Transcript Slide 1

The Prayer of Moses (as)
• Rabbi Sharheli sadri wa yussril Amri
wahlul uqdatammillisani yafqahu qawli
• Translation “O Lord!, expand my heart,
make my task easy for me, and untie the
knot from my tongue, so that they can
understand me”
Advance Directives and Living Wills for
American Muslims
Shahid Athar, MD, FACP
Medical Ethics Committee
IMANA & St. Vincent Hospital
Indianapolis, IN, USA
Presented on Sept.17 ,2010
At the IMANA/Hofstra University
The Disclaimer
I am on speaker’s bureau of several
pharmaceutical companies, however, this
CME presentation is not financially
supported by any of them
Learning Objectives
• 1. The need for Advance Directives and
Living wills
• 2. Shared decision making process in
patient care
• Examples of AD and LW
A case for Advance Directive
• JW ,74, father of a Catholic physician, suffered a
massive stroke which left him paralyzed and with
receptive and expressive aphasia. His AD stated
that he did not want mechanical ventilation or
nutrition/hydration in “terminal stage”. His
caregivers decided to put a G tube. He survived
150 days . When he became comatose, it was
decided to stop his feeding and allowed him to
die peacefully at home.
Patient Rights
• Basic human dignity and respect
• Access to certain information
• Protection of one’s privacy
• Safety
• Right to exercise control over one’s self (AUTONOMY)
Questions on Rights
• What are Rights of Man verses Rights of God?
• Who has ownership of the body (in life and after
death)? Is human body a dead person’s
property?
• We may have a right to donate an organ but do
we have right to be cremated?
• Do Muslims have a right to seek Shariah in EOL
issues ?(in Advance Directives and Living Wills)
• Autopsy: (What is forbidden in life is also
forbidden in death unless required by law)
Basic Human Dignity and Respect
• Underlying moral value.
• Protected by Constitution and state laws.
Right to Exercise Autonomy
• Informed Consent
• Right to refuse treatment
• Right to make Advance Directive
• Right to name Health Care Representative
Advance Directives
• In Advance of critical illness, disability, or
incapacity,
• One may issue Directives regarding his/her
wants, wishes, preferences about healthcare,
life-support, etc.
Myths about Advance Directives
• AD means “do not treat”
• HCR means giving up control of my
healthcare decisions
• AD is only for elderly
• AD is permanent and can not be changed
• Verbal wishes are not legal
• Physicians don’t have to follow them
Indiana Advance Directives
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Living Will
Life Prolonging Procedures Declaration
Appointment of Health Care Representative
Power of Attorney
Psychiatric Advance Directive
Organ donation
Out of hospital DNR
Others (JW - refusal of blood products)
Living Will
• Requirements:
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18 years of age
“sound mind”
“voluntary”
“in writing”
“dated”
“signed” (in presence of 2 witnesses)
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18 years of age, and,
Not the person who signed for declarant
Not the parent, spouse or child
Not entitled to share of estate
Not responsible for medical expenses
Living Will Provisions
• “My dying shall not be artificially prolonged”
– “incurable injury, disease or illness”
– “my death will occur within a short period of time”
– “use of life-prolonging procedures (lpp) would only
prolong the dying process”
• “I be permitted to die naturally”
• “I be provided with appropriate pain control”
Living Will
• Permits preference for “artificially supplied nutrition and
hydration”
– “Yes, even if effort to sustain life is futile or
excessively burdensome to me”
– “No, if effort to sustain life is futile or excessively
burdensome to me.”
– Let my Health Care Rep. decide
Living Will
– Requires hospitals to ask if pt has A.D.
– Requires that MDs give Living Will “great weight” in
determining intent of incompetent pt.
– Requires that form be substantially the same as set
out in the law, but that additions may be made
– Protects any healthcare provider honoring a patient’s
living will.
Living Will and Autonomy
– A competent patient may refuse any medical
treatment (even life-saving treatment).
– Living Will preserves that right after decision- making
capacity has been lost.
Life Prolonging Procedures Declaration
• States a patient’s preference to receive Life-Prolonging
Procedures (LPP).
• Expresses patient’s desire for life-prolonging procedures,
including nutrition, hydration, medication and other
interventions to extend life/dying process in event of a
terminal condition.
• Seldom used.
Health Care Representative
• Allows for the appointment of another individual to make
medical decisions if/when one lacks capacity for
decision-making
• Requirements:
– Appointer must have capacity at time of appointment
– Appointment must be in writing, signed and witnessed
(by one person) other than HCR
HCR – Powers and Responsibilities
– Acts only when appointor lacks capacity
– Acts in all matters of healthcare , even withholding/ withdrawing of
life-support
– Must act in appointor’s “best interest”
– May delegate powers to another
– HCR acting in good faith is immune from prosecution
– HCR giving consent to medical treatment is not financially
responsible for cost of treatment
Health Care Representative
• Compatible with Living Will
• Very important for patients who lack immediate family or
who desire someone other than family to be involved in
decision-making
Power of Attorney
• “durable power of attorney”
• “attorney in fact”
• May be empowered to act for you in financial matters
• May be empowered to act for you in healthcare matters
• Both
Power of Attorney
• Executed while one still possesses capacity
• Must be in writing
• Must be notarized
• Must be specific as to powers
• When used to convey healthcare powers the “attorney in
fact” is referred to as “healthcare power of attorney”
Competence v. Capacity
Competence - Legal Determination made by court
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If a person is adjudged incompetent, they are legally not capable of
making health care decisions or other decisions.
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Court will appoint guardian(s) to act on behalf of incompetent
person (known as a “ward”).
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Generally guardianship is a permanent/long term decision.
Capacity - Medical Determination made by MD
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Capacity requires ability to:
– Comprehend
– Deliberate
– Communicate
Capacity may wax and wane
What does “Ethical” Mean?
• Ethical – Conforming to moral standards.
• Moral Standards – Principals with respect to right or wrong conduct.
• Right – Virtuous.
• Virtuous – Characterized by moral virtue.
• Virtue – General moral excellence.
So what does “ethical” mean?
Ethics and Beliefs
In order to determine what is “ethical,” it is
necessary to establish what you believe.
Believe – to accept as true, genuine, real.
Belief – conviction of the truth of some
statement or reality of some being.
Beliefs
Ethics, morals and laws articulate the beliefs of:
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Individuals
Societies
Cultures
Religious Traditions
Lawmakers – legislators, judges, administrators
The majority and/or leadership of groups
Those in power
Ethical Questions Throughout the Ages
• When does life begin?
• Does man have a soul? If so, when does it
“enter” and “leave” the body?
• What treatments is a person morally obligated to
undergo in order to preserve their life or health?
• When is a person dead? (cardiac, pulmonary or
brainstem)
Foreseeing v. Intending
Is there a moral distinction between:
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Foreseeing the effects of your actions; and
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Intending the effects of your actions?
Foreseeing v. Intending
Case Examples:
• Child with cancer.
• Pregnant woman with toxemia.
• Patient in a PVS with feeding tube.
Child with Cancer
• MDs and parents agree to surgery, chemo and radiation.
• Intent of actions – Cure of cancer.
• Foreseeable effects of actions – Pain and debilitation.
• Do MDs and parents intend to cause pain and debilitation?
Pregnant Woman with Toxemia
• 18 week gestation pregnancy threatening the life of mother.
MDs and woman decide to deliver baby.
• Intent of actions – Save woman’s life.
• Foreseeable effects of actions – Death of baby.
• Do MDs and woman intend death of baby?
Patient in PVS with Feeding Tube
• Decision made to withdraw feeding tube.
• Intent of actions – Respect patient self-determination
by discontinuing unwanted medical treatment.
• Foreseeable effect of actions – Death of patient.
• Do MDs and family intend patient’s death?
Tube Feeding
• Is artificially delivered nutrition and hydration
– Medical Treatment?
– Basic Care?
– Morally obligatory for a person to accept?
– Morally obligatory for an MD to provide?
Withholding v. Withdrawing Treatment
• Is there a moral distinction between
– Withholding Treatment and
– Withdrawing Treatment?
Standard of Proof
When a patient is incapacitated, what level of certainty is required for lifesustaining treatment to be withdrawn?
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Patient’s written advance directive.
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Patient’s prior statements made to 2 or more witnesses.
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Patient’s prior statements made to one other person.
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Surrogate’s knowledge of patient’s values, beliefs, personality?
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Surrogate’s judgment regarding patient’s best interests (benefits and
burdens of treatment, hope of recovery and patient’s quality of life).
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Life-sustaining treatment should never be removed from an incapacitated
patient.
Sustaining Physical Life
Should a person’s physical life be sustained despite:
• The person’s wishes?
• The person’s “quality of life”?
• The expense, burden and/or suffering of family?
Burdens to Patient in PVS?
• Can a person with no capability for awareness
experience burdens from being on life support?
• If not, should the burdens to society and family be
considered?
• Do burdens to society and family justify discontinuation
of life support?
Benefits to Patient in PVS?
• Can a person with no capability for awareness
experience benefits from being on life support?
• If not, should the benefits to society and family be
considered?
• Do benefits to society and family justify continuation of
life support?
Family Disagreements
When there is a disagreement between family members concerning
dis/continuation of life support for an incapable patient, who should resolve the
conflict?
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Health care providers?
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Majority of patient’s family members?
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Courts?
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Legislature?
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Religious leaders?
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The patient should be kept alive with life support.
Beliefs…
• Are beliefs right or wrong? If so, who decides?
• Are a person’s beliefs about life and death likely to
change?
• Will end-of-life cases always stir intense passions?
Advance directives at the end of life
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NEJM April 1, 2010 (Silveria et all)
3746 subjects age 60 or older
42% needed decision making
73% lacked decision making capacity
Those who had durable power of attorney
for health care were less likely to die in a
hospital(38.8% verses 50.4%) and were
given less all care possible (8.1% verses
27.7%)
In-the-Moment End-of Life Decision Making
( Sudore et all AIM 8/17/10)
• To prepare patients in out patient setting to
participate in-the-moment decision making
by
• A. Assessing the readiness
• B. Educating and motivating
• C. Addressing the barriers
Steps to prepare patients for in-the moment
end of life decision making
1. Choosing an appropriate surrogate
2. Clarifying patients values over time
3. Establishing leeway in surrogate
decision making.
Islamic Living Will and Advance Directives
“IMANA recommends that all Muslims have
a “living will”, advance directive and a
proxy case manager to let the physicians
know of patient’s wishes when he/she
cannot give directions about decision
making process (i.e. when in coma)”
The Islamic Living Will
1 . Respects patients autonomy
1. To withhold or withdraw heroic procedures in a
terminal state
2. To continue hydration, nutrition and necessary
medication under physician’s directions
3. Appoints case manager if unable to give
directions (sibling, spouse, parent or adult
children)
4. No Autopsy unless required by law
References--• IMANA’ s position on medical ethics; available at
www.imana.org , published in JIMA 2008
• Khan,Faroque: Fordham Urban Law J, Nov’2002
• The Physician and the Hopelessly Ill Patient- published
by the Society For The Right to Die
• Athar, Shahid . Journal of law, Medicine and Ethics;
Spring’ 08 ” Enhancement Technologies and the PersonIslamic view”
• Silveira et all ; NEJM April 1,2010 “Advance directives
and decision making before death”
• Sudore,R.L; “ In- The- Moment AD”- Annals of IM , 17
Aug.2010.
The Disclaimer
I am on speaker’s bureau of several
pharmaceutical companies, however, this
CME presentation is not financially
supported by any of them
Thank You !(Shukran)
www.islam-usa.com
www.imana.org
[email protected]