The White & Black Coat of Euthanasia

There are many western countries that allow non-assisted suicide, like Ireland. A step further is allowing voluntary euthanasia, which countries like Netherland, Belgium and state of Oregon (US) have adopted the idea of legalising it.

We know that, as long as the doctor's intention is not to hasten death, certain thing like withdrawing ventilator support eventually will lead to a 'faster' death. But doctor usually did it in view of futility of the treatment, that the ventilator does not bring benefit to patients anymore, hence patient should be allowed to die.

Supporters of active voluntary euthanasia, that is the ability for terminal patients to request doctors to give them lethal injection to hasten death, argue that this is the right of full autonomy of patients. But then, we all do not have full autonomy. We cannot just injure other people, just because we have autonomy over our actions. When it involves harm to life, that's where autonomy stops.

Another argument is the beneficent role of doctor, to alleviate sufferings. Dying terminal patients are suffering, hence termination of their life is essentially terminating their sufferings. The exponential growth of palliative care specialty allows majority of these patients, whom we thought death is the only way to end suffering, to be treated with effective pain killer and medications, which essentially can ease their suffering.

Plus, there are times our decision at that particular moment in time, is something that we may regret, although we truly believe that was the correct one. The simplest example I usually give to my students is falling in love. At that moment in time, most people would swear that his/her partner is the best for them, only to realise the mistake that they have made, afterward. Although in this case, that person can regain his/her confidence back, dead patient will not be able to.

Also, we are also afraid that by allowing voluntary euthanasia, it will lead to non-voluntary euthanasia - that is when doctors decide for their incapacitated patients (babies, demented patients) the ability to administer lethal injection - which even many hardcore supporters of euthanasia find disturbing. In voluntary euthanasia, doctor will need to assess whether patients are capable of making that decision. So, what stop doctors from thinking that lethal injection is better, even in condition where patients cannot request.

At the end of the day, for those who believe in life after death, and that sickness may be positively viewed as destroyer of sins, it is difficult to accept the concept of voluntary euthanasia.

https://www.youtube.com/watch?v=wmqfpWeYGwI&feature=youtu.be

Stopping Life-Support Treatment

In the area of end of life (whether to continue or stop life support), multiple court decisions seem to favour the family side. In the case of baby K who was born with anenchephaly and ventilated, doctor's attempt to stop the treatment was met with judgment against them by 2 courts in US. The mother of baby K argue that in her deep moral/religious belief that ventilator treatment has been keeping baby K alive (search: physiological futility andalthough she understood that it will not cure the anomaly, every life, for her was precious (search: normative futility). There wasn't an issue about funding as the treatment was funded by insurance.

After the case, bioethicist came up with 5 conditions in which, if fulfilled, physician has duty to continue treatment:
1. in the context of ongoing doctor-patient relationship
2. the technology can preserve life
3. No competent collegue is willing to take over the patient's care
4. equitable funding - the care must be paid for privately
5. No other patient is put in jeopardy

In a contrary case whereby family wants to stop the treatment, but the doctor refused - as in the case of Karen Quinlan in 1975, which she overdosed some medication/drugs suffered massive brain damage. Doctor refused to stop treatment as he believed it was a medical duty to prolong life. The court sided with the family and commented that the family wish ought to be honoured. I do think that if the case happen today, the doctor would probably sided with family decision in the case of irreversible brain damage.

In deciding to stop medical treatment, there are 4 important issue to consider:
1.Active (eg:lethal injection) vs passive euthanasia (overseeing patients death). Passive euthanasia is widely considered acceptable in cases where the treatment, in doctors judgement, is futile.
2. Intention. Though different actions may produce similar outcome, a doctor's intention should not be to kill the patients/fasten the death.
3. Withholding vs withdrawing treatment. Although it is more difficult to stop treatment once it is instituted, generally, ethicist consider them as quite similar from moral prespective.
4. Ordinary vs extraordinary treatment. Ordinary treatment is considered when the treatment bring more benefit than risk, while extraordinary treatment is when benefit is not greater than harm.

My take on this is that, if there is a dispute with family members regarding stopping treatment, it will be wise to discuss this matter maturely, instead of making unilateral paternalistic decision.

Prolonging hospital visiting hours

Given that there may be additional benefit of allowing family to be present during round, should we allow them to be around patients even if the visiting hours are up?

Although majority hospitals in the world practice a limited visiting hour, there are some hospitals​ that practice open visiting policy. There are common believes that patients need rest in between visits, visitors may interfere with the patients care, security reasons and many more.

However, studies have shown that patients prefer flexibility in visiting hours. We all must have heard or exprienced on how the guards need to do round to clear visitors outside visiting hours. It is stressful for both the guards and family. And I personally has been scolded for being with my grandmother outside visiting hours (and perhaps the reason I have biased against restricted visiting hours).

Would people not continue visiting and makes the hospital overcrowded? I can argue that the reason visitors are overcrowding the beds is because of the limited time given for each visit. We can always limit the number of visitors per patient, while keeping the visiting schedule fairly flexible.

It comes to no suprise when majority of us would like to die at home, surrounded by people whom we love. Even if the patients at the hospital cannot routinely arrange to die at home, the very least we can do is to let them die with whom they love. Relaxing on the visiting time will allow this to happen.

Attached is a review article for those who want to read more. Even if we disagree with 24hr open visiting policy, it certainly makes us think whether limiting 2-4 hours for each visiting session is based on clear evidence.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4954899/

Bullying

"If people are trying to bring you down, that means you are already above them."

Berita kematian adik Thaqif berkemungkinan akibat penderaan fizikal (dan mental) membuatkan saya terfikir, sebanyak mana lagi kes yang lebih kurang sama, tapi tidak dilaporkan. Sampai bila harus kita menunggu dan setakat mana kes buli (dera) mengganggu kita?

Apabila berlaku sesuatu kecelakaan, kita boleh melihat melalui 2 cara. Salah satunya adalah, kes tersebut merupakan satu pengecualian daripada kebiasaaan (isolated case) dan satu lagi fahaman kes itu adalah 'tip of the iceberg'. Untuk pengurusan risiko yang berkesan, kita perlu menganggap bahawa kes kes seperti ini adalah 'tip of the iceberg', bahawa masih banyak kes-kes 'near miss' yang tidak membawa kematian, malah mungkin tidak dilaporkan. Ini mengakibatkan kadangkala kita mengganggap perkara begini jarang berlaku. Dianggarkan, untuk setiap kematian yang berlaku, terdapat beribu-ribu perlakuan yang tidak betul telahpun berlaku (tapi tidak mengakibatkan kematian).

Sesiapa yang pernah tinggal di asrama semestinya akan mengiakan bahawa kes buli memang berlaku, cuma sahaja, sama ada buli tersebut ringan ataupun berat. Saya menganggap kegagalan kita untuk membendung budaya ini dimanifestasikan dengan akhirnya kematian tersebut. Malah, saya rasa tidak jauh untuk dikaitkan bahawa dari kecil sampai ke besar, kejadian buli begini masih lagi berlaku, dan malangnya dianggap sebagai satu kebiasaan. Selagi mana kita masih lagi membudayakan buli, selagi itulah sukar untuk kita membendungnya.

Apa maksud saya? Mengambil contoh dalam sektor perubatan itu sendiri, sekiranya seseorang dipaksa bekerja sehingga menyebabkan 'kecederaan; kepada mental, fizikal mahupun sosial seseorang - maka saya menganggap itu mendekati buli. Ditambah lagi apabila mereka yang menegur ataupun mangsa yang cuba mengubah keadaan dianggap sebagai 'anomaly' ataupun luar kebiasaan dan disisih/dipulau. Kita dimomok dengan perkataan 'lembik', 'masa zaman saya dahulu...'

Mungkin kerana kita merasakan kita berjaya kerana pernah 'dibuli', maka kita mengganggap semua manusia perlu melalui kesusahan untuk berjaya. Jika kesusahan itu berlaku tanpa diminta (kesibukan masa, balik lewat sebab menyelamatkan pesakit), kita perlu bersedia untuk menghadapinya, tapi kita tidak perlu melakukan sesuatu semata-mata untuk mendapat susah. Mana mungkin kita tahu, entah-entah sekiranya kita tidak dibuli/tidak dididik dengan kesusahan, kita boleh berjaya dengan lebih cemerlang sekarang ini. Dalam keadaan bias dengan hanya melihat kepada diri kita, kita tidak tahu berapa ramai yang gagal disebabkan budaya tersebut. Benarlah, pembuli akan melahirkan pembuli, dan generasi seterusnya akan merana.

Kita boleh berjaya tanpa buli, kita boleh berjaya tanpa perlu menekankan konsep senior-junior secara melampaui batas, anak-anak buah kita boleh berjaya apabila mereka dibenarkan untuk mempunyai masa untuk famili dan diri mereka sendiri- sebagaimana manusia di negara maju yang berjaya, tanpa kebergantungan kepada budaya buli.

Of course it is impossible to get rid of bullying itself, but it can be minimised. I was also part of the environment who thought 'minor' bullying is part of life, it strengthened you - but how wrong I was. I am sure there are many incidents that shape my thinking now (that any sort of bullying is unacceptable), but if I can pinpoint to one single incident, that would be when I (and my friends) was welcomed with nasi ayam, and good conversations, and multiple enjoyable trips to the shops when I first arrived in Galway. May Allah guide us and you and me and all of us to keep fighting for what we believe is the best for our future generations.

Reference:
http://www.workplacebullying.org/

Family presence during round

It is common in Malaysia that family are required to leave during a teaching/grand round by nurses or doctors for many reasons. Some may say that the presence of family members will significantly prolong the rounds and some are uncomfortable in case that they misinterpret the information discussed among doctors.

Just to be clear, this practice is totally the opposite in certain other places. So obviously, not everybody agrees that doing so may bring more harm than good. We cannot deny that sometimes during rounds, we look for family members to discuss or to inform important things. In paediatric population, this practice is probably a must.

How about teaching for doctors or misconception by family members? Yes, it is possible that the family may ask question that may delay the round, but we know as well that not every family members do that. It is in the minority I would say in Malaysia. Surveys have shown that family members highly appreciate if they are being brought into picture during rounds and between 85-100% wishes to be by the bedside if given the choice. Nurses and doctors - they are not so keen for obvious reason. American College of Critical Care Medicine (ACCM) recommended that family and parents be given opportunity to be present during round.

This article (http://www.atsjournals.org/…/pdf/10.…/AnnalsATS.201301-006PS) discuss the steps for conducting family presence during rounds.