دورة في المنعقد اإلسالمي الفقه مجمع مجلس الصادرعنمن بعمان / ١٤٠٧صفر ١٣- ٨الثالث األول / ١٦ -١١ه تشرين رقم ١٩٨٦أكتوبر وقراره ،
في ٨٨ / ٠٨/ ٤د( ١) بجدة الرابع تمره مؤ دورة من في جمادى ٢٣ - ١٨السعودية/ ١٤٠٨اآلخرة الموافق / ١١- ٦ه شباط ١٩٨٨فبراير
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Time of Death
• Time of Death = Complete cardiopulmonary arrest after withdrawal
يجوز • اإلنعاش أجهزة جسمه على ركبت الذي المريضوقررت h نهائيا h تعطال دماغه وظائف جميع تعطلت إذا رفعهارجعة ال التعطل أن خبراء اختصاصيين أطباء ثالثة من لجنةبفعل يعمالن يزاالن ال والتنفس القلب كان وإن فيه،
لكن المركبة، توقف األجهزة إذا إال h شرعا بموته يحكم الاألجهزة رفع بعد r تاما والقلب التنفس
دورته في اإلسالمي العالم لرابطة التابع اإلسالمي الفقهي المجمع قرار فيالمكرمة مكة في المنعقدة هـ 1408العاشرة
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4 Ethical Principles
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4 Ethical Principles in Islam
The principle of la darar wa la dirar )a person must not harm himself or someone else( – prohibited to
cause a loss to another person
Principle of maslahah )Self and public interest( is to address the needs of humankind and confers the
welfare of most people.
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The Major Islamic Ruling Principles
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28
The Sharia Law System
Category Arabic
Do it Not do it
Obligatory(Prescribed)
FardWajeb Reward Punishment
Recommended(Desirable)
MustahabMandu
bReward No
Punishment
Permitted(Allowed)
MubahHalal No Reward No
Punishment
Discouraged(Disliked)
MakruhManbot
h
No Punishment
Reward
Forbidden(Prohibited)
HaraamMahd’ur Punishment No Reward
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Is Medical Treatment Necessary?
• Definite:o The desired results are achieved without failo e.g. stop bleeding to sustain life o Mandatory (واجب)
• Probable/Expected:o The desired results are often achieved but not always o e.g. many medical treatments o Sunnah (سنه)
• Imagined:o The desired results are not a realistic expectation o e.g. some medical treatments o Permissible (مباح)
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Resuscitation In Islam
• Two opinions1. Recommended (مندوب)= التداوي حكم
2. Obligatory ( كفاية الروح = (فرض إنقاذ
• Most people agree on second opinion because إجراء • يمكن فال الحال هذه في له اختيار ال المريض
اإلنعاش مسألة على التداوي حكماإلنعاش • ألجهزة وحاجته خطرة حالة في في المريض
بحيث والشراب للطعام كحاجته h ضروريا h أمرا أصبحتللهالك نفسه عرض فقد تركه لو
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Fatwa # (12086) Dated (1989) by the Saudi Committee for Fatwa & Islamic
Affairs
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Fatwa # (12086) Dated (1989) by the Saudi Committee for Fatwa & Islamic
Affairs
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Do Not Resuscitate order: when the treatment becomes futile.
Withdrawal or withheld therapy is permitted in brain death.
PermittedPermitted (MubahMubah)
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Active Euthanasia:
Passive Euthanasia: Patient should be provided with food, drink, nursing, and relief from pain until death.
Suicide
Murder. "take not life which Allah has made sacred" Qur’an 6:151.
Forbidden (Haraam)Forbidden (Haraam)
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• In patients with deep coma/persistent vegetative state –forbidden (Haram) by most authorities
• In Brain Death – many authorities said is allowed (Halal)
What About Withdrawal ?
الفقه عمان مجمع في المنعقد اإلسالمي المؤتمر لمنظمة التابع الثالث اإلسالميعام في ١٩٨٧ باألردن اإلسالمي العالم لرابطة التابع الفقهي المجلس وفتوى ،
العاشرة ه ١٤٠٨/ ٢ / ٢٤في دورته
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المريض • عن اإلنعاش أجهزة رفع فأكثر متخصصون أطباء ثالثة قرر إذاالشلل ) - : مثل شديد عجز حالة األول السؤال في حالته الموضحة
- ) فإنه شديد عقلي بتخلف ومصاب ، من الدماغي يقررونه ما اعتماد يجوزاإلنعاش أجهزة بالعالمات رفع ذلك يعلم حتى بموته الحكم يجوز ال ولكن ،
الحكم في عليه يعتمد فال الدماغ موت أما ، موته على الدالة الظاهرةبموته
السؤال • في المذكورة الحالة في األجهزة رفع المختصون األطباء قرر إذااألهل معارضة إلى يلتفت ال فإنه ، األول
أن • أو يضره وال المريض ينفع الدواء أن المختص الطبيب ظن على غلب إذاالعالج تأثير كان ولو ، عالجه مواصلة له يشرع فإنه ، ضرره من أكثر نفعه
يتوقعه ما خالف مستمرا نفعا بالعالج ينفعه قد سبحانه الله ألن مؤقتا؛األطباء .
What About Withdrawal ?
[ ( ) رقم العلماء كبار هيئة هـ 1419 /4 /6وتاريخ ( 190قرار
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My Study
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• Questionnaire-based study
• 12-questions questionnaire distributed to physicians at SMC
• Total sample size 152 physicians
My Study
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Characteristic Number Percent Age < 40 years 103/144 71.5
Age ≥ 40 years 41/144 28.5
Male 109/152 71.7
Female 43/152 28.3
Muslims 140/150 93.3
Other Religions 10/150 6.7
Basic Characteristics
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Sub-specialty
Total Number = 135
17.7%
51.1%
25.9%
5.3 %
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Professional Level
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Answer to Questions DNR Policy
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Do you Feel Comfortable or at Ease when Talking to Relatives about DNR??
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Do you Feel Comfortable or at Ease when Talking to Relatives about DNR??
Majority of females don’t feel comfortable (P value < 0.05)
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Withdrawal in Brain Dead
There is a significant number of physicians Who said NO !!!!
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Why not Withdrawing in Brain Dead ?
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Persons Involved in DNR Decision
The main persons involved in DNR decisions are the Caring Team and consultant
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Reasons for Making DNR
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Conclusions
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• There are many misconceptions concerning DNR decisions among health care professionals
• In the era of resource utilization and scares ICU beds, making DNR decisions might seem necessary if the treatment is futile
• A clear Law is needed to regulate this matter
Conclusions
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