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quackdoc

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I recently was posted in the ICCU.We came across a case of Diabetic Ketoacidosis.The patient had complicating left parietal haemmorhage and soon detiorated to maintainence on ventilator.
Howvever the patient couldnt be saved as he was going in for MODS and bloopd pressure was falling drastically.The prognosis was explained to the attendants and they gave us the permission to switch off the ventilator.
The problem was that if one doesnt look over the legal issues is it possible to just gloss over the fundamental question of life and death?I mean the life just means here a switch?
With the brief history of the presnting compaints and the worsening case scenario is it justified that the process of death is hastened?Even when the prognosis doesnt give any hope in the face of accepted medical facts?Is it worth it to utilise scarce medical resources on patients whose death is iminent anyway?
I am not sure whether this rule would apply to me.If you were in this kind of a situation what would you have done?
I feel that religion has a big role to play in decision making.However I want you to examine this issue from a viewpoint thats bereft of your religious/political ideology.
As a physician,as a doctor whos been asked to make that instant decision.
 

12R34Y

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what you have described is NOT euthanasia.

Euthanasia involves an ACTIVE part in the death of the patient.....example......giving huge dose of morphine to stop respirations or some other deliberate ACT.


Some people may think that any case of letting someone die is euthanasia. This is not so.

Euthanasia always involves the INTENTION TO BRING ABOUT THE PERSON'S DEATH. This is very different to allowing a terminally ill patient to die when there is nothing more that medicine can effectively do for them. This is not euthanasia.

Euthanasia is NOT:
(1) Withdrawing or withholding life sustaining treatment which is judged to be either medically futile or overly burdensome for the patient.

This decision is not euthanasia because there is no intention here to kill the patient. It is perfectly legal and good medical conduct.

In the pro-euthanasia lobby there is a move to call (it passive euthanasia, but this is a misnomer. There is no intention to kill and so it is not euthanasia at all.

Euthanasia is NOT commencing treatment that would not provide a benefit to the patient.

Euthanasia is NOT withdrawing treatment that has been shown to be ineffective, too burdensome or is unwanted.

Euthanasia is NOT "turning off" life support in intensive care units.

we've been hammering this home in med ethics in the last few weeks.

later
 
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sorry bro, euthinasia is divided into active and passive. passive is withholding lifesaving treatment. active is kevorkian.

But dont fool yourself into thinking there is a difference.
In either way the death of the patient is forseen and deemed "better" that the patients continued existance. If this wasnt the case turning of a life support machine would be murder.
 
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quackdoc

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Euthanasia.The definition differs.The ends matter but the means dont.How is it concerned whether morphine has been injected or even the life support systems shut down?The patient dies anyway isnt it?
The fact is that I wanted to know howd one would feel when the decision to terminate the patients life has to be taken.At that point of time one needs to look at the issue from a detached point of view in the sense that the patient is another human being?
In the present case the patients attendants didnt have money to pay the hospital bills!Even if the insurance pays for that how far and for how long its justified to continue the life support?
 

12R34Y

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sorry bro.....but passive and active euthanasia are pretty much discredited at least that is what i'm reading on the web and my current med ethics professors lecture to us about.

there is not difference in active v.s. passive it is a made up distinction.

the difference btw euthanasia and giving someone morphine for severe pain is the INTENT.

what is your intent? that is the question you have to ask...........is your intent to kill the patient? absolutely not (if it is the intent then that is euthanasia)............is your intent to treat severe irretractable pain?...........will the relief of that pain require high doses of morphine?.............it may suppress the respirations.............your intent is to provide pain relief NOT kill.

later
 
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It is philisophical trickery to try and separate "killing" from "doing somthing for reason X which will undoubtably cause death"

You give super doses of morphine, knowing that the patient will die, you might as well have shot him in the head. Its called the principle of double effect and it's illogical.
 

medic8m

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Originally posted by hightrump
It is philisophical trickery to try and separate "killing" from "doing somthing for reason X which will undoubtably cause death"

You give super doses of morphine, knowing that the patient will die, you might as well have shot him in the head. Its called the principle of double effect and it's illogical.

Are you saying that giving someone morphine for pain, which may hasten their inevitable death, is equivocal to shooting them in the head?

Also, what makes you think the principle of double effect is "illogical"?
 

medic8m

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I know that the morphine-cancer-patient situation is always used but FYI: There is little evidence that opioid analgesics actually cause severe respiratory depression WHEN titrated appropriately. The risk is greatest with the first administration. There seems to be parallel curves for the development of tolerance to the analgesia and to respiratory depression.
 
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Originally posted by medic8m
Are you saying that giving someone morphine for pain, which may hasten their inevitable death, is equivocal to shooting them in the head?

Also, what makes you think the principle of double effect is "illogical"?

im not talking about doing things which 'may' cause death. In that case you can clearly not wish death. Im talking about people turning of life support and pretending that they didnt intend death. Be a man and face up to the fact that you killed someone. Its not a bad thing. Death is only bad if.....its bad. But at some point a patients life may be a burden they nor any sane person would want to bear. Sometimes people realize this and will remove somone from life support, it still happens all the time. But they will throw up any barier they can to saying they 'did' anything.

The principle of double effect simply makes no sense. You constrct a scenario using double effect and ill show you why.
 

medic8m

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Originally posted by hightrump
im not talking about doing things which 'may' cause death. In that case you can clearly not wish death. Im talking about people turning of life support and pretending that they didnt intend death. Be a man and face up to the fact that you killed someone. Its not a bad thing. Death is only bad if.....its bad. But at some point a patients life may be a burden they nor any sane person would want to bear. Sometimes people realize this and will remove somone from life support, it still happens all the time. But they will throw up any barier they can to saying they 'did' anything.

The principle of double effect simply makes no sense. You constrct a scenario using double effect and ill show you why.

I agree with what you're saying, i think its the just semantics of saying you "killed" someone. Yes, turning off a ventilator and saying you didn't intend death is weak. I think people often say things like "let nature take its course" in order to be respectful or tactful. Also, people who want to extend life at any cost, no matter what the quality, use the phrase "kill". That's why I find it so troublesome.

Re: double effect.. I believe it is a philisophical principle that "allows" one to commit acts which would normally be deemed unethical. For example, speeding to get your pregnant wife to the hospital. Doesn't the whole practice of medicine revolve around this principle: risk vs. benefit. Generally speaking, you wouldn't go into someone's room and cut their leg off, correct? However, if they were septic and needed amputation to save their life, you likely would. In sum, this represents an action that will have two effects, one good and one bad. Why is that so illogical?
 

12R34Y

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I'm sorry, but i still don't believe that i'll be "killing" all of my patients in the future.

I can't think of a great example, but these people are essentially "artificially alive".............you did not cause them to die. Their end stage disease, years of smoking, renal failure, COPD, sepsis, whatever "killed" them. They will not live indefinately with artificial life support. eventually you will die whether on a respirator or not.(duh.)

ARe you saying that if you are running a code blue in the ED and you are ARTIFICIALLY pumping someone's heart (femoral pulse present) and bagging the patient ARTIFICIALLY and you stop reviving them that you KILLED the patient????

that's ludicrous.

The code blue patient technically had a pulse (artifically) and was breathing, chest rise and the whole bit.................yet you think that by stopping you "killed" the patient.....

The AMI or PE or bullet through the head or whatever.......KILLED that patient.
 
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Originally posted by medic8m

Re: double effect.. I believe it is a philisophical principle that "allows" one to commit acts which would normally be deemed unethical. For example, speeding to get your pregnant wife to the hospital. Doesn't the whole practice of medicine revolve around this principle: risk vs. benefit. Generally speaking, you wouldn't go into someone's room and cut their leg off, correct? However, if they were septic and needed amputation to save their life, you likely would. In sum, this represents an action that will have two effects, one good and one bad. Why is that so illogical?

that is not double effect. Do a google search on it. That is just weighing the pros and cons. I belive all we can do is weight to pros and cons and make a decision. But anyway, double effect is a philosophical idea that is very specific. Im too lazy to describe it.

but here is just something off google.

Thus, a pregnant woman bearing a nonviable fetus is found to have a cancerous womb that will cause her death if it is not excised as soon as possible. The operation of hysterectomy is morally lawful, for this operation is permissible in itself as a normal means of saving the woman's life. She does not positively will the death of her child, but permits it as an unavoidable evil. Both the benefit to her health and the death of the child follow from the surgery with equal directness or immediacy in the order of causality, though the death of the child is prior in the order of time. The woman's chance of restoration to health (the good effect) is sufficiently desirable to compensate for the death of the fetus (the bad effect), which would probably not survive even if the operation were not performed.

However, if the woman is suffering from kidney disease, heart trouble, or tuberculosis, which would be easier to care for if she were relieved of the pregnancy, it would be immoral to perform an abortion. For in such a case the third condition for the proper use of the principle of the double effect would be lacking. The relief to the woman would come as an effect of the abortion, not directly as an effect of the surgery. Hence, a bad means would be employed to produce a good end.

Even if the woman's life would be gravely endangered unless an abortion were performed (a situation rarely verified in view of modern medical progress), it would be a grave violation of God's law to kill directly an innocent child to save her life.


so the pros and cons are the same. Abort the baby, save the mother. But a person against abortion would allow a hystorectomy if the belived in double effect beacuse to them, a hystorectomy of a uterus containing a baby is not killing the baby.
Its ridiculous. Either both are wrong or both are right depending on your stance on abortion. Either the death of the baby is acceptable to save the mother or its not. Double effecter try and hide from the Pro/Con decision, by drawing some irrelavant distiction about where the cancer happens to be located.

anyway, type double effect into google and you will be swimming in descriptions.
 
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Originally posted by 12R34Y


ARe you saying that if you are running a code blue in the ED and you are ARTIFICIALLY pumping someone's heart (femoral pulse present) and bagging the patient ARTIFICIALLY and you stop reviving them that you KILLED the patient????

No, my point is that if you KNOW that death is immenent and unaviodable it doesnt matter if you simply stop treating them or give them a lethal injection. In fact sometimes the latter is preferable. What if your patient is on a ventalation and you decide to halt this "artificial" treatment. They WILL die, and they MAY die very painfully, suffocating...in terror... OR you could puposfully oversedate them to death, they could die peacfully. I know which end I would prefer. Of course people dont do this because in the first case you 'let them die" and in the later "you killed them." And in the end it doesnt matter because either way they will only live a few minutes, but at least in the later case the would die in relative peace.

I object to you acting as if a treatment can be discontiued if it is artifical, as if the word had any real meaning. What treatment isnt artificial? Can you stop giving CPR to an otherwise heathy kid after 10 seconds and say "Well its not like i KILLED him, i just stopped artificial treatment" no...you might as well have killed him.
Atrificiality has nothing to do with it. The decision to go on treating or not should be based only on the pros and cons of that treatment.

When i say killing and letting die are the same you must control for all other variables. You must choose cases where EVERYTHING is the same, except for the killing and lettign die. You cant compare stopping futile CPR with shooting your b*tchy wife. It does work like that.

If you wanted to compare something....shooting your wife for example...You would compare it this way...

You are walking on a railroad and a train starts coming. Your wife walks off the tracks and then you say "shouldnt have screwed the milkman" and shoot her. OR the train comes and your wife gets her foot caught in the rails, with plenty of time to help her outyou say "shouldnt have screwed the milkman" and walk off as she gets flattened. I claim there is no difference in the two.
 

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i think that part of the debate goes back to what is legal and what is not. it seems like this debate is avoiding the fact that most often when the plug is pulled it is done so at the patient's or family's request. patients have the right to refuse unwanted medical treatment, i don't think anyone seriously questions that.

if you take a broad enough scope of the situation, anything we do leads to death. here, the doc is simply stopping further medical treatment. sure, that may hasten death, but to positively claim it causes death is another question entirely.

i too, often question the philosophical underpinnings of the commission/omission debate. but in the end i would feel comfortable pulling the plug, but i am not sure that i would give a patient a huge dose of morphine.
 

medic8m

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Originally posted by japhy
i think that part of the debate goes back to what is legal and what is not. it seems like this debate is avoiding the fact that most often when the plug is pulled it is done so at the patient's or family's request. patients have the right to refuse unwanted medical treatment, i don't think anyone seriously questions that.

Thank god the patient has that right. The real sticky situations come about when the family members wishes differ from the patients.

i heard a story about an ICU patient with his wife at the bedside. He was end stage COPD and wanted to be taken of the respirator. He said if we dont take him off he will sue. His wife said if we take him off she'll sue.

The situation ended with his wishes being followed. I think many elderly patients simply endure treatment for the sake of their family. i think one goal in an acute care setting is to get family and patient on the same page regarding intensity of care. If they all agree it will solve 99% of the problems, legal and otherwise.
 

japhy

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it is horrible to see families fighting like that during the final days of a loved one. i am interested to know how many people here have a living will?
 

quackdoc

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Intresting discussion that has kept this forum alive.All of us would one day or the other have to make the final decision.I feel that the debate has centred more on the definition of the process rather than the nitty gritty.
In the isolated case how would you decide the prognosis?I mean if there is any chance of improvement?Wouldnt that be a wrong decision to "pull the plug"?I feel that the "death" needs to be defined.
In the present case which I described above,the patients attendants had requested to "go in for the kill".However if we consider the legal aspect of it one would be answerable in the sense that this could have been requested by the greedy relatives in some way or the other.They of course considered the opinion of "eliminating" him?That doesnt absolve us of the responsisbility of "killing" him.Isnt it?
I feel that it should be a collective decision.There should be a medical board of specialists( but no ethicalists-they seem to be too biased),a legal opinion must be sought,and the board should review each case on merit.
The prognosis of the disease in question.As one of the members rightly pointed out in this discussion regarding the morphine and the cancer pain,how far is it justified to use the scarce resources in that case?
Well as far as the abortion is concerned I feel that if the child is not wanted it should be aborted.Simple.Because we as parents are responsible.What if the economic conditions dont justify?What if the child is having some gross abnormal development like a chrmosomal disorder?We d be condemning the child for the rest of his/her life.
So as I said earlier,one needs to look at the issue in a detached manner.Favourably the collective should decide.That also rules out the bias and otherwise too absolves one of the legal tangle also.I know when I had to assist in the decision I was po ed off for 3 whole days.I feel taking a collective decision would minimise that feeling of guilt also.
What do you all feel?
 

fab4fan

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Originally posted by hightrump
It is philisophical trickery to try and separate "killing" from "doing somthing for reason X which will undoubtably cause death"

You give super doses of morphine, knowing that the patient will die, you might as well have shot him in the head. Its called the principle of double effect and it's illogical.

No, it's not the same. As a hospice nurse, I have pts all the time who are actively dying and need increased pain meds. My intent is not to hasten a pt's death, but to relieve suffering. If the pt happens to die shortly after I gave him meds, it may have been a result of the meds, but it may not. Hard to say when someone is in active dying mode.

You can't really have an informed opinion on this until you have boatloads of hands-on exp. Great topic to discuss in a class, but experience is the best teacher.
 

zambezi

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Originally posted by medic8m
Thank god the patient has that right. The real sticky situations come about when the family members wishes differ from the patients.

i heard a story about an ICU patient with his wife at the bedside. He was end stage COPD and wanted to be taken of the respirator. He said if we dont take him off he will sue. His wife said if we take him off she'll sue.

The situation ended with his wishes being followed. I think many elderly patients simply endure treatment for the sake of their family. i think one goal in an acute care setting is to get family and patient on the same page regarding intensity of care. If they all agree it will solve 99% of the problems, legal and otherwise.

I agree with this...Getting the family/loved ones on the same page is so important...There is alot that can be done, but should it be done? How far does the patient and family want to go? It is tough when everyone is not on the same page.
On another note--
I have seen patients try to die for days-- sure we can keep them alive with technology--but where is the line drawn? What type of quality of life will the patient have if they survive? It breaks my heart to see patients on multitudes of iv medications (ie:amiodarone, natrecor, primacor, epi, dopamine, dobutamine--yes, all of these at once--the epi, dopamine and dobutamine all double stregnth), CRRT, 2 weeks post-op major surgery, a fun list of previous medical history. Patient not doing well--bradying down, bp 60-80s..the plan? Pt goes to surgery (again)...the family is hoping for the best- getting reassured by the dr (who, bless his heart, has good intentions but can't let go). Do we want to code an 80+ year old patient in this condition? It happens.
I don't agree with discontinuting life support on a whim or in an effort to "kill" the patient. However, with such advanced technology, we a "helping" patients to live that would have died. We are prolonging suffering for the patient and the family. In these situations, let patients die with dignity. I would never want my family member to go through something like that-- (can you tell it has been a long week?)
As a nurse, I hate to have to code patients in the above situation, it is just not fair to the patient or to their family (thankfully, it doesn't happen too often). We owe patients our best care, but I guess my only point is, as medical providers- you will have tough decisions to make. Sometimes dying might be the better option, as difficult as that decision is to make.
 
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