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

1. DNR: OUTSTANDING ETHICO-
LEGAL-FIQHI ISSUES
Dr Omar Hasan Kasule Sr
Omar Hasan K Kasule Sr Department of Bioethics King Fahad Medical City

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. 3.0 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. 4.0 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. 5.0 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Thank you