KS ChewEmergency Medicine Department

Universiti Sains Malaysia

Principle #1 Autonomy

Does my action impinge on an individual’s personal autonomy?

Do all relevant parties consent to my action?

Do I acknowledge and respect that others may choose differently?

Principle #2 Beneficence Who benefits from my action and in what

ways?

Principle #3: Non-maleficene Which parties may be harmed by my action? What steps can I take to minimise this harm? Have I communicated risks involved in a

truthful and open manner?

Principle #4: Justice

Is my proposed action equitable? How can I make it more equitable?

Substantial resources (supply costs and manpower) are often invested in this clinical setting, in which there is a low likelihood of benefit, while the care of other patients is delayed (distributive justice).

A proper informed consent must satisfy FOUR essential elements:

1 ‘disclosure’ of information by the doctor (it is a medical duty of care to disclose)

2 adequate ‘understanding’ of information by the patient

3 patient’s ‘voluntariness’ during the consent process, and

4 the patient has sufficient mental ‘competence’.

Under Bolam test, a doctor is not negligent if what he has done is accepted by a responsible body of medical opinion.

Under the Bolitho case, the court must be satisfied that the exponents of a body of professional opinion have a logical basis and had directed their minds to the comparative risks and benefits in reaching a defensible conclusion. The opinion of the expert witnesses must be founded on logic and good sense.

1 The name of the operation2 Nature of the proposed treatment3 What the operation involves4 Other treatment options or

alternatives5 Potential complications6 Risks of the operation

7 Risks of no treatment8 Special precautions required

postoperatively9 Benefits of treatment10 Limitations of treatment11 Success rate of operation12 What happens on admission13 How patient will feel after treatment

Duty of Care◦ A doctor on duty in ER automatically assumed the

duty to treat ANY patient Standard of Medical Care

◦ Was there actually a negligence (to the jury’s satisfaction)?

Damages◦ Did the patient suffer actual damages? How

extensive? Proximate cause

◦ Did the negligence cause the damages?

Incompetent patients include:

Children

Mentally disordered patients

Patients who are temporarily unconscious, permanently unconscious through disease, trauma, injury, who has the capacity to consent but are unable to.

The common law - It is lawful to give treatment without consent in cases of urgency and necessity.

Doctrine of necessity Bona fide/acting in good faith

Lord Bridge - “treatment which is necessary to preserve life, health and well-being of the patient my lawfully be given without consent.”

Is governed by two important principles:

A. The Principle of Patient Autonomy Advanced directives (DNAR) If patient preferences uncertain, emergency

conditions should be treated until those preferences are known

B. The Principle of Futility Definition: If the purpose of a medical

treatment cannot be achieved, the treatment is considered futile.

The key determinants - duration remaining in cardiac arrest, length and quality of life expected

“Physicians are NOT obliged to provide care when there is scientific and social consensus that the treatment is ineffective.”◦ American Heart Association

“Physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient”◦ American College of Emergency Physician, 1998

CPR maybe withheld even if requested by the patients “when efforts to resuscitate a patient are judged by the treating physician to be futile”◦ AMA Council on Ethical and Judicial Affairs, 1991

“Whereas patients have a right to refuse treatment, they do not have automatic right to demand treatment; they cannot insist that resuscitation must be attempted in any circumstances”◦ European Resuscitation Council, Resuscitation

Guidelines 2005

…“futility is a professional judgment that takes precedence over patient autonomy and permits physicians to withhold or withdraw care deemed to be inappropriate without subjecting such a decision to patient approval.”◦ Schneiderman LJ, Jecker NS, Jonsen AR. Medical

futility: its meaning and ethical implications. Ann Intern Med. 1990 Jun 15;112(12):949-54.

“It is wise for a doctor to seek a second opinion in making a momentous decision to withhold resuscitation for fear of the doctor’s own personal values, or the questions of available resources might influence his/her decision.”◦ European Resuscitation Council, Resuscitation

Guidelines 2005

1 Spouse2 Adult child3 Parent4 Any relative5 Person nominated as the person caring for

the incapacitated patient6 Specialized care professionals7 Must act in best interest of patient

May be colored by the doctor’s conviction on issues of death, life, etc viewed through a socio-cultural and religious lens◦ The concept of God◦ The sanctity of human life◦ The view of pain and suffering◦ The afterlife, etc

“Most doctors will err on the side of intervention in children for emotional reasons, even though the overall prognosis is often worse in children than in adults.”◦ European Resuscitation Council

DNAR order means just that - in the event of cardiopulmonary arrest, CPR should not be attempted at all. Other treatment should be continued; e.g. pain relief, sedation on required basis in terminal illnesses.

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

– WHO Definition, 1948

A 80-year old man with history of frequent exacerbation of COPD is diagnosed with acute pulmonary edema, currently complicated with respiratory failure Type 2. All other treatment modalities fail to prevent his deterioration. You know that his prognosis is not good but he needs mechanical ventilation to support his worsening respiratory effort.

Would you have intubated him? If the relatives insist on you to actively

resuscitate him but you do not, would you be liable to be sued?