MEDICAL ETHICS OF CARING FOR THE CRITICALLY ILL
- TEACHING AND EXPERIENCING
Ethos is said to be the moral nature, set of ideas or beliefs of a person or group.
Ethics can be defined as the science which deals with morals.
Ethic is a system of moral behaviour.
These are definitions taken from Longmans Dictionary of Contemporary English. Based on the definitions above, how does one define Medical Ethics of Patient-Care, of Critical Care, of Caring for the Critically Ill? As with many terms involved with patient-care or clinical care, a word definition is difficult particularly in critical care which is a dynamic situation.
Thus from a clinical point of view, one tends to look at the Medical Ethics of Critical Care as a Dynamic Doctor-Patient Relationship focussing on What’s Best For the Patient under the Circumstances. The doctors must try their best to fulfill the patient’s cry for help to alleviate his pain and suffering (Therapeutic Care) while bearing in mind a basic tenet of the Hippocratic Oath - Beneficence, No Maleficence. The essence of a good doctor-patient relationship stems from respect for one another. The doctor who follows his ethical principles will treat and respect his patient as a fellow human being in need of help. The doctor will command the respect of the patient (and relatives of the critically ill) by his benevolent behaviour. One does not have to show how clever one is (including running down colleagues). Patients are in awe of arrogance in doctors - especially those who are obviously “smart alecs”, are superspecialised, are so popular and busy that the patient is made to FEEL like a case note or a number.
In Critical Care (Perioperative Care, Resuscitation, Intensive Care, Pain Relief) unexpected or unwanted events can occur. The patient and/or relatives who were brushed aside (“the doctor never talked to me”, “he never allowed me to talk”, “he never listened to me”) have been implanted with the seeds of discontent which can turn to anger. The breakdown in the ethical doctor-patient relationship is ripe for an eruption as an allegation of Medical Negligence/Malpractice.
In the age of the rat race in our country and with recent rapid advances in Critical Care (more doctors being produced, more specialisation or even superspecialisation), one must not forget that the basic need of our multi-racial, cultural, and religious people is to be treated by doctors as fellow human beings.
The inclusion and teaching of Medical Ethics in medical education (for undergraduates and postgraduates) is important and very relevant today in Malaysia. The medical profession is at the crossroads to provide the best standards of healthcare whilst not forgetting to meet the needs of all patients.
The teaching of Medical Ethics in Critical Care is not just a matter giving a series of didactic lectures etc.. It is a continuous process of learning from experience (students see and watch the examples set by the supervisor/teacher). This is clinical teaching by mentorship. As clinical teachers, one must remember that the discerning mind of students today can see the ethical and the unethical standards of care we practise - this is part of their learning curve!
So how does one fit in the teaching and learning of clinical medical ethics into already tight and crammed medical curricula?
Most existing medical schools in Malaysia have some form of on-going teaching in medical ethics. What is required is to bring in Medical Ethics in Critical Care as a definitive, structured teaching module/programme in the medical curricula.
Suggested Critical Care Ethics Teaching Programme
1) Lectures - General Introduction to Elementary Clinics to the whole class just before they commence definitive clinical discipline postings.
2) Lectures/Tutorials/PBL/Ward rounds incorporated as part of small group clinical postings relevant to different disciplines.
3) Continuous “teaching by example” during posting.
4) End of posting assessment? Format.
Topics
1) General Introduction - examination of patient (history, physical examination, investigations, diagnosis, treatment)
• Consent (?consciousness, implied consent)
• Invasive procedures
• Privacy/Dignity/Confidentiality
2) Perioperative Management
• Consent - examination, investigations, indications, explanation, potential outcomes, withholding information, therapeutic privilege
• Concept of Team Management
• Responsibilities and best interests
3) Resuscitation
• Duty to attempt
• Stabilize, support failing vital systems
• transfer to better facility or call-in facility not available
• Withholding Futile Therapy, DNR (in Malaysia?)
4) Intensive Care
• Proper multidisciplinary facilities & care (nurses, equipment, space, design, doctors)
• Admission/Discharge criteria (clinical decision, to save life, to bring back a human being)
• Keeping relatives informed from the start (success, brain damage/persistent vegetative state, failure and Brain Death)
• “Death in ICU”
Concept of Brain Death and SUBSEQUENT MANAGEMENT (unethical to ventilate after proper certification of Brain Death).
5) Pain Relief
• Acute pain (obstetric analgesia, post-operative/post-trauma analgesia, what’s best for the patient
• Head/sports injuries
• Chronic pain - multidisciplinary management, end of life ethical issues in terminal cancer patient in pain, living will/advance directive
• Doctor’s duty to relieve pain and suffering (palliative care, comfort in dying, TLC)
Futile Therapy vs Assisted Suicide
The importance of ingraining ethical principles in our doctors for patient-care in this country has already been mentioned as for altruistic, societal reasons (every member of society has the right to the best standard of healthcare available - a basic human right). Currently, the medical profession is facing new challenges as advances in Critical Care are opening new vistas - some creating clinical dilemmas (To Do or Not To Do?). These clinical dilemmas can have medico-legal implications.
This is the added value of ingraining Medical Ethical Principles of patient-care in our doctors to guide them as to what to do/not do but also WHY we do/not do in clinical practice. We should treat our patients according to good Medical Ethical Principles (good clinical practice). The law should not tell us HOW to treat our patients.
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Emeritus Prof. A.E. Delilkan
Emeritus Professor, Anaesthesiology & Critical Care
Founder President, Malaysian Association for the Study of Pain
Founder President, Malaysian Chapter (in formation of the Pain International Association for the Study of Pain
All-Malayan & Malaysian Cricket Captain (1959-1973)
Chairman, Medical Ethics Section, PPSR
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