Doctors and laws course

Content
• consent
• confidentiality
• Reports and certificate
• competency and capacity
• Torts
• Malpractice
• Malpractice in different specialties
• Documentation errors - how to write a medicolegal report
• Euthanasia, DNR
• Disclosure , withholding treatment
• Organ transplantation
• Futility
• Patient Safety

1- Consent
Types of consent
Implied consent : It is not expressly granted by a person, but it is arising by
inference from the patient's behavior (Patient show an act that he is his agree
for clinical interference such as entering a doctor's chamber and expressing his
problem) .It is needed in ; General physical
examination ;Some procedures like vaccinations

Informed consent: it is the agreement obtained from a subject, or from his

authorized representative to the subject’s participation in an activity .It is
providing information by the physician to the patient to help him to make an
informed decision.
3. Unanimous consent : or general consent, by a group of several parties
(e.g., an association) is consent given by all parties
Expressed consent: may be in oral, nonverbal, or written form and is
clearly and unmistakably stated. Issues may arise when the consent is
through oral communication, as stated under ‘implied consent’.
TYPES:
Oral consent: For most minor examinations and procedures performed under
local anesthesia, e.g., insertion of IV cannula, suture of minor lacerations…

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Written consent: For more invasive tests or for major procedures with
significant risks e.g., breast biopsy, blood transfusion, all operations requiring
general anesthesia, etc.….
When consent must be obtained
According to the Health Care Consent Act 1996, consent is required for:
Anything that is done for a therapeutic, preventive, palliative, diagnostic,
cosmetic or other health-related purpose, and
includes a course of treatment, plan of treatment or community treatment plan.

Who can give consent?

o The person himself (sane, conscious, over 18).
o An agent appointed by the patient under an
o enduring power of attorney (medical treatment)
o A person appointed by legal authority (legal guardian)
o The patient’s spouse.
o The patient’s nearest relative over the age of 18
When is consent not needed?
If there is a medical emergency .This means treatment is needed to prevent
death, serious damage to the patient's health, or suffering from significant
pain or distress. ( Lifesaving measurement )
Pre-requisites for Medical Practitioner
Taking Consent
Valid Consent
Valid consent can be defined as the voluntary agreement by an individual to a
proposed procedure, given after appropriate and reliable information
about the procedure, including the potential risks and benefits, has been
conveyed to the individual
Condition of valid consent

o NO FORCE
o NO FEAR
o Given after sufficient information
Requirements For Obtaining Valid Consent
o It must be given by a person with legal capacity, and of sufficient
intellectual capacity to understand the implications of undergoing the
proposed procedure.
o It must be taken in a language which the person understands.
o It must be given freely and voluntarily, and not coerced or induced by
fraud or deceit.
o It must cover the procedure to be undertaken.
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 o The person must have an awareness and understanding of the proposed
procedure and its known or potential risks.

The person must be given alternate options to the proposed treatment or

procedure.
The person must have sufficient opportunity to seek further details or
explanations about the proposed treatment or procedure.
There must be a witness/interpreter, who may be another registered medical
practitioner or a nurse.
The person must be given alternate options to the
proposed treatment or procedure.
The person must have sufficient opportunity to
seek further details or explanations about the
proposed treatment or procedure.
There must be a witness/interpreter, who may be another registered medical
practitioner or a
nurse.
Documentation:
It is important to document the process of consent taking:
It should be dated and signed by the patient or guardian,
the doctor and an independent witness. Assisting nurse
preferably should not be a witness.
It should be prepared in duplicate, and a copy handed over to the patient.
The original form should be preserved, like all other medical records, as a
legal record that the patient agreed to the treatment
Informed Consent for Treatment or Procedure
Components:
The nature of the decision/procedure
Reasonable alternatives to the proposed intervention
The relevant risks, benefits, and uncertainties related to each alternative
Assessment of patient understanding
The acceptance of the intervention by the patient

Standard Consent Form

A standard consent form should contain:

o Patient identification data: Name, IC Number, Address, gender
o Name of procedure/surgery to be performed in full
o Type of anesthesia

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 o Name(s) of registered medical practitioner(s) performing the procedure/
surgery.
o Permission to proceed with any additional procedure that may become
necessary during the surgery and related to the procedure for which the
original consent had been obtained.
o A statement to the effect that the person who is
o performing the procedure has explained to the patient (or next-of-kin) the
nature of the procedure and the potential material risks.
o A statement to indicate that the Patient has received and read additional
Explanatory Notes, if so, provided by the practitioner.
o Signature of Patient/next-of-kin (relationship) and IC Number and date
o Signature of Practitioner and name stamp, and date
o Signature & name of Witness (to the signing of the form) and date.
Refusal Of Treatment
o The patient maintains the right to refuse any medical procedure regardless of
the reason.
o Some of these reasons may include religious beliefs, concern regarding risks
of procedure or skepticism regarding possible success of the procedure.
o An exception to the general right of patients to refuse medical care may
exist when the best interest of a child of theirs would dictate there is no
other appropriate adult to care for that minor child.

‫) من الئحة اداب المهنة‬28( ‫مادة‬

‫ال يجوز للطبيب إجراء الفحص الطبي للمريض أو عالجه دون موافقة (مبنية على‬
‫ ويعتبر ذهاب المريض‬،‫المعرفة) من المريض أو من ينوب عنه قانونا ً إذا لم يكن المريض أهالً لذلك‬
‫ وفي حاالت التدخل الجراحى أو شبه الجراحى يلزم‬،‫إلى الطبيب فى مكان عمله موافقة ضمنية على ذلك‬
‫(مبنية على المعرفة) من المريض أو من ينوب عنه قانونا كتابة اال في دواعى‬ ‫الحصول على موافقة‬
‫انقاذ الحياة‬.
‫وعلى الطبيب الذي يدعى لعيادة قاصر أو ناقص األهلية أو مريض فاقد الوعي في حالة‬
‫خطرة أن يبذل ما في متناول يديه إلنقاذه ولو تعذر عليه الحصول في الوقت المناســــب على‬
‫ كما يجب عليه أال يتنحى عن عالجه‬.‫الموافقة (المبنية على المعرفة) من وليه أو الوصي أو القيم عليه‬
‫إال إذا زال الخطر أو إذا عهد بالمريض الى طبيب آخر‬

: -‫ من قانون العقوبات‬268‫مادة‬
‫كل من هتك عرض إنسان بالقوة أو بالتهديد أو شرع في ذلك يعاقب باألشغال الشاقة من ثالث سنين إلى سبع‬
‫وإذا كان عمر من وقعت عليه الجريمة المذكورة لم يبلغ ست عشرة سنة كاملة أو كان مرتكبها ممن نص‬
.‫ يجوز إبالغ مدة العقوبة إلى أقصى الحد المقرر لألشغال المؤقتة‬267 ‫عنهم في الفقرة الثانية من المادة‬
‫وإذا اجتمع هذان الشرطان معا يحكم باألشغال الشاقة المؤبد‬

4
 2-MEDICAL CONFIDENTIALITY
• Definition: It is the right of the patient to have his personal and medical
information kept private. Such information should be available only to
the physician of record and other health care and insurance personnel as
necessary.
• Principles:
− Confidentiality is for personal and medical information.
− Personal and medical information will not be disclosed to others unless
the individual has given a specific permission for such release.
− Doctors have no right to supply anyone, even close family members,
with the patient’s medical records or information, even after patient’s
death.
• Importance:
− Creating a trusting environment by respecting patient’s privacy
encourages the patient to be as honest as possible during a health
care visit.
− It may also increase the patient’s willingness to seek care.
− For conditions that might be stigmatizing, such as reproductive,
sexual, public health, and psychiatric health concerns,
confidentiality assures that private information will not be
disclosed to family members or employers without patient’s
consent.

• Release of information
The information can only be transferred if the patient has signed
a consent requesting transfer of information. It is the patient who must sign
the information consent not the healthcare provider.

• Circumstances where a physician is allowed to divulge a patient’s

secret or breach confidentiality:

1- Notification of communicable or infectious diseases to the health

authorities.

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 2- Legal requirements: notification of births, deaths, stillbirths,
therapeutic abortions, drug addiction.
3- To relatives: when they must care for the patient at home, except
when the patient refuses.
4- If the patient is incompetent or minor, information is normally
delivered to parents or guardians.
5- With the permission of the patient.
6- For the sake of the patient: e.g., in emergency, mental illness.
7- In life insurance companies: a physician should examine a person
before he gets a life insurance. He should be honest when informing
the insurance company about his medical condition. In cases where
previous knowledge of some disease has been acquired by the medical
officer, and at the time of examination no sign of it is present, he
cannot legally report it, for the report would be a breach of confidence
and actionable.
8- To defend himself when accused of malpractice.
9- Psychotic patients with violent tendency.
10- In national security threat e.g., terrorist activity.
11- Victims of neglect or abuse.

12- In case of crimes:

- Committed crimes: If the physician learns of a serious crime e.g., by
treating wounds due to assault or rape either in a victim or assailant,
then the issue of confidentiality clashes with the need to protect some
individual or the public at large from possible further damage.
The criminal procedure law (‫ )قانون اإلجراءات الجنائية‬states that every
person that knows about a crime should notify it. However, there is no
obligation nor any conviction if he did not.
- Crimes about to be committed: Obviously, when it comes to the
knowledge of a doctor that a crime is about to be committed, whether
the information comes to him in the course of his professional work or
not, it is his duty as a citizen to prevent it.

• Principles that should be followed on allowing breach of

confidentiality
1- It must be to proper authorities.
2- Not beyond what is required or relevant.
3- Reason for disclosure must be documented in the medical records.
4- Patients are informed about such disclosure.

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 • Accusing a physician of divulging a patient’s secret:

There are three points that should be considered in accusing a

physician of divulging a patient’s secret:
1 .There was divulging of a secret.
2.The secret was known to the physician through his profession.
3. The disclosure of the secret has led to a harm or damage to the
patient (physical or psychological).
The secret is:
Any information about the patient that could be kept by the physician
except under legal circumstances.

238 ‫ وزير الصحة والسكان رقم‬/‫) من الئحة آداب المهنة لألطباء بقرار‬30( ‫مادة‬
‫ ال يجوز للطبيب إفشاء أسرار مريضه التى اطلع عليها بحكم مهنته إال‬:2003 ‫لسنة‬
‫إذا كان ذلك بناء على قرار قضائى أو في حالة إمكان وقوع ضرر جسيم ومتيقن‬
‫يصيب الغير أو في الحاالت األخرى التى يحددها القانون‬
‫ من قانون العقوبات‬310 ‫مادة‬:
‫كل من كان من األطباء أو الجراحين أو الصيادلة أو القوابل أو غيرهم مودعا إليه‬
‫بمقتضى صناعته أو وظيفته كسر خصوصي أؤتمن عليه فأفشاه فى غير األحوال‬
‫التى يلزمه القانون فيها بتبليغ ذلك يعاقب بالحبس مدة التزيد على ستة شهور أو‬
‫بغرامة ال تتجاوز خمسمائة جنيه‬

3-Medical records and certificates

A medical record is a written document of a patient's medical condition
and provided care.

The information contained within a patient's medical record is covered by all

the same rules of confidentiality as any other privileged medical information.

▪ Confidentiality of a medical record:

- The record is a confidential document involving the doctor-patient relationship.
- This record should not be communicated to a third party e.g., a relative, without the
patient’s prior written consent, unless required by law or to protect the patient or the
community.

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 - Physicians who use or receive information from medical records share in the
responsibility of preserving patient’s confidentiality. They should be aware of the
legal rules of medical confidentiality in their health care institution.
- When this data is published in professional journals the identity of the
patient is never divulged, and all identifying data is either eliminated or
changed. If this confidentiality is breached in any way, patients may have
the right to sue.
- Unlawful break of confidentiality has ethical and legal consequences (imprisonment
for 6 months and a fine).

▪ Patients have the right to obtain a copy of their own medical records, provided this
does not put their health into danger.
▪ Importance of medical records:
a- Serving as a basis for planning patient’s care.
b- Providing information for continuous follow up of individual patients.
c- Documenting communication between medical personnel sharing in patient's care.
d- Revising records is mandatory in investigating medical malpractice claims.
e- Serving as a document to educate medical students and resident physicians.
f- Providing data for hospital auditing, quality assurance and medical research.

▪ Medical reports and certificates:

Registered practitioners are in certain circumstances requested to issue medical certificates,
notifications, reports, or other documents, signed by them, for use in courts or for
administrative purposes
Circumstances in which a physician is asked to issue a medical report or certificate:
1- Birth certificate: including date and place of birth, sex of the baby, names of parents.

2- Death certificate: The physician must sign a certificate indicating the cause of death of a
deceased person.
It is forbidden for a physician to sign a death certificate in any of the following cases:
a. Suspected or confirmed violent death, whether homicidal, suicidal, or accidental.
b. Death where the physician did not examine the deceased by himself.
c. Death where the physician is unable to establish the cause of death.
Such cases must be notified to the designated medico-legal authority.

3- Vaccination: including the type, time, and place of the vaccination.

4- Infectious diseases: reported to the health authorities for public health protection.

8
5- Work accidents: reporting the cause of accident, effects, and time for recovery.

6- Occupational diseases: reports should include type of disease, need for diminishing effort,
or change of work and time needed for rest.

7- Injuries: a primary medico-legal report is issued including personal data and data related to
the injury; type of wound, site, causative instrument, associated lesions, complications, and
the expected time for cure.

8- Age determination: for persons who have no birth certificates.

9- Test for sanity.

10- Sick - leave reports.

11- For insurance.

Any physician who is writing a medical report or certificate, which is not true, or
misleading will be accused of forgery and punished by imprisonment or a fine and erasure of
his name from the medical register.

Legal rules that should be followed on issuing a medical report or certificate:

1-It should be accurate, containing correct and complete information about the condition.
2- Based only on scientific standards without personal expectations.
3- Including in details all the data that have been asked for.

4- Not including any dictated data by any person.

5-The physician should be sure of the identity of the person, he is giving the report on.

6-Delivered to the patient himself except when he is incompetent due to underage or insanity;
in these cases, it is given to his guardian.

7-The physician should not sign the certificate if he is not the one who wrote it. A physician
should certify only what he has personally verified.

Keeping medical records:

If patients’ records are medically or legally needed, physicians have an obligation to keep
these records for:

9
1- Follow up of the patient’s condition (e.g., immunization records, operative notes, and
chemotherapy).
2- Legal requirements as in criminal injuries.

3- Investigating medical malpractice claims.

:221 ‫القانون المدنى مادة‬

‫كل شخص صنع بنفسه أو بواسطة شخص آخر شهادة مزورة على ثبوت عاهة لنفسه أو لغيره باسم طبيب أو‬
.‫جراح بقصد أن يخلص نفسه أو غيره من أى خدمة عمومية يعاقب بالحبس‬

:‫ عقوبات‬222 ‫مادة‬

‫كل طبيب أو جراح أو قابلة أعطى بطريق المجاملة شهادة أو بيانا ً مزورا ً بشأن حمل أو مرض أو عاهة أو وفاة‬
‫مع علمه بتزوير ذلك يعاقب بالحبس أو بغرامة ال تجاوز خمسمائة جنيه مصرى فإذا طلب لنفسه أو لغيره أو‬
‫أخذ وعدا ً أو عطيه القيام بشئ من ذلك أو وقع الفعل نتيجة لرجاء أو توصية أو وساطة يعاقب بالعقوبات‬
.‫المقررة فى باب الرشوة‬

.ً ‫ويعاقب الراشي والوسيط بالعقوبة المقررة للمرشي أيضا‬

4- How Do I Determine if My Patient has Decision-

Making Capacity?

Competency is a global assessment and legal determination made by a judge in

court.

Capacity is a functional assessment and a clinical determination about a

specific decision that can be made by any clinician familiar with a patient’s
case.

Sane , conscious over 18 years old is a person considered competent and have
the capacity to take a decision

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Hospitalists frequently encounter situations in which a patient’s capacity is
called into question; in most cases, this is a determination a hospitalist can
make independent of consultants.

The four key components to address in a capacity evaluation include:

1) communicating a choice, 2) understanding, 3) appreciation, and 4)

rationalization/reasoning.

In case of doubt – make a consultation with a psychiatrist.

5,6,7- Torts , malpractice , malpractice in different

specialties

• When a medical practitioner undertakes the care of a patient, he enters

implied contract to treat the patient with reasonable skill and care.
So, there is a commitment by the physician to do his best of knowledge and skills
for the benefit of the patient.

Malpractice (malpraxis) is professional negligence( by act or omission) by a

health care provider in which the treatment provided falls below the accepted
standard of practice in the medical community and causes injury or death to the
patient,
Standards and regulations for medical malpractice vary by country and jurisdiction
within countries. Medical professionals may obtain professional liability
insurances to offset the risk and costs of lawsuits based on medical malpractice.
• Negligence unproductive of damage will not give the right to an action, but
negligence causing damage will do.
• If there is any doubt of negligence, the patient can sue the physician for
malpractice.
Tort (Definition) A tort is a civil wrong, a non-criminal or non-contract related
wrong, committed by one individual (defendant) who has caused some injury
(physically, mentally, or financially) to a second individual (plaintiff or
prosecution).

11
 A plaintiff must establish all five elements of the tort of negligence for a
successful medical malpractice claim.( Basic considerations in proving
malpractice):

1. A duty was owed: a legal duty exists whenever a hospital or health care
provider undertakes care or treatment of a patient.
2. A duty was breached: the provider failed to conform to the relevant standard
care.
3. The breach caused an injury: The breach of duty was a direct cause and the
proximate cause of the injury.
4. Deviation from the accepted standard: It must be shown that the practitioner
was acting in a manner which was contrary to the generally accepted standard in
his/her profession.
5. Damage: Without damage (losses which may be pecuniary or emotional),
there is no basis for a claim, regardless of whether the medical provider was
negligent. Likewise, damage can occur without negligence, for example, when
someone dies from a fatal disease.

Negligence may be defined as the omission to do something which a reasonable

man would do or doing something which a reasonable man would not do (act of
omission or commission).
• When a patient can prove that he has suffered harm because of a physician’s
failure to provide a reasonable standard of care, which any ordinary physician in
his position would take, he has the right to receive financial compensation.

Most legal actions for negligence are within the civil law, few undergo
criminal prosecution of the physician for example:
• Illegal abortion.
• Death of a patient resulting from gross ignorance or negligence of the
physician.

Types of malpractice faults

1. Technical faults:
When the physician does not follow the scientific basic rules in his profession for
diagnosis and treatment. These may be major or minor faults.
2. Objective mistakes:
When a surgeon forgets any object inside a surgical wound e.g., Towel,
instrument…etc. all objective mistakes are major malpractice.
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The basis of evaluating the malpractice
1. The professional level of the physician.
A general practitioner cannot be considered negligent just because a specialist
might have served a patient better.
2. The severity of the case.
3. The time and place of the act.
The act is compared with the attitude taken by an ordinary physician with the same
standard, qualification, experience, and circumstances.
4. A medical injury may have been caused by any one or more of the medical
personnel who have treated the patient.
5. “The thing speaks for itself” e.g.
Foreign bodies and slipping instruments in surgical procedures
Burns from heating modalities
Injury to a portion of the patient’s body outside the field of treatment

TYPES OF MEDCAL MALPRACTICE

I. Malpractice in diagnosis (wrong or delayed diagnosis)

II. Prescription Drug and Medication Malpractice
III. Malpractice in surgeries ( surgical errors)
IV. Other types according to specialty

I. Malpractice in diagnosis
To reach a proper diagnosis the physician should:
• Take a careful history
• Examine his patient thoroughly
• Ask for investigations (whether laboratory or radiological)
• Consult colleagues or professors if he is not sure of a diagnosis
• Otherwise, he may fall under malpractice if he misses a diagnosis due to
ignorance by the basic scientific knowledge.
Liability may be proved when the physician fails to diagnose a condition
which would have been diagnosed by a competent practitioner.
o Recent studies have found that misdiagnosing a condition is the leading type
of physician error, and that the five most misdiagnosed diseases or conditions are
infections, tumors or masses inside the body, heart attack, (pulmonary embolism),
and heart disease.
• Sometimes missed diagnosis or mistake in reaching exact diagnosis is due to
Inexperience
The disease being in its early stage.
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II. Mistakes of treatment

The physician is free in choosing the method of treating his patient if he is using
scientific basis agreed upon by physicians. The physician is sued for malpractice of
treatment in the following conditions:
If he prescribed a wrong drug
If he was inaccurate dose of medications
Defective or dangerous drugs ( non-approved medications )

III . Surgical mistakes

. Responsibility of the surgeon lies in the following stages:
• Writing the first admission sheet and diagnosis of the case
• Stage of preparing for operation (examine, ask for specific investigations, be
sure of fitness of patient for operation)
• An informed consent (entailing the diagnosis, surgical procedure, anesthesia
and expected complications) is signed by the patient except in emergencies
• A surgical report should be filled including every detail, and any problem at
the time of the operation should be mentioned
• The surgeon should do an operation only in his specialty
• He is responsible for sterilization of the surgical wound
• In operations the surgeon is responsible for the actions of his team while
acting under his immediate supervision (nurses and assistants).
• Responsibility of the hospital authorities lies in the selection of nurses
• The responsibility for anesthesia belongs to the anesthetist not the surgeon.

Why Do Surgical Errors Occur?

Common reasons for surgical errors:
• Incompetence: Lack the skill to perform the surgery successfully.
• Insufficient Preoperative Planning – It is critical that a surgeon be well-
prepared for surgery. This can include reviewing, and preparing for, any
complications that are likely to occur. It can also include proper selection of
nurses and assistants .

• Fatigue – This is quite common. Surgeons notoriously work long shifts. This
results in fatigue. Tired people are more likely to make mistakes when compared
with well-rested people.
• Drugs/ALCOHOL – Some surgeons may use drugs and ALCOHOL to cope
with the stress they sometimes face.

14
• Neglect –This could include failing to ensure their instruments are properly
sterilized. It could also include the decision to use surgical equipment known to be
defective

Examples of Surgical malpractice:

• Operating on the wrong patient
• Operating on the wrong side: limb, organ…etc.
• Incorrect surgical incisions (wrong location)
• Unnecessary operations ( patient doesn’t need it or will not get benefit from
it )
• Damage to internal organs or neurovascular structures
• Leaving swabs or instruments in the surgical wound

Examples of Orthopedic malpractice:

• Missed fractures
• Tissue damage from over tight plaster
• Residual deformity after management ( malunion and limb length
discrepancy )

IV. Other specialty malpractice

A. Obstetrician malpractice

• Criminal abortion and complicated therapeutic abortion

• Birth injuries: fractured bone, Erb’s palsy and DDH and Brain damage of
newborn due to hypoxia from prolonged labor (cerebral palsy cases)
• Hysterectomy without being sure of the diagnosis (pregnancy in an old
women diagnosed as a mass in the uterus and doing hysterectomy)

B. Anesthetic malpractice

• The anesthetist is responsible for: preoperative preparation of the patient,

anesthesia during the operation, and follow up in recovery.
Examples of malpractice include:
• Brain damage from allowing hypoxia to occur
• Neurological damage from spinal or epidural injections
• Incorrect or excessive anesthetic agent
• An allergic reaction to medication used
• Allowing awareness of pain during anesthesia

15
 ‫‪Legal advises for malpraxis prophylaxis:‬‬

‫•‬ ‫‪Never guarantee a cure‬‬

‫•‬ ‫‪Get the patient’s informed consent for all procedures (at least all surgical‬‬
‫)‪procedures‬‬
‫•‬ ‫‪When in doubt ask for consultations (consultation protects the patient and‬‬
‫‪protects yourself).‬‬
‫•‬ ‫‪Do not criticize another practitioner‬‬
‫•‬ ‫‪Do not fail to provide maximum care in the selection of assistants‬‬
‫•‬ ‫‪Do not base an important diagnosis on a clinical impression, use available‬‬
‫‪diagnostic aids‬‬
‫•‬ ‫‪Keep up with the advances of medicine. However, do not be too advanced‬‬
‫‪and do not experiment on patients‬‬
‫•‬ ‫‪Do not, in absence of emergency, perform any surgery without an informed‬‬
‫‪consent‬‬
‫•‬ ‫‪Good housekeeping: keep good medical records, full and accurate. Keep‬‬
‫‪results of all tests performed on the patient.‬‬
‫•‬ ‫‪Records are “witnesses whose memories never die”. In the defense‬‬
‫‪of malpractice suits, bad records hurt as much as good records‬‬
‫‪help.‬‬

‫مسئولية الطبيب الجنائية عن وفاة المريض‬

‫تنص المادة ‪ 238‬من قانون العقوبات المصري علي ((من تسبب خطأ في موت شخص آخر بأن كان‬
‫ذلك ناشئا عن إهماله أو رعونته أو عدم احترازه أو عدم مراعاته للقوانين والقرارات واللوائح واألنظمة‬
‫يعاقب بالحبس مدة ال تقل عن ستة أشهر وبغرامة ال تجاوز مائتي جنيه أو بإحدى هاتين العقوبتين‪.‬‬
‫وتكون العقوبة الحبس مدة ال تقل عن سنة وال تزيد علي خمس سنين وغرامة ال تقل عن مائة جنيه‬
‫وال تجاوز خمسمائة جنيه أو بإحدى هاتين العقوبتين إذا وقعت الجريمة نتيجة إخالل الجاني إخالال‬
‫جسيما بما تفرضه عليه أصول وظيفته أو مهنته أو حرفته أو كان متعاطيا مسكرا أو مخدرا عند ارتكابه‬
‫الخطأ الذي نجم عنه الحادث أو نكل وقت الحادث عن مساعدة من وقعت عليه الجريمة أو عن طلب‬
‫المساعدة له مع تمكنه من ذلك‪.‬‬
‫وتكون العقوبة الحبس مدة ال تقل عن سنة وال تزيد علي سبع سنين إذا نشأ عن الفعل وفاة أكثر من‬
‫ثالثة أشخاص فإذا توافر ظرف آخر من الظروف الواردة في الفقرة السابقة كانت العقوبة بالحبس مدة ال‬
‫تقل عن سنة وال تزيد علي عشر سنين‪)).‬‬
‫تتكون جريمة القتل الخطأ أثناء ممارسة الطبيب لمهنته من الركن المادي (يشمل الخطأ والضرر‬
‫وعالقة السببية) والركن المعنوي (يشمل صورة أو أكثر من صور الخطأ مثل اإلهمال أو الرعونة أو‬
‫عدم االحتراز أو مخالفة اللوائح)‬

‫‪16‬‬
 ‫‪ ‬طبقا للمادة ‪ 264‬من قانون اإلجراءات التي تنص علي أنه ((إذا رفع من ناله ضرر من‬
‫الجريمة دعواه بطلب التعويض إلي المحكمة المدنية ثم رفعت الدعوى الجنائية جاز له إذا‬
‫ترك دعواه أمام المحكمة المدنية أن يرفعها إلي المحكمة الجنائية مع الدعوى الجنائية))‬
‫‪ ‬أما بخصوص سقوط الدعوى المدنية بالتقادم فإن المادة ‪ 172‬من القانون المدني تنص‬
‫علي أنه ((تسقط بالتقادم دعوى التعويض الناشئة عن العمل غير المشروع بانقضاء ثالث‬
‫سنوات من اليوم الذي علم فيه المضرور بحدوث الضرر وبالشخص المسئول عنه وتسقط‬
‫هذه الدعوى في كل حال بانقضاء خمس عشرة سنة من يوم وقوع العمل غير المشروع))‪.‬‬
‫التعويض المادي‬
‫إذا استطاع المريض أن يثبت أنه يعاني من ضرر ناتج عن خطأ الطبيب فإنه يستحق تعويض مادي‪.‬‬
‫الهدف من التعويض المادي هو مساعدة المريض الستعادة حالته قبل الخطأ الطبي ‪ ,‬بمعني محاولة‬
‫تعويضه عن فقده العائد المادي الذي قد يكون فقده بسبب اإلعاقة التي ألمت به نتيجة خطأ الطبيب‪ .‬في‬
‫حالة وفاة المريض فإن أهل المريض يستحقون هذا التعويض لتعويضهم عن فقدانهم للعائل‪ .‬األضرار‬
‫يمكن أن تكون‪:‬ـ‬
‫)‪(1‬األضرار العامة مثل األلم والمعاناة من التشوه وفقدان التمتع الطبيعي بالحياة‪.‬‬
‫)‪(2‬األضرار الخاصة مثل زيادة األنفاق الطبي نتيجة تعدد التداخل الجراحي وزيادة فترة بقائه في‬
‫المستشفي إلصالح الخطأ ‪ ،‬وتكلفة إعادة التأهيل وفقد الدخل الحالي والمستقبلي ‪ ،‬وهذه تشمل أيضا‬
‫مصاريف الجنازة للمتوفى‪.‬‬
‫)‪(3‬أضرار عقوبية أو تأديبية مثل الحكم بالتعويض نتيجة الضرر المتعمد من الطبيب أو اإلهمال‬
‫الجسيم أو الخداع وذلك لمعاقبة الطبيب المخطئ‪.‬‬
‫كذلك يمكن تقسيم األضرار إلي‪:‬ـ‬
‫)‪(1‬ضرر مباشر (اقتصادي) مثل فقد الدخل ‪ ,‬واألنفاق الطبي ‪ ,‬وعالج المضاعفات والتأهيل‪.‬‬
‫)‪(2‬ضرر غير مباشر (غير اقتصادي) يشمل األلم ‪ ،‬واالكتئاب العاطفي ‪ ،‬وفقدان التنعم بالحياة‬
‫الزوجية‪.‬‬

‫‪Laws that regulate medical practice in Egypt had been‬‬

‫‪settled and progressed over years:‬‬
‫‪The first legal text was declared in 1948, then modified in 1949 and settled as‬‬
‫‪Law No. 415 of 1954. Some of its subjects were recently modified and‬‬
‫‪introduced in September 2019.‬‬
‫‪Law No. 45 year 1969 that specifies registration requirements at the medical‬‬
‫‪syndicate and the disciplinary system for physicians.‬‬
‫‪Law No. 51 year 1981 that regulates healthcare facilities.‬‬

‫‪17‬‬
Public health laws and instructions of ministry of health about trading of
pharmaceutical substances and preparations affecting general health and
psychological state.

5) The Code of Professional Ethics issued by Minister of Health and Population

Decree No. 238 of 2003, which includes:
Physician’s Oath
Duties of the physician towards the community, the profession, the patients,
and the colleagues.
Medical interventions of a special nature; Gender correction, Assisted
fertilization and Organ and tissues donation and transplantation.
Conduct of experiments and medical research on humans.
The medical liability involves two main types: Civil (Tort or contract) and
Criminal
Most claims in respect to medical injury are brought in Tort.
Personal injury lawsuits are usually based on the tort law so that a lawsuit is a
request for compensation for damages that have occurred.
Legal procedures to be followed in a malpractice
lawsuit
Patients' reaction to disappointed expectations is usually translated into a
malpractice lawsuit raised by their lawyers, but there are other different
methods for the patients to announce their dissatisfaction with the outcome of
their healthcare, such as complaints in specialized medical boards (for
example, committee of medical ethics in Egyptian medical syndicate).
The aggrieved party (victims) of medical malpractice have the right to raise a
litigation against whoever caused him/her a harm. This is allowed only for the
victim or his/her heirs.
The litigation can be either civil (for compensation, before civil court) or
criminal (in front of criminal justice)
In Egypt, when a case of medical malpractice is raised, a series of legal
procedures will take place:
First, the patient or a family member shall present a claim to the nearby police
department.
Second, the legal authorities will investigate the case.
Then, a forensic expert will be assigned, a forensic report of living or an
autopsy report will be issued.
Finally, liability or no liability will be concluded
18
 Basis of Evaluation of Medical Malpractice Claims
To prevail in a medical negligence suit, the plaintiff must prove by the greater
weight of the evidence all four elements of the cause of action:
A duty to the patient
A breach of that duty or standard of care
A compensable injury to plaintiff
Proximate causation of the breach of duty to the injury or damages
In most cases, the standard of care and any alleged breach of that standard of
care and proximate causation must be proved through the introduction of
expert testimony rather than merely evidence-based guidelines.
The plaintiff often uses documentary evidence such as medical records,
medical literature, and demonstrative aids such as models, charts, medical
chronologies, and diagrams.
A party accused of medical negligence defends itself either by showing that
one of the elements is missing or by establishing an affirmative defense.
An affirmative defense is a legal argument in which the defendant admits the
existence of all required elements, yet his or her actions should be excused.

8- How to write a medicolegal report

https://studio.youtube.com/video/tUWohD58-HA/edit

9 ,10ETHICAL ASPECTS IN TERMINALLY ILL PATIENT, DNR ,

disclosure

• Introduction

− Terminal illness: is a disease that will result in the death of the patient
regardless of any treatment intervention.
− Often, a patient is considered terminally ill when their estimated life
expectancy is six months or less, under the assumption that the disease
will run its normal course.
− Similarly, a patient with a slowly progressing disease, such as AIDS, may
not be considered terminally ill because the best estimates of longevity
were greater than six months. However, this does not guarantee that the
patient will not die unexpectedly early. In general, physicians slightly

19
 overestimate the survival time of terminally ill cancer patients, so that, for
example, a person who is expected to live for about six weeks would likely
die around four weeks.

• Stages of Terminal Illnesses

Five stages of Dying in Terminally Ill Patients (Kubler-Ross)
1. Denial and Isolation: State of shock, denial that it is your death. 'No, it
can't be me' is often asked, usually temporary, but you may shop
around for other opinions. Deep feeling of isolation.
2. Anger: Feelings of anger, rage, envy, and resentment. 'Why me?' is
asked. Anger is displaced in all directions, the hospital team, especially
nurses, often take the brunt.
3. Bargaining: Negotiate openly with hospital staff and secretly with your
God to postpone death for a promise of good behavior.
4. Depression: When you can no longer deny the illness. You can have no
more surgery/medication. You grow weaker and become depressed.
5. Acceptance: You find a sort of peace, a peace which is largely a
function of weakness and a diminishing interest in the world. Spiritual
peace and contentment.

• Etiology of Terminal Illnesses

There are many causes of terminal Diseases such as the Idiopathic

Pulmonary Fibrosis, Lung Cancer, Leukemia, Pancreatic Cancer; Liver
Cancer also includes Hepatitis B, AIDS, Alzheimer, and acute heart
diseases.

• Management of terminally ill patient:

1-Treatment: Some terminally ill patients stop all debilitating treatments to

reduce unwanted side effects. Others continue aggressive treatment in the hope
of an unexpected success. Still others reject conventional medical treatment
and pursue unproven treatments such as radical dietary modifications. Patients'
choices about different treatments may change over time.

2- Palliative care: Patients with a terminal illness are often placed in palliative
care, which provides pain relief and other measures designed to make the end
stages of terminal illness as comfortable as possible. Palliative care facilities do
not usually engage in life saving measures such as resuscitating patients or
20
emotionally and physically draining treatments like chemotherapy. The staff of
palliative care facilities try to ensure that their patients have dignified,
comfortable deaths without fear and pain.

3- Psychological care: Being informed that your medical condition is terminal

can be a very intense experience. Most doctors are aware of this and exercise
care when informing patients and family members. In addition, grief counseling
is highly recommended both for the patient and his or her family. A terminal
illness gives everyone involved a period to come to terms with death, which can
be very valuable. Terminal patients need the support and love of their friends
and family members. Giving comfort for the dying is one of the most important
compassionate acts that anyone can perform.

Ethics in dealing with terminally ill patients:

WMA Declaration of Venice on Terminal Illness

(Adopted by the 35th World Medical Assembly, Venice, Italy, October 1983
and revised by the 57th WMA General Assembly, , South Africa, October
(2006)

• When addressing the ethical issues associated with end-of-life care,

questions regarding euthanasia and physician-assisted suicide inevitably
arise. The World Medical Association condemns as unethical both
euthanasia and physician-assisted suicide. WMA policy on these issues
is fully applicable in the context of this Statement on Terminal Illness.

• PRINCIPLES
1. The duty of physicians is to heal, where possible, to relieve suffering and to
protect the best interests of their patients. There shall be no exception to
this principle even in the case of incurable disease.
2. In the care of terminal patients, the primary responsibilities of the physician
are to assist the patient in maintaining an optimal quality of life through
controlling symptoms and addressing psychosocial needs, and to enable the
patient to die with dignity and in comfort. Physicians should inform
patients of the availability, benefits, and other potential effects of palliative
care.

21
3. The patient's right to autonomy in decision-making must be respected about
decisions in the terminal phase of life. This includes the right to refuse
treatment and to request palliative measures to relieve suffering, but which
may have the additional effect of accelerating the dying process. However,
physicians are ethically prohibited from actively assisting patients in
suicide. This includes administering any treatments whose palliative
benefits, in the opinion of the physician; do not justify the additional
effects.
4. The physician must not employ any means that would provide no benefit
for the patient.
5. Physicians should recognize the right of patients to develop written advance
directives that describe their wishes regarding care if they are unable to
communicate and that designate a substitute decision-maker to make
decisions that are not expressed in the advance directive. In particular,
physicians should discuss the patient's wishes regarding the approach to
life-sustaining INTERVENTIONS as well as palliative measures that
might have the additional effect of accelerating death. Whenever possible,
the patient's substitute decision-maker should be included in these
conversations.
6. Physicians should endeavor to understand and address the psychosocial
needs of their patients, especially as they relate to patients' physical
symptoms. Physicians should try to ensure that psychological and spiritual
resources are available to patients and their families to help them deal with
the anxiety, fear and grief associated with terminal illness.
7. The clinical management of pain in terminal patients is of paramount
importance in terms of alleviating suffering. Physicians and National
Medical Associations should promote the dissemination and sharing of
information regarding pain management to ensure that all physicians
involved in terminal care have access to best practice guidelines and the
most current treatments and methods available. Physicians should be able

22
 to pursue clinically appropriate aggressive pain management without undue
fear of regulatory or legal repercussions.
8. National Medical Associations should encourage governments and research
institutions to INVEST additional resources in developing treatments to
improve end-of-life care. Medical school curricula should include the
teaching of palliative medical care. Where it does not exist, the
establishment of palliative medicine as a medical specialty should be
considered.
9. National Medical Associations should advocate for the development of
networks among institutions and organizations involved in palliative care to
foster communication and collaboration
10.Physicians may, when the patient cannot reverse the final process of
cessation of vital functions, apply such artificial means as are necessary to
keep organs active for transplantation if they act in accordance with the
ethical guidelines established in the World Medical Association Declaration
of Sydney on the Determination of Death and the Recovery of Organs.

EUTHANASIA AND THE TERMINAL PATIENT

• Definition :Euthanasia is an act where a third party, usually implied to

be a physician, terminates the life of a person—either passively or
actively
− The modern concept of euthanasia came into being in the 20th century
after the invention of life-extending technologies.
− However, the use of modern medical technologies can also keep patients
alive who are
1. living in a situation that they consider to be worse than death,
2. living in a coma
3. Living In a persistent vegetative state (PVS).
 PVS is “complete unawareness of the self and the environment,
accompanied by sleep-wake cycles, with either complete or partial
preservation of hypothalamic and brain stem autonomic functions.
− There is a need to determine the boundaries of prolonging life versus
the avoidance of unjustifiable and unwanted suffering. Decisions
concerning dying patients should be based solely on the medical

23
 condition of the patient, his or her wishes and the degree of their
suffering.
− Commission of acts that hasten death is prohibited, whereas
commission of life-sustaining therapies is permissible. Sanctity of life
overrides autonomy by prohibiting any action that intentionally and
actively shortens life (i.e., active euthanasia or physician-assisted
suicide); the patient previously requested even if these acts. On the
other hands the principle of autonomy overrides sanctity of life by
permitting the withholding of treatments if this was the wish of the
patient.
− Many laws around the world distinguish between two types of
treatments:
1. The first is continuous life-sustaining therapies (cardiac
pacemaker or respirator), which cannot be stopped because this
is viewed as an act that shortens life.
2. The second is intermittent life-sustaining therapies (dialysis,
chemotherapy, radiotherapy), which can be stopped if they are
directly related to the dying process. Terminating intermittent or
cyclic life-sustaining treatments is viewed as omitting the first or
next treatment rather than committing an act of withdrawal.
These decisions are founded in some legal systems where there
is no obligation to actively prolong pain and suffering of a dying
patient, but any action that intentionally and actively shortens
life is prohibited.

• Definitions
a) Suicide: a voluntary act by which a person intends and causes his or her
own death
b) Assisting a suicide implies that one offers aid to a person desirous of
committing suicide. Usually, the aid is a physical action, but it could
simply involve verbal persuasion
c) Physician-assisted suicide occurs when the action of a physician, at the
request of a patient, directly causes that person’s death
- This is usually performed to end physical or psychological suffering
- Such acts, although given a different name today by its proponents, are
all acts of EUTHANASIA, and receive the same moral treatment
d) Euthanasia: literally, “a good death” an action or omission which of
itself or by intention, causes death.

• Types of Euthanasia
24
 I. Active: the cause of death is directly induced by one’s own self, or some
other agent
II. Passive: the cause of death is not resisted, but there is a moral obligation
to resist
➢ Euthanasia has been practiced
− Voluntarily (wished for by the patient )
− Involuntarily (without the consent)
− Involuntary euthanasia: Euthanasia conducted against the will of
the patient
o Considering the argument , some agree on that act to :
1- Relieve pain and suffering
2- Rational beings should be able to PLAN when death happens; it is fear
from death or lose our dignity at time of death.
3- Euthanasia and Assisted Suicide should be treatment options that
constitute a CONTINUUM OF CARE
• Conclusions
1. Terminating life at the request of an individual is not immoral because it
is the individual’s decision to make. ( In some countries not in Egypt
and other many countries )
2. Terminating life may be justified in some circumstances if, and only if,
there is compelling evidence that to continue living would be more
harmful to the person than dying.
3. Terminating life is unethical today because there are not enough
protections that would allow for a just and fair practice of euthanasia.
4. Terminating life is always unethical because it violates the moral belief
that life should never be taken intentionally or the basic human right not
to be killed.

I. Artificial nutrition and hydration

In terminal patient

 Decisions about nutrition and hydration are among the most emotionally
and ethically challenging issues in end-of-life care.
 The main dilemma concerns the nature and social meaning attached to
providing people with food and water. Clinically, the American Medical
Association does not distinguish between nutrition and hydration and
other life sustaining treatments.

25
 Others argue that nutrition and hydration treatments are palliative care
that fulfill a basic human need and should not be denied to patients at the
end of life.
 Usually, laws prohibit the withholding of food and fluid from a currently
incompetent dying patient for the following reasons:
A. The value of life in such situations overrides the previous autonomous
wishes of the patient which are now unknown,
B. Food and fluid are regarded as a basic need of any living being, rather
than a form of treatment, socially and emotionally there is a fundamental
difference between food and fluid and other life-sustaining treatments.
C. Dying of starvation and dehydration is regarded in Moslem philosophy
as an indignity to life, withholding food and fluid is unrelated to the dying
process and hence is regarded as a form of euthanasia.
 When the patient approaches the final days of his or her life, defined by
some laws as less than two weeks, it is permissible to withhold food and
even fluids if such was the clear wish of the patient before becoming
incompetent. At this final stage of life, food and even fluids may cause
suffering and complications.
 Nutrition and hydration treatments may burden (or provide only minimal
benefit to) some dying patients. As a person’s physical body shuts down
before death, food and water are no longer processed in the same way as
a healthy body. Instead of hydrating the patient, water can cause bloating
and swelling, and nutrition may cause intestinal problems that can add to
a patient’s discomfort.

II. Resuscitation in terminal patient

− Resuscitation treatments and technologies restore and maintain breathing

and heart function. Cardiopulmonary resuscitation (CPR) doubles a
person’s chance of survival from sudden cardiac arrest, which is the
leading cause of death in adults.
− However, while CPR is valuable for treating heart attacks and trauma,
using CPR with some dying patients may be inappropriate and cause
complications. For some terminally ill patients, CPR is an unwanted
procedure. However, the universal use of CPR makes it difficult for health
professionals to not use CPR with dying patients. Patients who do not
wish to receive CPR may seek a do-not-resuscitate (DNR) order from
their doctor. Family members of patients who cannot speak for themselves
may also seek a DNR order on their relative’s behalf.
26
 − DNR orders might be issued for the following patients:
• Patients for whom CPR may not provide benefit.
• Patients for whom surviving CPR would result in permanent damage,
unconsciousness, and poor quality of life.
• Patients who have poor quality of life before CPR is ever needed and
wish to forgo CPR should breathing or heartbeat cease.

III. Breaking bad news

• Definition:
It is “any news that adversely and seriously affects an individual’s view of
his or her future.”
• Protocols:
In the following paragraphs, the most important protocols in “Giving Bad
News” have been demonstrated
I. SPIKES protocol: suggested by Buckman in 1992, is an organized and
effective procedure for communicating bad news
II. ABCDE protocol:
This protocol delivered by Rabow and McPhee in 2000
A – Advance preparation; B – Build a therapeutic
Environment- relationship; C – Communicate well.
D – Deal with patient and family reactions; E – Encourage and validate
emotion

III. B R E A K S protocol: B – o b t a i n Background; R – establish

Rapport; E – Explore patients’ knowledge; A –
Announce a warning; K- Kindling; S – Summarize

IV. PEWTER Model:

- It is specifically developed for emergency department personnel, which
despite providing emergency care; may encounter delivering news of death,
violent crimes, school shootings, natural disasters, or terrorist attacks
The S-P-I-K-E-S protocol

It is a strategy and not a script. It highlights the most important features of a

bad news interview and suggests methods of assessing the situation as it
evolves and responding constructively to what happens.
o Setting (S): Patient meeting with the doctor
- Privacy: private place like interview rooms, office with locked door or around
patient bed

27
- Involve significant others: Prescence of other family members or friends
according to patient will
- Sit down: doctor and patient sitting comfortably without barriers or doctor
sitting in nearby chair if patient in bed
- Look attentive and calm: doctor sit calm quiet, keeping eye contact with
patient
- Listening mode: silence and good patient listening with no interruptions
- Availability: during this meeting no phone or mobile calls allowed, and extra
time give for such meetings than routine ones.
o Perception (P):
- This step is the centre of the “before you tell, ask” principle.
Before you break bad news to your patients, you should glean a fairly
accurate picture of their perception of the medical situation—in particular, how
they view the seriousness of the condition.
If a patient is in denial, it is often helpful not to confront the denial at the
first interview

o Invitation (I):
Although most patients want to know all the details about their medical
situation, you can’t always assume that this is the case. Obtaining overt
permission respects, the patients’ right to know (or not to know)
o Knowledge (K):
Before you break bad news, give your patient a warning that bad news is
coming
Use the same language your patient uses.
Avoid technical, scientific language.
Give the information in small chunks and clarify that the patient
understands what you have said at the end of each chunk
Tailor the rate at which you provide information to your patient
o Empathy (E):
The technique that is most useful for this task is called “the empathic
response,” and it comprises three straightforward steps
1. Listen for and identify the emotion (or mixture of emotions).
2. Identify the cause or source of the emotion,
3. Show your patient that you have made the connection between the above
two steps—that is, that you have identified the emotion and its origin
- Validation: Once you have shown empathy an identified and acknowledged
your patient’s emotion, you are ready to validate or normalize his or her
feelings
o Strategy and summary (S)
28
 One of the best ways to prepare a patient for participation in treatment
decisions is to ensure that he or she understands the information you have
provided.
Before the discussion ends, summarize the information in your
discussion and give your patient an opportunity to voice any major concerns or
question
You and your patient should go away from the interview with a clear
plan of the next steps that need to be taken and the roles you both will play in
taking those steps.

• Ethical views in BBN:

There are three basic models for breaking bad news: nondisclosure, full
disclosure, and individual disclosure.
Model 1: Nondisclosure
Three basic assumptions underlie this model that it is appropriate for the doctor
to decide what is best for the patient without reference to him/her; those
patients do not want to know bad news; and those patients need to be protected
from bad news
Disadvantages:
It is a violation of the right of humans for information about themselves
It denies patients and their relatives the opportunity to work through
their grief and to work through issues relating to their loss together
It undermines the doctor-patient relationship, since honest
communication and mutual trust are impossible

Model 2: Full Disclosure

It involves giving full information to every patient as soon as it is

known.
The patient has a right to full information, that all patients want to know
bad news about themselves, and that it is appropriate for patients to make their
own decision, since they must live with the consequences.
It is often a paternalistic approach, since it takes no account of the
patient's desires about the timing and amount of information disclosed

Model 3: Individualized Disclosure

29
 This model involves tailoring of the amount and rate of disclosure to the
desires of the individual patient through negotiation between the doctor and the
patient.
The approach is based on the assumptions that people are different in the
amount of information they want and in their methods of coping, that time is
needed to absorb and adjust to bad news, and that a partnership relationship
between the doctor and patient is in the best interests of the patient
The problem with such an approach is determining what information
individual patients would like to receive. Without a clear methodology to
determine a patients' need, this approach could be actualized as giving the
patient the information the provider believes he or she could handle
IV. Mechanical ventilation in terminal patient

Mechanical ventilation is the most common life support treatment

withdrawn in anticipation of death. Mechanical ventilation is such a common
treatment at the end of life, that some care providers may regard mechanical
ventilation as “death-delaying” rather than “life-prolonging.” Some patients
become dependent on the ventilator or die while being treated. Therefore, for
some patient’s ventilation is considered a non-beneficial treatment that
negatively affects patients by delaying natural death or requiring families and
physicians to decide to withdraw treatment
Approximately 75% of dying patients experience breathlessness, or
dyspnoea, as they die. The feeling can be uncomfortable to patients and
frightening for loved ones to witness. Ventilation may be given to these
patients, not to extend life but to help with breathlessness. Ventilation may
help them sleep better, experience less anxiety, and eat and drink more
comfortably
V. Pain management in terminal patient
Many of the ethical dilemmas surrounding hospice and palliative care
stem from the use of pain-relieving drugs in terminally ill patients.
Questions about the importance of treating symptoms, the value of
individual autonomy, and fears of addiction to narcotics all play a role in how
people view pain management
Morphine is the most used narcotic for treating pain and other symptoms
experienced by seriously ill patients. Morphine is particularly good at relieving
the two most common symptoms experienced by dying patients – pain and
shortness of breath the fear that respiratory depression, a side effect of
morphine, will be severe and result in death may cause a physician to under-
prescribe the drug, even to terminally ill patients suffering intense pain.

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 Fears of overdosing and hastening death in terminally ill patients may be
unfounded, as recent research has not found narcotics to shorten life or depress
respiration in dying patients even when higher doses of narcotics are given

VI. Kidney dialysis in terminal patient

The ethical challenges for dialysis withdrawal arise when stopping
dialysis becomes an option patients want to consider
Withdrawal should occur when patients are either:
capable of making decisions and decide to forgo dialysis
a written health care directive expresses a desire to discontinue dialysis
a health care agent considers discontinuation of dialysis the best course
of action
When the physician decides dialysis no longer beneficial.
Shared decision making between the patient and physician must occur,
and if the patient lacks decision-making capacity, the health care agent should
be involved.
Physicians should provide patients with all available information –
including available treatment options, consequences of dialysis withdrawal,
and other end of life care options – like hospice and palliative care.

DNR
Do-not-resuscitate order
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A do-not-resuscitate order, or DNR order, is a medical order written by a
doctor. It instructs health care providers not to do cardiopulmonary
resuscitation (CPR) if a patient's breathing stops or if the patient's heart stops
beating.

What is a DNR?
Ideally, a DNR order is created, or set up, before an emergency occurs. A DNR
order allows you to choose whether you want CPR in an emergency. It is
specific about CPR. It does not have instructions for other treatments, such as
pain medicine, other medicines, or nutrition.

The doctor writes the order only after talking about it with the patient (if
possible), the proxy, or the patient's family.

What is Resuscitation?
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CPR is the treatment you receive when your blood flow or breathing stops. It
may involve:

Simple efforts such as mouth-to-mouth breathing and pressing on the chest

Electric shock to restart the heart
Breathing tubes to open the airway
Medicines
Making the Decision
If you are near the end of your life or have an illness that will not improve, you
can choose whether you want CPR to be done.

If you do want to receive CPR, you do not have to do anything.

If you do not want CPR, talk with your doctor about a DNR order.
These can be hard choices for you and those who are close to you. There is no
hard and fast rule about what you may choose.

Think about the issue while you are still able to decide for yourself.

Learn more about your medical condition and what to expect in the future.
Talk to your doctor about the pros and cons of CPR.
A DNR order may be a part of a hospice care plan. The focus of this care is not
to prolong life, but to treat symptoms of pain or shortness of breath, and to
maintain comfort.

If you have a DNR order, you always have the right to change your mind and
request CPR.

How is a DNR Order Created?

If you decide you want a DNR order, tell your doctor and health care team
what you want. Your doctor must follow your wishes, or:

Your doctor may transfer your care to a doctor who will carry out your wishes.
If you are a patient in a hospital or nursing home, your doctor must agree to
settle any disputes so that your wishes are followed.
The doctor can fill out the form for the DNR order.

The doctor writes the DNR order in your medical record if you are in the
hospital.
Your doctor can tell you how to get a wallet card, bracelet, or other DNR
documents to have at home or in non-hospital settings.
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 Standard forms may be available from your state's Department of Health.
Make sure to:

Include your wishes in an advance care directive (living will)

Inform your health care agent (also called health care proxy) and family of
your decision
If you do change your mind, talk with your doctor or health care team right
away. Also tell your family and caregivers about your decision. Destroy any
documents you have that include the DNR order.

When You are Unable to Make the Decision

Due to illness or injury, you may not be able to state your wishes about CPR.
In this case:

If your doctor has already written a DNR order at your request, your family
may not override it.
You may have named someone to speak for you, such as a health care agent. If
so, this person or a legal guardian can agree to a DNR order for you.
If you have not named someone to speak for you, under some circumstances, a
family member can agree to a DNR order for you, but only when you are not
able to make your own medical decisions.

Alternative Names
No code; End-of-life; Do not resuscitate; Do not resuscitate order; DNR; DNR
order; Advance care directive - DNR; Health care agent - DNR; Health care
proxy - DNR; End-of-life - DNR; Living will - DNR
11- organ transplantation
ETHICAL ISSUES IN ORGAN TRANSPLANTATION

• Definition
− Organ transplantation is the surgical replacement o malfunctioning organ by
another human organ. Kidney, heart, pancreas, liver, lung have already been
successfully transplanted, as well as organ parts tissues such as bones, cornea,
skin, or bone marrow.
− Even the transplantation of several organs at once has been ventured (so-called
multiorgan transplantation).
− More recently, and still rarely, extremities such as hand, arm, or foot, and even a
face were transplanted.

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− A graft is similar can be considered a form to a transplant. It is the process of
removing tissue from one part of a person’s body (or another person’s body) and
surgically re-implanting it to replace or compensate for damaged tissue (cornea,
bone marrow).

• Types of transplantation:

A. Autograft or Auto transplant : Organs and/or tissues are transplanted within the
same person's body (Skin graft in plastic surgery). There are no legal or ethical
limitations as regards Autograft.

B. Allografts: Organs and/or tissues are transplanted between two subjects of the
same species which can be either from a living person or dead (cadaveric
person).
The successful transplant depends on the more similarity (resemblance)
between the tissues' antigens of the donor and recipient. Rejection remains one
of the main causes of failure in organ transplantation because it is difficult to
find identical completely matching tissues. Organ transplantation offers a better
quality of life for the recipient.

o Blood transfusion is the commonest form of transplantation

Legal rules before Blood transfusion
• No risk harm to health of recipient( donor should be free from
transmissible disease)
• Do not harm donor’s health
• Voluntary Informed consent
• Keep donor's information confidential
• Payment is ethically unacceptable

C. xeno-grafts : which are living animal organs or tissue transplanted into humans

• Sources of organ donation :

1. Living organ donation

Organ donation by living donors presents a unique ethical dilemma, in is that

physicians must not risk the life of a healthy person to save or improve the life
of a patient.

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 Living people who wish to donate their organs can donate do it by in two
ways:
1. Donate one-half of a paired organ set (Kidney).
2. Donate a portion of an organ (A portion of the liver, a lobe of the lung).
Living donors are often a relative related to the patient, but that this is not
always the case. Donation may be
a) Directed donation: Family members or close friends frequently donate organs to
loved ones person
b) Non-directed donation: Some people donate their organs to a stranger.

Rules to be followed in Organ donation

a) There should be no harm to donor.
b) The operation should be done in a respectable well-prepared hospital
c) Free and Voluntary informed consent should be obtained from a competent
adult.
d) Some think children and the mentally disabled should never be living donors.
They are simply being used with a violation of their bodily integrity, risks to
their health and life, and no benefit to themselves. ( The sentence is not clear )

Living donor complications:

a) Health problems: Pain, discomfort, infection, bleeding, and potential future
health complications are all possible.
b) Psychological problems: family members may feel pressured or guilt to donate
when they have a sick family member
c) No donor advocate: While the patients have advocates, (transplant surgeon or
medical team ), donors do not have such an advocate and can be faced with a
complicated process with no one advice

2. Cadaveric organ donation

This type of donation deserves the support of by the medical profession,

of the law, and of people in general (regular or religious ) . The donation of
organs should, in all circumstances, respect the last will of the donor, or the
consent of the family present.
A person is considered dead once either the heart stops beating or brain
function ceases (called brain death). The use and possible use of cadavers
vegetative (brain-dead individuals maintained on life support) for transplants has
provoked ethical and legal debate. Various concerns include respect for the dead
and their wishes, respect the family's wishes and benefitting others.

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 • Commodification and organ trade: ‫التسليع و تجارة األعضاء‬
- The existence and distribution of organ transplantation procedures in developing
countries, while almost always beneficial to those receiving them, raise
many ethical concerns.
- Both the source and method of obtaining the organ to transplant are major ethical
issues to consider, as well as the notion of distributive justice.
- he World Health Organization argues that transplantations promote health, but the
notion of "transplantation tourism" has the potential to violate human rights or
exploit the poor, to have unintended health consequences, and to provide unequal
access to services, all of which ultimately may cause harm
- To meet legitimate ethical and regulatory concerns, any commercial scheme must
have built into it safeguards against wrongful exploitation and show concern for
the vulnerable, as well as considering considerations of justice and equity.

Brain death
Brain death is defined as the irreversible loss of function of the brain,
including the brain stem. The most common causes of brain death in adults are
traumatic brain injury and subarachnoid hemorrhage.
Preconditions necessary before considering the diagnosis of brain death:
1) The person must be in continuous deep uninterrupted coma.
2) The cause of the coma can be explained by extensive damage to the structure of
the brain, such as severe traumatic concussion, massive intracranial hemorrhage,
after intracranial surgery, a large intracranial tumor or obstructed blood supply
to the brain: confirmed by adequate diagnostic measures.
3) At least six hours have passed since the onset of coma.
4) There is absence of any attempt at spontaneous breathing.

The criteria of brain death include

• Deep coma with no response to painful or verbal stimuli
• Complete absence of all brain stem reflexes of the (breathing, coughing, gagging
and responses of the pupils of the eyes).

• An important test is that when if the ventilator is disconnected for several

minutes, there is no evidence of spontaneous breathing (during this test a
continuous supply of oxygen is delivered to the person’s lungs). Disconnecting
the ventilator causes levels of carbon dioxide (CO2) and acid to rise and, if the
brain were capable of functioning, this would make spontaneous breathing
occur.

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• Complete lack of blood flow to the brain by angiography.
• Flat EEG
The tests are repeated carried out twice to minimize any chance of error.
Two sets of tests should always be performed; these may be carried out by the
two practitioners separately or together. The tests are repeated to remove the risk
of observer error. The timing of the interval between the tests is a matter for
clinical judgment but the time should be adequate for the reassurance of all those
directly concerned. The interval between the tests will depend upon the primary
pathology, the clinical course of the disease and the progress of the patient.
Although death is not pronounced until the second test has been completed the
legal time of death is when the first test indicates brain stem death.

Rules to be followed
a) Because of a potential conflict of interest, the transplant team should be different
from the team providing care for the potential donor
b) No organs are removed until the donor's death has been declared assured by a
competent authority other than the recipient's physician or the transplant team.
c) No Payment for organs as most experts argues that buying and selling human
organs is unethical an immoral and disrespectful practice
d) Once a person dies; his or her organs may be donated if the person consented to
do so before they passed away (A person’s consent to donate their organs is
made while still living and appears on a driver’s license or in an advance
directive). If the deceased person’s organ donation wishes are unknown, the
hospital, physician, will approach a family member to obtain consent to remove
the organs.

12- Futility

MEDICAL FUTILITY
What is "medical futility"?
"Medical futility" refers to interventions that are unlikely to produce any
significant benefit for the patient. Two kinds of medical futility are often
distinguished:

1. Quantitative futility, where the likelihood that an intervention will

benefit the patient is exceedingly poor, and
2. Qualitative futility, where the quality of benefit an intervention will
produce is exceedingly poor.

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Both quantitative and qualitative futility refer to the prospect that a specific
treatment will benefit (not simply have a physiological effect) on the patient.
Futility does not apply to treatments globally, to a patient, or to a general
medical situation. Instead, it refers to a particular intervention at a particular
time, for a specific patient. For example, rather than stating, “It is futile to
continue to treat this patient,” one would state, “CPR would be medically futile
for this patient.”
What are the ethical obligations of physicians when a health care provider
judges an intervention is futile?
The goal of medicine is to help the sick. Physicians have no obligation to offer
treatments that do not benefit patients. Futile interventions may increase a
patient's pain and discomfort in the final days and weeks of life; give patients
and family false hope; delay palliative and comfort care; and expend finite
medical resources. However, determining which interventions are beneficial to
a patient can be difficult since the patient or surrogate might see an
intervention as beneficial while the physician does not. Physicians should
follow professional standards and should consider empirical studies and their
own clinical experience when making futility judgments. They should also
show sensitivity to patients and families in carrying out decisions to withhold
or withdraw futile interventions.
Although the ethical requirement to respect patient autonomy entitles a patient
to choose from among medically acceptable treatment options (or to reject all
options), it does not entitle patients to receive whatever treatments they ask for.
Instead, the obligations of physicians are limited to offering treatments that are
consistent with professional standards of care and that confer benefit to the
patient.
Who decides when a particular treatment is futile?
Generally, the term medical futility applies when, based on medical data and
professional experience, a treating health care provider determines that an
intervention is no longer beneficial. A Because health professionals may
reasonably disagree about when an intervention is futile, all members of the
health care team would ideally reach consensus. While physicians have the
ethical authority to withhold or withdraw medically futile interventions,
communicating with professional colleagues involved in a patient’s care, and
with patients and family, greatly improves the experience and outcome for all.
What if the patient or family requests an intervention that the health care
team considers futile?

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You have a duty as a physician to communicate openly with the patient or
family members about interventions that are being withheld or withdrawn and
to explain the rationale for such decisions. The aim of respectful
communication should be to elicit the patient’s goals, explain the goals of
treatment, and help patients and families understand how particular medical
interventions would help or hinder their goals and the goals of treatment. It is
important to approach such conversations with compassion. For example,
rather than saying to a patient or family, "there is nothing I can do for you," it
is important to emphasize that "everything possible will be done to ensure the
patient's comfort and dignity."
In some instances, it may be appropriate to continue temporarily to make a
futile intervention available to assist the patient or family in coming to terms
with the gravity of their situation and reaching closure. For example, a futile
intervention for a terminally ill patient may in some instances be continued
temporarily to allow time for a loved one arriving from another state to see the
patient for the last time. However, futile interventions should not be used for
the benefit of family members if this is likely to cause the patient substantial
suffering, or if the family’s interests are clearly at odds with those of the
patient.
If intractable conflict arises, a fair process for conflict resolution should occur.
Involvement of an ethics consultation service is desirable in such situations.
The 1999 Texas Advance Directives Act provides one model for designing a
fair process for conflict resolution.
What is the difference between futility and rationing?
Futility refers to the benefit of a particular intervention for a particular patient.
With futility, the central question is not, "How much money does this
treatment cost?" or "Who else might benefit from it?" but instead, "Does the
intervention have any reasonable prospect of helping this patient?"
What is the difference between a futile intervention and an experimental
intervention?
Making a judgment of futility requires solid empirical evidence documenting
the outcome of an intervention for different groups of patients. Futility
establishes the negative determination that the evidence shows no significant
likelihood of conferring a significant benefit. By contrast, treatments are
considered experimental when empirical evidence is lacking, and the effects of
an intervention are unknown.
Is an intervention more likely to be futile if a patient is elderly?

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Futility has no necessary correlation with a patient’s age. What determines
whether a treatment is futile is whether the treatment benefits the patient. In
cases where evidence clearly shows that older patients have poorer outcomes
than younger patients, age may be a reliable indicator of patient benefit, but it
is benefit, not age, that supports a judgment of medical futility. For patients of
all ages, health care professionals should advocate for medically beneficial
care, and refrain from treatments that do not help the patient.
Why is medical futility controversial?
While medical futility is a well-established basis for withdrawing and
withholding treatment, it has also been the source of ongoing debate. One
source of controversy centers on the exact definition of medical futility, which
continues to be debated in the scholarly literature. Second, an appeal to
medical futility is sometimes understood as giving unilateral decision-making
authority to physicians at the bedside. Proponents of medical futility reject this
interpretation and argue that properly understood futility should reflect a
professional consensus, which ultimately is accepted by the wider society that
physicians serve. Third, in the clinical setting, an appeal to “futility” can
sometimes function as a conversation stopper. Thus, some clinicians find that
even when the concept applies, the language of “futility” is best avoided in
discussions with patients and families. Likewise, some professionals have
dispensed with the term “medical futility” and replaced it with other language,
such as “medically inappropriate.” Finally, an appeal to medical futility can
create the false impression that medical decisions are value-neutral and based
solely on the physician’s scientific expertise. Yet clearly this is not the case.
The physician’s goal of helping the sick is itself a value stance, and all medical
decision making incorporates values.
13- Patient safety
Patients safety could be evaluated either in practice or research

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Patient and medical practice
According to the non-maleficence principle of medical ethics, ensuring
patients’ safety and preventing any injury or damage to them is a major priority
for healthcare providers.
Every physician must assume the duty of preventing all harm. Harm from
errors, system flaws, accidents, complications, and known risks are all
consequences that must be avoided wherever possible.

Magnitude of the problem

WHO estimates that tens of millions of patients worldwide suffer disabling

injuries or death every year due to unsafe medical practices and care? Nearly
one in ten patients is harmed due to preventable causes while receiving health
care.

Ethical issues in practice

A- informed consent

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Who can give consent?
The person himself ( sane , conscious , over 18 ) .
An agent appointed by the patient under an enduring power of attorney
(medical treatment)
A person appointed by legal authority ( legal guardian ) .
A guardian for a minor
The patient’s spouse .
The patient’s nearest relative over the age of 18
The only time consent is not needed is where:
There is a medical emergency ( according to the country laws )
This means treatment is needed to prevent death, serious damage to the
patient's health, or suffering from significant pain or distress.

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b- Documentation:
It is important to document the process of consent taking:
It should be dated and signed by the patient or guardian, the doctor, and an
independent witness. Assisting nurse preferably should not be a witness.
It should be prepared in duplicate, and a copy handed over to the patient.
original form should be preserved, like all other medical records, as a legal
record that the patient agreed to the treatment.
c-Refusal of treatment
The patient maintains the right to refuse any medical procedure regardless of
the reason. Some of these reasons may include religious beliefs, concern
regarding risks of procedure or skepticism regarding possible success of the
procedure. An exception to the general right of patients to refuse medical care
may exist when the best interest of a child of theirs would dictate there is no
other appropriate adult to care for that minor child.
In practice, Ethical concerns related to patient safety can be classified into four
main categories:
1.The imperative to implement and follow safe practices
2. Responding to adverse events
3. Responding to the injured patient

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4. Taking responsibility for problem doctors
Ethics in Research
Patient safety research is often included under the broader category of quality
improvement, and more generally of health services research.

A- Components of Informed Consent of research

Must Include the Following Information:
It is a research
Why being research done?
What researchers want to accomplish?
What will be done and for how long?
Risks & benefits of trial?
Other treatments available?
Can withdraw from trial whenever desire?
Compensation for unexpected injuries?
• A statement describing the extent , if any , to which confidentiality of
records identifying the subject will be maintained

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 • An explanation of whom to contact for answers to questions about the
research and research subject’s rights , and whom to contact in the event
of research-related injury to the subject
• A statement that participation is voluntary , refusal to participate will
involve no penalty or loss of benefits to which the subject is otherwise
entitled , and the subject may discontinue participation at any time
without penalty or loss of benefits , to which the subject is otherwise
entitled
• A statement about treatment and compensation if something went wrong
during research
B- Confidentiality
Staff involved in the conduct of patient safety research and patient safety
activities should be aware of the principles and methods related to preserving
privacy and confidentiality.
C-Duty to report
Researchers observing clinical encounters have a duty to intervene to protect
these patients if all the following are present and the research staff observing
these events have sufficient expertise and experience to interpret these
situations appropriately:
• they are highly suspicious that an error is imminent.
• they believe it is highly likely that the error will result in direct, severe,
or irreversible harm.
• their immediate action or intervention will prevent or reverse some of
the negative effects of the error; Where sufficient expertise and
experience to interpret the situation is not present, staff should seek
advice from more experienced professionals.
E- Withholding information
Patient safety researchers who propose to withhold information from potential
research participants as part of their research must do all the following:
• Demonstrate to a research ethics committee that no other research
method will suffice.
• Persuasively argue that significant advances could result from the
research either for the local setting or more broadly.
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 • Consider whether asking participants to consent to participate, without
disclosing the nature or precise timing of the intervention, is reasonable.
• Ensure that withholding information itself will not cause a study to
involve greater than minimal risk.
Ethics committee
In those cases where a research ethics committee approves an activity where
information has been withheld from the participants, the committee must also:
Ensure that nothing has been withheld that, if divulged, would cause a
reasonable person to refuse to participate.
Determine if debriefing of those who participated is possible or appropriate.
Ensure that a general disclosure of the type of research that is proposed is in
place, if possible.
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