Withdrawal of Treatment

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Del curso dictado por University of Cape Town

Organ Donation: From Death to Life

60 calificaciones

University of Cape Town

Organ Donation: From Death to Life

60 calificaciones

Considering someone for organ and tissue donation at the end of life is complicated. The boundary between life and death is more complex than ever before and it falls to medical professionals to help clarify a situation at an often confusing and emotionally stressful time. In this course you will learn about the science behind death determination and when it is possible for deceased organ donation take place. The lectures will cover medical standards at the end of life - from brain death testing, to requesting informed consent from a grieving family. By improving knowledge of good ethical practices, cultural and religious considerations and the logistics of the organ donation process this course will empower the interactions and discussions of medical professionals and the general public at an often confusing time. This course will help you to ensure that the option of organ donation is compassionately explored in all appropriate situations at the end of life in the best way possible. Watch the course trailer here https://www.youtube.com/watch?v=Ak-kVtmZGRs The course is certified for continuing professional development (CPD) points in South Africa. Send your completion certificate to organdonation@uct.ac.za together with your HPCSA number for 25 general and 5 ethics points. For another interesting course on organ donation and transplantation, see Clinical Kidney, Pancreas and Islet Transplantation from Leiden University https://www.coursera.org/learn/clinical-kidney-transplantation

De la lección

Donation after Circulatory Death

Not all end of life decisions in the Intensive Care Unit and the discussions that go with them can rely on the clarity of a brain death diagnosis. Just under half of all deaths in Intensive Care Units involve non-beneficial treatment being withdrawn or withheld. In less well resourced countries limited access to ICU means these decisions as to when treatment is futile frequently occur earlier, outside of the ICU setting. In week 2 we will discuss end of life care and the ethical principles which help guide us in making difficult decisions in the ICU. What do we do when interventions may prolong suffering with no reasonable chance of recovery? We will see how the dead donor rule can be applied after circulatory arrest and that in certain patients it may be possible to honour their wish to be an organ donor. We will cover the different types of donation after circulatory arrest and go over the process of donation after circulatory death in detail. We will end the week by covering tissue donation and what happens to the body of the donor after the organ donor operation is complete.

Introduction to Week 21:24

A Good Death4:37

Principles in Medical Ethics6:41

Withdrawal of Treatment7:32

An Approach to Withdrawal of Non-beneficial Treatments2:59

Conoce a los instructores

David Thomson
Dr
Critical Care Specialist and Transplant Surgeon

Withdrawal of treatment is a challenging and emotive issue.

It is influenced by many factors.

The patient's prognosis, values and

treatment preferences, cultural and religious beliefs, the families and

the doctor's beliefs and practices as well as the resources available.

It is important to stress that withdrawal of treatment is not withdrawal of care.

The care of the patient is never abandoned by the healthcare team.

We always begin with the intent to make the patient better and

interventions can be justified on this basis.

But we must be able to reevaluate our treatment goals when expected outcomes

are not achieved.

The decision to withdraw treatment marks a point in the process of medical

therapy with the primary focus is adjusted from saving the patients

life to making their last moments as comfortable as possible.

The benefits of modern medical therapies, such as cardiopulmonary resuscitation,

renal dialysis, mechanical ventilation, nutrition and hydration, are considerable.

However, life has a natural end.

And the use of such supportive treatments can in certain cases sustain life

artificially in patients for whom there is little or no hope of recovery.

It is not in the best interests of a patient to start or

continue such treatments if we cannot restore them

to a quality of life they would find acceptable.

The doctor's responsibility is not to supply every single type of treatment to

a patient, but rather to always to provide appropriate care.

Recognizing the limits of medical therapy is part of that key.

We do not want to be complicit in prolonging suffering in the dying process

in any patient.

Arriving at the point where ongoing therapy is futile occurs commonly.

In the United States of America 38% of deaths in intensive care units involve

active withdrawal of treatment, and a further 10% entail withholding treatment.

Defining futility is difficult.

The term nonbeneficial is preferable to futile as the crux of the matter

is whether or not a treatment is able to help the patient.

Let me give you an example from my own ICU practice.

We have the capability to place patients on phenoarterial

extracarpurial membrane oxygenation.

VA-ECMO, this entails placing a large pipe into a central vein to drain blood,

as well as a large pipe into an artery to return it.

When the pump achieves adequate flow rate, we are able to completely support

a patient who has a nonfunctional heart and lungs.

It is essentially cardiopulmonary bypass run in the ICU.

It is physiologically possible to do this for almost every patient.

But we don't do VA-ECMO for every patient because the ECMO team has to make

a judgement call about whether there is a potential benefit.

Such an intervention is extremely invasive, expensive, and

needs to be justified by a reasonable chance of a successful outcome.

VA-ECMO is a particularly high tech example of organ support.

But the same argument can be made for

any treatment offering a patient no reasonable chance of recovery.

Be it mechanical ventilation, ionotropic support,

artificial nutrition, intravenous fluids, or even antibiotics.

All can artificially and inappropriately prolong life.

Many clinicians feel that it is easier not to start or

withhold a treatment than to stop or withdraw it.

While there is a natural tendency to believe this,

there is no ethical distinction between the two.

This is supported legally where in numerous cases,

the courts have found that it is equally justifiable to actively withdraw

as to passively withhold non beneficial life sustaining treatments.

Withdrawing or withholding treatment is not euthanasia.

It is a decision that recognizes the limits of medical therapy, and

allows a person to progress on their natural course.

Euthanasia actively seeks to end the patient's life.

It is illegal in South Africa and

most countries removing mechanic ventilation from a patient.

And giving opioids such as Morphine can feel like very direct actions, but

when the intent is to scure comfort they are appropriate.

Leaving a patient on ventilator in such a situation and waiting for

the patient to die from another cause.

Such as bedsores or recurrent pneumonias is like saying we'll let nature take

a course and ignore the consequences of our interventions.

Opiates are the mainstay of palliative medicine.

They can be titrated to relieve unpleasant symptoms,

such as dyspnea and pain, to whatever dose is required by the patient.

There is no maximum dose.

Sedation over and

above what the patient needs to be comfortable, is however unacceptable.

Families may ask, please can we just get this over with?

As long as there is no evidence of suffering or

discomfort, that is as far as the doctor is allowed to go.

It is often seen as easier to not make a decision and

let things be than to intervene.

But inaction is itself a form of action and may directly cause suffering.

For example, leaving a patient on high doses of medication,

such as an adrenaline infusion as the only option to maintain the blood pressure

is obviously inappropriate when it is causing complete gut and limb ischemia.

Withdrawing the adrenaline is the more humane course of action,

even if this results is the imminent demise of the patient.

The intent is to prevent suffering.

DNR, do not resuscitate orders are an effective way to prevent inappropriate

treatments at the end of life.

These formally recognized but uncertain situations, all therapeutic options have

been explored, and further escalation of treatment is inappropriate.

Attempting CPR on a patient with no treatment options available or

when they have expressed a wish not to be resuscitated is wrong.

These situations can commonly be anticipated and where possible,

advanced directives should be sought.

Critically ill patients often lack the capacity to participate in decision making

regarding their treatment.

In cases where the patient is unable to make decisions a surrogate decision maker

usually the next kin is asked to make decisions on the patient's behalf.

The focus on end of life treatment decision making should be focused on joint

decisions making.

The doctor brings medical experience to discussion and

the family represents the patient opinion on the expected outcome which medical

treatments can offer.

There is a common misperception that unlimited resources can overcome

any medical condition.

The financial cost of intensive care therapy is high.

A lack of funds should not be the precipitating event for

a discussion about prognosis, but rather the clinical situation.

To recap, there is no ethical or legal difference between withdrawing or

withholding treatment.

Withdrawal of non beneficial treatment is not euthanasia.

It allows a patient to die with dignity and as little discomfort as possible.

When treatment options have been exhausted and

there is no hope of meaningful recovery.

Finally, I must emphasize again that it is only non beneficial treatments which

are withdrawn, never the care of the patient.

[MUSIC]

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