Thursday, September 15, 2016

Rules Governing a Doctor in an ICU

Professor Avraham Steinberg published a guide on how to treat patients in an ICU; the protocol was reviewed and approved by Rabbi Shlomo Zalman Auerbach and Rabbi Shmuel Vosner:

The following protocols pertain to patients in the ICU that fulfill the following conditions:
(a) Patients who were accepted into the ICU on the assumption that there was hope to save their life.
(b) Patients who received intensive care, including mechanical ventilation, treatment for infections, treatment to sustain blood pressure, treatment to prevent clots and bleeding, blood transfusion, parental feeding and permanent monitoring of blood pressure, pulse, breathing, and oxygen saturation.
(c) Patients who after all that was done above experienced irreversible failure of at least three vital organ systems, and when all the doctors who are caring for them, which includes all the doctors of the ICU, and all the specialist consults for the various medical problems of the patients, have decided that there is no chance to save their lives, and their death from their disease is expected in a short time, and specifically on condition that the patients are suffering, therefore we can assume that they [the patients] would not want to continue with unending suffering. These rules are true for all patients in an ICU, whether they are adults, children, or newborns.

The central halachic principle in relationship to these patients is based on the balance between the requirement to save a life and the prohibition of shortening life actively (with one’s own hands), and the need to reduce further unending suffering on the other hand.

Therefore one should act accordingly:

(a) One should not start any new treatment that will lengthen the life of suffering of these patients.
(b) One should stop ordering new tests, such as blood tests that are supposed to asses the status of the patient, since the patient suffers because of them, and there is no purpose in performing these tests.
(c) There is no purpose in checking and guarding the patient in this condition, including checking the blood pressure, pulse, oxygen saturation (even though these are done automatically with machines that are attached to the patient beforehand), and there is no need to treat the state of the patient based on the values that are shown on the screen, since the patient is suffering, and there is no purpose in these tests.
(d) One should continue treating the patient with pain-killers in order to reduce the amount of pain and suffering the patient experiences.
(e) It is prohibited to do any action that will lead to the immediate death of the patient. If it is questionable whether the given action will lead to the immediate death of the patient, it may not be performed.
(f) Therefore it is prohibited to disconnect a patient from a respirator, if the opinion of the doctors is that it is possible that his breathing is completely dependent on the machine. It is prohibited to immediately and completely stop medications such as dopamine, which are intended to maintain the blood pressure of the patient, if it is the opinion of the doctors that it is possible the blood pressure will fall immediately and the patient will die immediately.
(g) It is permitted to change or end therapy, if the opinion of the doctors is that the patient will not die immediately (even if because of the action the patient will die in a number of hours), as long as the doctors deduce that the patient is suffering, under the condition the changes will be done over a set of stages, with an analysis of the state of the patient after the changes have been made.
(h) Therefore, it is allowed to lower the rate of breathing of the respirator until the rate that the patient still breathes with his own force; it is allowed to lower the oxygen concentration that is flowing to the patient via the machine until it reaches 20 percent, which is the normal room oxygen concentration; one may lower the level of dopamine, as long as there is no serious change in the blood pressure of the patient, or even if there is a change but it will not lead to the immediate death of the patient; one may stop the total parental nutrition of the patient and change it to nasogastric tube or even to give only IV water and glucose; one may stop giving medications that are meant to prevent clots from forming or bleeding, such as heparin and H2 blockers; one may stop the giving of insulin to lower the level of glucose in the blood. All of this is on condition the patient is suffering. Therefore, it is permitted to refrain from refilling medications or restarting treatments that are given in a discrete basis and not on a continuous basis, for example: to stop treatment with dialysis; to stop treatment with dopamine after the bag is done; to refrain from replacing the IV bag of antibiotics after the bag is completed. All of this is if the patient is suffering. These protocols are only applicable on patients who fall into the category of all of the above-mentioned requirements. In any other case a competent rabbinic authority should be asked.

-Steinberg, Avraham, “Rules Governing a Doctor in an ICU,” Assia, 1998, nos.63–64, pp.18 ff.