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

‘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

Presentation Outline

• Problems with DNR decision in our societies • Definitions • When to consider DNR • Islamic Point View of DNR• My Study • Conclusions

Problems with DNR Decisions in Our Societies

Problem # 1 Ignorance

Many people are so ignorant to understand the meaning of “DNR” and

futility of treatment.

Problem # 2 Misconceptions Regarding Death

Misconceptions among most of the population leading to lack of

understanding and acceptance of “DEATH”.

( رميم وهي العظام !!!!!!!! ( يحي

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

• 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

Definitions

• 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

• Intravenous Fluids• Nasogastric tube feeding• Dialysis • Vasopressors • Mechanical ventilation

Life – Prolonging Measures

• 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

• Euthanasia: comes from the Greek “Eu-thanatos” which means “ an easy or good death”

• Killing the patient for their own benefit

Euthanasia

• 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

• 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

When to Consider DNR ?

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 ?

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

• 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:

Islamic Point-View

What’s Unique about Ethics in Islam

What is Moral in Islam is Always Legal (Halal)

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.

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

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

4 Ethical Principles

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.

The Major Islamic Ruling Principles

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

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)

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

Fatwa # (12086) Dated (1989) by the Saudi Committee for Fatwa & Islamic

Affairs

Fatwa # (12086) Dated (1989) by the Saudi Committee for Fatwa & Islamic

Affairs

Do Not Resuscitate order: when the treatment becomes futile.

Withdrawal or withheld therapy is permitted in brain death.

PermittedPermitted (MubahMubah)

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)

• 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

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

My Study

• Questionnaire-based study

• 12-questions questionnaire distributed to physicians at SMC

• Total sample size 152 physicians

My Study

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

Sub-specialty

Total Number = 135

17.7%

51.1%

25.9%

5.3 %

Professional Level

Answer to Questions DNR Policy

Do you Feel Comfortable or at Ease when Talking to Relatives about DNR??

Do you Feel Comfortable or at Ease when Talking to Relatives about DNR??

Majority of females don’t feel comfortable (P value < 0.05)

Withdrawal in Brain Dead

There is a significant number of physicians Who said NO !!!!

Why not Withdrawing in Brain Dead ?

Persons Involved in DNR Decision

The main persons involved in DNR decisions are the Caring Team and consultant

Reasons for Making DNR

Conclusions

• 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