MUDr. Ľubomíra Romanová, PhD.: Withdraw / Withhold - Ukončenie/ nezahájenie plnej liečby | Medicínske právo
              

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MUDr. Ľubomíra Romanová, PhD.: Withdraw / Withhold - Ukončenie/ nezahájenie plnej liečby


 | 26.3.2012 | komentárov: 285

Jednou z najdôležitejších otázok pri odňatí/a nenasadení liečby je problém/pojem márnosť (futility - zbytočnosť) liečby.

Obrazok V duchu Hippokratovej prísahy platí, že ak aj lekár nedokáže uzdraviť pacienta, stará sa oň do konca života. Chorý by mal vedieť a možno aj rešpektovať obmedzenosť liečebných možností. Avšak, technický pokrok viedol  k vzniku mnohých podporných systémov, ktoré dokážu dočasne preklenúť čas, keď zlyhávajú životné funkcie. Priniesol so sebou aj nové  problémy dlhodobého prežívania ľudí v kóme, pacientov neschopných opustiť nemocnicu alebo prístroje, ktorých obsluha je viazaná na vyškolený personál.
Prípad Karren Ann Quinlan. Išlo o dievča s poškodeným mozgom, ktorého rodičia prežívajúc márnosť liečby a neznesiteľnosť jej života, žiadali cestou súdu ukončiť jej liečbu a odpojenie od dýchacieho prístroja.

Na druhej strane je nezriedkavým prípadom neustále požadovanie rozširovania a predlžovania liečby od rodinných príslušníkov u nevyliečiteľných pacientov. Nútenie lekárov konať podľa ich želania napriek znalostiam bezvýchodiskovej situácie, je frustrujúce pre obe strany.  Prípad Baby K. Dieťa narodené bez mozgu, napojené na prístroje. Napriek bezperspektívnosti jej sociálneho života rodičia neustále žiadali vykonávať „pre záchranu života, všetko čo sa dá“

K  pochopeniu márnosti liečby je potrebné analyzovať tieto činitele:

1.    Profesionálna integrita lekára. Lekár nie je obchodník, nekupčí so zdravým a životom, nemal by aplikovať liečbu, ktorá je škodlivá, ale nemal by skresľovať výdobytky vedy, preceňovať svoje možnosti, rozdávať falošnú nádej a predlžovať umieranie.

2.    Osobná integrita lekára. Nie je možné požadovať od lekárov a personálu úkony, ktoré by mohli považovať za odpudivé alebo mravne zlé.  Predlžovanie života u pacientov v bezvedomí, ktorí pod vplyvom neurologického poškodenia menia svoj fyzický obraz pod vplyvom kontraktúer, hypotrofie svalov, opakovane bojujú s vyčerpávajúcimi infekciami alebo preležaninami. Patrí sem napríklad opakovaná resuscitácia u komatóznych pacientov bez známok zachovania činnosti kôry mozgu.

3.    Rešpekt k autonómii pacienta. Lekár môže a má povinnosť snažiť sa presvedčiť  a získať vzájomnú zhodu (compliance) a spoluprácu s pacientom a jeho príbuznými pri riskantnej liečbe. Na druhej strane nemožno očakávať, že absolútne všetky      (neadekvátne) požiadavky  pacienta a rodiny budú vykonané.

4.    Ekonomické aspekty. Koncepcia zbytočnej liečby musí byť jasne odlíšená od koncepcie drahej liečby, ktorá môže zachrániť život. Ekonomiku liečby treba vnímať ako ekonomickú hodnotu, ktorá je priamo úmerná dobru, ktoré spôsobí. Ak liek dokáže pacientovi zlepšiť kvalitu života, je indikovaný a vhodný pre danú diagnózu, je potrebné urobiť všetko, aby ho dostal. Je neakceptovateľné podávať nevhodný liek len preto, že je drahý a niekomu inému v podobnej situácii pomohol.

5.    Nerovnaký prístup k hodnotám života. Tento činiteľ vystupuje na povrch pri živote ťažko obmedzenom (telesne alebo duševne). Pri pluralite názorov medzi lekármi, významnú cenu majú názory rodinných príslušníkov a samotných pacientov.  

Odňatie/ nezahájenie liečby v intenzívnej medicíne

Intenzívna medicína dokáže nahradiť a udržať základné životné funkcie. Primárny dôvod jej existencie je dočasné nahradenie vitálne dôležitých funkcií ( dýchanie, krvný obeh, obličky, pečeň... ) Predĺženie života nemusí byť spojené s obnovením funkcií, čo znamená, že prognóza pacienta bez prístrojov je nepriaznivá, bez nich umrie. Zásady liečby kriticky chorých pacientov sa riadia týmito etickými princípmi:

1.    Zachovanie a ochrana života
2.    Nedopustiť, zbaviť utrpenia a bolesti
3.    Nepoškodiť somaticky a psychicky
4.    Prejaviť rešpekt voči autonómii
5.    Spravodlivé / racionálne rozdeľovanie liečebných prostriedkov
6.    Pravdivo a zrozumiteľne informovať pacienta (pokiaľ sa dá) a  rodinu

Márnosť liečby v intenzívnej medicíne je chápaná lekármi, ktorí ju vykonávajú a ich vedomosti sa opierajú o patofyziológiu životne dôležitých funkcií, o využívanie techniky, ktorá ich nahrádza. Ako vyjadriť márnosť liečby inými slovami?

•    Intervencia / výkon nemá patofyziologické odôvodnenie
•    Intenzívna liečba zlyháva ( organizmus prestáva reagovať zlepšením)
•    Rovnaký liečebný postup u tohto pacienta opakovane zlyhal
•    Liečba nevedie ku vytýčenému cieľu  - k obnoveniu funkcie orgánu

Práve intenzívna medicína, pohybujúca sa na hrane života a smrti pacienta sa opiera o EBM evidence based medicine – na medicíne založená na dôkazoch. EBM je jednou zo snáh ukázať, že mnohé intervencie sú používané na základe skúseností, sú zaťažené skôr emotívnym účinkom na lekárove myslenie. Zvyčajne sú spojené s jeho skúsenosťou a presvedčením, že sú účinné, hoci neexistujú pre ich opodstatnenie vedecké podklady. V prípade, že intenzívna medicína napriek úsiliu, v prvej fáze prijatia pacienta ide často aj o heroické  medicínske opatrenia ( masívne krvné transfúzie, mimotelový obeh, kontinuálna dialýza), nedokáže vrátiť vitálne funkcie do normy spojenej s prežívaním pacienta, dochádza v súlade s princípmi liečby kriticky chorých k dvom situáciám.

Withhold  - Nezahájiť, nenasadiť plnú liečbu u pacientov s nepriaznivou prognózou. Ide o prípady, kde ani všetko zahrňujúci medicínsky postup stav pacienta nezlepší. Pacient dostane základnú terapiu. Nesmie mať bolesti, hlad, smäd a psychicky diskomfort. Pacient spí, v prípade spontánnej dychovej aktivity je bez dýchacieho prístroja. V prípade, že je schopný komunikácie je mu umožnený trvalý kontakt s príbuznými. V prípade, že pacient je schopný existovať mimo intenzívnej jednotky, je prevedený do paliatívnej starostlivosti na iné oddelenie.
Pacient po operácii čreva pre rozsiahlu rakovinu. Dochádza k strate viac ako 80% čreva. Takýto pacient nie je schopný prijímať akúkoľvek stravu. Aj keď dočasne výživa podávaná do žily je schopná ho udržať živého, nie je schopný prežiť chemoterapiu. Chemoterapia sa nezaháji. Pacient sa neresuscituje. Ostáva mu niekoľko týždňov alebo mesiacov života.

Withdraw  - Odňatie, ukončenie liečby, ktorá neprináša terapeutický účinok, napriek všetkým medicínskym kritériám, ktoré ochorenie a liečba so sebou nesú. Pacientom sa neodnímajú tekutiny, strava, liečba bolesti, kyslík v prípade dusenia sa. V prípade, že pacientovi bola diagnostikovaná mozgová smrť ( zastavenie cirkulácie mozgom - pacient je len biologickou jednotkou) a pacient nebol zaradený do transplantačného programu, zastaví sa aj výživa, prívod tekutín. Zvyčajne ostáva na dýchacom prístroji.
V Európe existujú pracoviská, kde po diagnóze mozgovej smrti, sú zastavené  prístroje, ktoré udržiavajú telesnú schránku pri živote, až kým sa úplne nezastaví riadenie a kontrola obehu,  tým aj srdce.

Rozhodovacie procesy o Withhold / withdraw therapy

Opakované klinické vyšetrenie, zobrazovacie vyšetrenia( CT, ultrazvuk, angiografia..) zlyhávajúcich orgánov (mozog, srdce, pľúca, pečeň,..) musí obsahovať  kompletná dokumentácia.
Konsenzus o márnosti liečby medzi lekármi z viacerých lekárskych odborov ( Intenzivista, neurológ, psychiater, chirurg, onkológ...) s príslušnou dokumentáciou a zápisom do chorobopisu. Jednotliví konziliári napíšu svoje stanovisko..
Dôležitá je dohoda a konsenzus s ošetrovateľskou sférou a personálom, ktorý je zapojený do komplexnej liečby pacienta.
Existuje pojem rodinná konferencia, kde sa príslušnici najbližšej rodiny pacienta stretnú s konzíliom odborníkov. Získajú podrobené informácie. Do rodinnej konferencie môže byť zapojený aj pacient, ak je kompetentný pochopiť a schopný prijať správu o prognóze stavu a liečby. Nie vždy je možné dokonale vysvetliť márnosť ďalšieho počínania rodine. Rozhodnutie o rodinnej konferencii je potrebné v krátkej, ale jednoznačnej  polohe uviesť do chorobopisu. Tento zápis musí byť jasný všetkým, ktorí sa o pacienta starajú.
Rozhodnutie o odňatí alebo nenasadení liečby by malo byť denne prehodnocované, pretože napriek vysadeniu liečby, niektoré fyziologické funkcie sa môžu meniť.
Pacient môže byť schopný prijať stravu, ktorú predtým vracal, začne sa znovu kŕmiť. Aj pri odňatí a nenasadení liečby je bezpodmienečné nutné  naďalej poskytovať lekársku ( ordinácia liekov na úľavu bolesti), ošetrovateľskú, psychologickú a sociálnu starostlivosť a pozornosť.

AUTORKA: MUDr. Ľubomíra Romanová, PhD. - prednostka anestéziológie a intenzívnej medicíny (FZO ) FNsP J.A.Reimana v Prešove, známa blogerka a autorka knihy Vlasy dupkom
FOTO: scientificamerican.com




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