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【Local Medical】Rescue him or let him die with dignity?Dilemma for doctors facing critically ill patients

【Local Medical】Rescue him or let him die with dignity?Dilemma for doctors facing critically ill patients


Text◆He Jianxing Edited by◆Liang Yingxiu

Faced with seriously ill patients lying on the hospital bed, “to save or not to save” is a dilemma that doctors often face, especially in the geriatric medicine department and palliative care, which are most often exposed to life, aging, illness and death. In such a situation, doctors must Is saving lives the priority? Or to ensure that the patient’s life dignity is protected?

(Kuala Lumpur News) According to the guidelines given by the Malaysian Medical Council, “Doctors have the responsibility to comfort and care for patients, and at the same time save lives within their capabilities.” This also provides doctors with a clear direction when rescuing.

Looking at the development of medicine today, it is true that there are more new technologies and the birth of drugs, but this does not mean that the chance of doctors rescuing patients has increased by 100%, because doctors are not the ones who control life and death; Humans are human beings, so there are times when they can’t do it, but doctors must have the responsibility to comfort and care for patients, especially those patients whose time is running out.

It is impossible to save all patients

Prof. Tan Maw Pin, Consultant of the Department of Geriatric Medicine at the University of Malaya Medical Center, pointed out that many times when facing critically ill patients in the hospital, both the doctor and the patient often have dilemmas, tensions, and conflicts over whether the patient needs further treatment. Even conflict situations.

Consultant, Department of Geriatric Medicine, University of Malaya Medical Center
Professor Chen Mubin
(Prof. Tan Maw Pin)

“There have even been tragedies in China or India where medical staff were beaten or even killed by their family members. This is actually due to the differences in the understanding of medical treatment, illness and prognosis between the two parties, as well as their different opinions and expectations. “

She said, just think about it, what do the medical staff do when a person is sent to the emergency room because his heart has stopped and fell into a coma? Of course it means giving first aid, but what does first aid include? Medical staff in emergency rooms often mention the word “CPR”. The translation of this word is cardiopulmonary resuscitation, but the CPR mentioned here is actually synonymous with first aid. In addition to giving priority to cardiopulmonary resuscitation for compression, it also includes When it comes to intubation, electric shock, emergency medicine, etc., medical staff must provide targeted treatment according to the patient’s condition, rather than generalizing a set of methods. For example, if cardiopulmonary resuscitation cannot be performed, other medical methods are not used. This is obviously not correct. practice.

Then imagine another scenario, that is, a seriously ill patient, such as a terminal cancer patient, is sent to the emergency room because of chest pain, but he is tired of everything in life, and tells the medical staff that if he has chest pain and is in a coma, he should not be saved. Him, should the medical staff continue to save him based on their bounden duty to save people? Or respect the patient’s wishes? The answer is that he must be rescued, but the patient’s wishes must also be respected.

The reason is that “reasonable treatment” by medical staff is both medical practice and medical ethics. It is necessary from a legal perspective. Medical staff have the responsibility to provide patients with appropriate medical treatment and care, but it does not mean that doctors must ” “Successfully” rescue patients who are seriously ill or near the terminal stage, otherwise they will be derelict in their duties. If this is true, she said frankly, “all doctors are derelict in their duties, because they simply cannot do this.”

Reduce harm with professional knowledge

In some regions, such as Taiwan, there is a so-called Do Not Resuscitate (DNR) policy, but what about in Malaysia?

She said that it must be admitted that it is still in a gray area. However, in Malaysia, the decision to save lives is still made by doctors first and family members second. Doctors saving lives is their bounden duty and a right granted by the law, but it is more important. The mission is to “care and comfort” seriously ill patients, respect the patient’s wishes, and allow him to live with dignity in his last moments, including saying goodbye to his loved ones with peace of mind.

If a patient who is on the verge of the last stage of his life continues to have a lot of intubations inserted and is surrounded by instruments to extend his life, who wants this?

“Does every medical student still remember the oath they took when they graduated, that is, the Hippocrates Oath of Doctors? The phrase ‘I will protect human life as much as possible’ is our principle as doctors. , returning to the second scene mentioned just now, as doctors, we cannot judge from the physiological manifestations whether the patient’s words are true or false. If he is ‘joking’ and we do not do our best to provide reasonable treatment, So if he passes away and his family wants to hold him accountable, what should I do as a doctor?”

“I must admit that many times when faced with the life and death of patients,

Doctors endure not only physical fatigue, but also mental suffering.

Medical staff are by no means hard-hearted, they also have feelings.

Many times doctors don’t want them to make the decision of “resuscitate” (resuscitate).

But given the great responsibility that comes from heaven, all doctors can do is use their professional knowledge to reduce harm.

Let no one get hurt as much as possible,

But there are too many things to consider behind this, including resource allocation. “

She recalled that the DELTA variant virus was raging across the country in July of the year before last. At that time, the University of Malaya Medical Center (UMMC) was one of the hardest-hit areas. Standing in the ward, she thought repeatedly about the elderly people who had been diagnosed in front of her. Which one should she save? “There are only so many respirators and other medical resources. Taking out one person’s respirator and giving it to another person means that the life of the previous person has come to an end. Looking back on those torturous days, she said she didn’t know How it passed.”

Hope to be protected from legal liability

In fact, our country has initially drafted an elder law a few years ago through the efforts of different experts and non-governmental organizations, and has already submitted it to the National Assembly. Unfortunately, our country’s political situation has been turbulent in the past few years. It is a pity that the relevant draft law has not yet seen the light of day.

As a geriatrics doctor, she sincerely hopes that the government or the Malaysian Medical Council can set up a special committee to ensure that doctors can make decisions about “rescuing and incurable” based on the actual situation. No need to face unnecessary legal liability.

As a doctor, she really doesn’t want the news about doctors in India or China being chased or even killed by patients’ family members to happen in Malaysia. This is a fear for every doctor and will also affect the doctor’s decision to make the right decision. Diagnosis. “

my country’s legal clarification Provide reasonable treatment

Whether you like it or not, we may have to face death from the moment we are born, because there is life and death, and the existence of palliative care is to improve the patient’s quality of life and reduce the pain caused by the patient’s illness.

Over the years, we have often come across a question: does the so-called reduction of harm or pain reduce the pain of patients or caregivers or family members? This is something we must think deeply about.As the most common contact with death, palliative care often falls into the difficult decision of “to save or not to save”. Fortunately, our country has a very clear legal explanation.It is clarified that medical staff must provide “reasonable treatment”. The so-called reasonable treatment means caring and comforting the patient first, and providing rescue within the scope of their ability.

Guidelines have gray areas

Dr Lam Chee Loong, director of the Department of Palliative Care at the University of Malaya Medical Center and chairman of the Malaysian Hospice Care Committee, said that from another perspective, this also allows medical staff to have a relatively clear guideline, and in fact regardless of the law There are some gray areas in the provisions or the guidelines issued by the Malaysian Medical Council, and medical staff are also deeply troubled and confused. However, it must be emphasized that doctors have an unshirkable responsibility to save people. From his personal standpoint, he will uphold professionalism. Treatment is given, but the patient’s wishes will also be respected, that is, the patient’s wishes will be taken into consideration when rescuing.

Medical staff must have a correct attitude

“There was an example before where a patient’s daughter complained that she actually wanted to bring her mother to the hospital for treatment. First, she was worried about contracting COVID-19, and secondly, her mother wanted to die at home, but because there were not enough medical resources at home, she ended up I had to take my mother back to the hospital for a follow-up consultation, and then she learned that there are different palliative care support groups in our country. These non-governmental organizations have been working quietly to provide good overall and symptomatic care to patients at home, as well as provide psychological support and education. , and her mother can also receive good care at home afterwards, which once again highlights that giving patients good comfort and appropriate care is the top priority.”

And he once again emphasized that doctors are not omnipotent, and there are things they cannot do. Therefore, no matter what position they are in, such as palliative care doctors or medical staff, they must establish a correct mentality. It is necessary to rescue patients, but they cannot be ignored. If you push yourself too hard, something will happen to the doctor too.

Director, Department of Palliative Care, University of Malaya Medical Center
Also Chairman of the Malaysian Hospice Council
Dr. Lin Zilong
(Dr Lam Chee Loong)



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