In the care of very sick patients deemed to be in the last stages of their life, there are advance directives that guide the medical team on what steps to take or avoid in order to keep them alive.
When patients have terminal illnesses and cannot be saved certain medical interventions may be deemed “futile care”. The intervention makes no difference in the terminal outcome.
This advance directive is given on medical advice based on the patient’s condition and the likelihood of recovery.
This is not euthanasia. Euthanasia, illegal in Kenya and many other countries, is assisting a patient to die. It means measures to end the patient’s life are instituted.
A do-not-resuscitate order, or DNR order, is, therefore a medical order written by a doctor or medical team giving instructions to the healthcare providers on what to do when the terminally ill patient stops breathing.
This includes instructions not to do cardiopulmonary resuscitation (CPR) if a patient's stops breathing or if the patient's heart stops beating. CPR is the treatment done when the heart stops beating or blood stops flowing or breathing stops. It is meant to restart these physiological processes or to temporarily help the body until it recovers from illness causing the problem. The resuscitation may involve mouth-to-mouth breathing and pressing on the chest, electric shock to restart the heart, breathing tubes to open the airway or intubation and ventilation, and medicine to stimulate the heart to start pumping again.
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Ideally, a DNR order is created before an emergency occurs specifically addressing what is to be done if the above procedures are required. Instructions on other treatments may be included in the order. For example pain medicine, nutrition, dialysis, chemotherapy and radiotherapy.
Prognosis or expected outcomes of the illness is discussed with the patient, his family or next of kin. If the patient is too unwell to participate in the discussion or to make a lucid decision the next of kin will make the decision about the above.
Medical ethics dictates that the guarded outcome should be shared with the patient and the family to guide end of life choices. Doing CPR and putting a terminally ill patient on life support or ventilation in an ICU is considered futile care because the condition will not be reversed and the outcome will be the same — death. A decision can be made not to sustain life temporarily without long term benefit to the survival or comfort of the patient.
Quality of life is an important aspect in the care of a patient at the end of life. The interventions instituted should not worsen the quality of life especially because they will not save his or her life.
The utilitarianism school of thought considers that the person has various absolute rights over himself, over his body and mind.
Utilitarianism pro-euthanasia arguments are thus to the effect that the person has an explicit right to self-determination and hence a right to decide when to die. It is considered that death is a private matter and provided it occasions “no harm to others”, the State or other people have no right to interfere. This philosophy manifests in various healthcare guidelines across the world.
One such guideline is Advance Medical Directives (AMD). These pertain to treatment preferences and the designation of a surrogate decision-maker in the event a person should become unable to make medical decisions on their own behalf. These directives take the form of a living will or a Health Care Proxy.
The living will specifies what types of medical treatment are desired, usually to the effect that if an attending physician determines the patient’s condition is terminal, life-sustaining measures which merely prolong death with no prospect of recovery should be withheld or discontinued. The Health Care Proxy designates another person to make health decisions if the maker is not in a position to physically or mentally.
The other healthcare guideline is the DNR order or Allow Natural Death. These orders were introduced in 1960 and have been adopted by most European states.
They have not received legislative adoption in Kenya and it is necessary that action is urgently taken. Given the widespread concerns regarding the terminally ill, it is crucial that the Law Society of Kenya and the Kenya Medical Practitioners and Dentists Council converge to discuss these matters.
Dr Kiarie is an oncologist
Mr Ngatia is a lawyer