Speech by Dato` Dr Mrs S T Kew Master, Academy of Medicine of

B E R I TA AKADEMI / VOL. 13 No. 2
PP 6561/12/2004 JUNE 2004
Speech by Dato’ Dr Mrs S T Kew
Master, Academy of Medicine of Malaysia
at the AGM / ASM of College of Surgeons
1 4 M AY 2 0 0 4
I would like to thank the College of Surgeons and the
Organizing Committee of the ASM for inviting me here
this morning. I would also like to congratulate the
College of Surgeons – there are many things that the
College can be justly proud of:
1.
Indeed College of Surgeons is the largest College
in the Academy in terms of fellowship and
membership number: this has always been the envy
of other colleges of the Academy.
2.
Through the years, College of Surgeons has been
very active in skills training, both basic and
advanced – several workshops are held every year
in the Klang Valley. In fact, this is the most active
College in skills training.
3.
College of Surgeons has also been very active in
organizing local and international meetings in the
various surgical subspecialties every year. This is
highly commendable.
4.
College of Surgeons is steep in tradition. You see
the procession and the stage party this morning.
It is remarkable to be able to successfully hold AM
Ismail Oration on an annual basis without fail –
last year we had Datuk Dr Hussein Awang, and
this year, Prof Russell Strong as the AM Ismail
Orator.
5.
College of Surgeons has strong and close links with
regional and international surgical fraternity.
The College is a Member of Asian Surgical
Association. Dr Chang Keng Wee, current
President of ASA, is a Fellow of this College. I also
take note of the RACS travelling fellowship –
something which continues to cement the close
cooperation between the two colleges.
unifying force, as it were, for the surgeons, whatever the
subspecialties, i.e. a College that is able to represent the
interest of the surgeons.
College of Surgeons needs to take the lead role in
putting in place and streamlining the credentialling of
various surgical subspecialties, working closely with
other stake holders like Ministry of Health, Universities
and Specialty Professional bodies. We already have the
Academy specialist register, and we are moving towards
the national specialist register. College of Surgeons
needs also to take the lead role in training, in
assessment and in certification of higher surgical
specialist training in this country.
To this end, I would like to congratulate the people who
have worked hard to make the Vascular Society of
Malaysia a reality. I am happy to note the support and
cooperation by the College of Surgeons to this new
society.
On the home front, College of Surgeons and College of
Physicians and the Academy have been through thick
and thin in the College Land Development Project:
at least now we are hopefully seeing the beginning of
the end of a long, long wait to have our own Academy
building. Here, we need the support of all fellows and
members. College of Surgeons, being the largest College
in terms of fellowship & membership number, will have
to play an important role. Together with other colleges
in the Academy, we hope to be able to raise about
RM3 millions, over and above what we already have,
and to see the project to a successful conclusion.
This ASM will once again provide a forum for the
College to bring together fellows and members: an
annual CME cum social event that is very much looked
forward to. It is with great pleasure that I declare the
Annual Scientific Meeting of the College of Surgeons
open. It is also my pleasant duty to officially launch the
Vascular Society of Malaysia.
College of Surgeons has been successful in many arena.
The challenge now is to make the College relevant in
the face of rapid development in various surgical
subspecialties. We can look upon the College as an
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CALENDAR OF EVENTS
05 – 06 August 2004 (Thursday – Friday)
28 – 30 August ( S a t u rday – Monday)
4TH INTERNATIONAL ADVANCED ENDOSCOPY WORKSHOP
WORLD FORUM ON THE CHILD 2004
“EXPLORING NEW DEPTHS”
“CHILD DEVELOPMENT, HEALTH AND EDUCATION : THE CHALLENGES OF THE
NEW MILLENNIUM”
Organiser
Venue
Secretariat
Tel
Fax
Email
: Selayang Hospital
: Selayang Hospital, Selangor, Malaysia
: Day Care Endoscopy Unit
Hospital Selayang
Lebuhraya Selayang-Kepong
68100 Batu Caves, Selangor
: +603 6120 3233 ext 2177
: +603 6120 7753
: endoscopy@selayanghospital.gov.my
Organiser
Venue
Secretariat
Tel
Fax
Email
Website
25 – 28 August 2004 ( Wednesday – Saturd a y )
5 MOH-AMM SCIENTIFIC MEETING
(Incorporating the 7 th NIH Scientific Meeting)
TH
“QUALITY AND MEDICAL PROFESSIONALISM”
Organiser
Venue
Secretariat
Tel
Fax
Email
Website
:
:
:
:
:
:
:
Academy of Medicine of Malaysia &Ministry of Health Malaysia
Sunway Lagoon Resort Hotel, Petaling Jaya, Selangor, Malaysia
19 Jalan Folly Barat, 50480 Kuala Lumpur
+603 2093 0100, 2093 0200
+603 2093 0900
acadmed@po.jaring.my, acadmed@streamyx.com
http://www.acadmed.org.my/html/5th-MOHAMM_f.htm
02 – 04 September 2004 (Thursday – Saturd a y )
AGM/ANNUAL SCIENTIFIC MEETING OF MALAYSIAN PAEDIATRIC ASSOCIATION
Organiser
Secretariat
Tel
Fax
26 – 29 August 2004 (Thursday – Sunday)
29 ANNUAL DERMATOLOGY CONGRESS AND ANNUAL GENERAL MEETING
: Kulliyah of Medicine, International Islamic University Malaysia
: Kulliyah of Medicine, International Islamic University Malaysia,
Kuantan, Pahang, Malaysia
: c/o Azlin
World Forum on the Child
Dean’s Office, Kulliyah of Medicine
International Islamic University Malaysia
25150 Kuantan, Pahang
: +609 571 6402
: +609 571 6770
: medean@iiu.edu.my
: http://www2.iium.edu.my/worldchild/
: Malaysian Paediatric Association
: 3rd Floor (Annexe Block)
National Cancer Society Building
66 Jalan Raja Muda Abdul Aziz
50300 Kuala Lumpur
: +603 2691 5379
: +603 2691 3446
TH
“CLINICAL DERMATOLOGY – RECENT ADVANCES”
Organiser
Venue
Secretariat
Tel
Fax
Email
05 – 09 September 2004 (Sunday – Thursday)
14TH TRIENNIAL CONGRESS OF ASIA PACIFIC ORTHOPAEDIC ASSOCIATION
: Dermatological Society of Malaysia
: CyberLodge, CyberJaya, Selangor, Malaysia
: c/o Mr Andrew Tan
Summit Co (M) Sdn Bhd
Lot 6 Jalan 19/1
46300 Petaling Jaya, Selangor
: +603 7958 2740
: +603 7957 2200
: info@dermatology.org.my
Organiser
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Secretariat
Tel
Fax
Email
Website
: Asia Pacific Orthopaedic Association
: Shangri-La Hotel &Mutiara Hotel, Kuala Lumpur
Wilayah Persekutuan, Malaysia
: 19 Jalan Folly Barat, 50480 Kuala Lumpur
: +603 2093 0100, 2093 0200
: +603 2093 0900
: acadmed@po.jaring.my, acadmed@streamyx.com
: http://www.apoa2004.com
PERAK COLLEGE OF MEDICINE
OPHTHALMIC ANAESTHESIA
KP(JPS)5195/441/Jld.I(19), PKP.300A4/P/A2/039
COURSE AND WORKSHOP
The Perak College of Medicine, in providing the teaching of
medicine and allied health sciences, is continuously looking for
more qualified candidates to fill the various positions indicated
below:
(In conjunction with the National Healthcare Group
Annual Scientific Congress 2004)
DATE ➺ 16 October 2004 (Saturday)
TIME ➺ 0800 – 1700 hrs
VENUE ➺ Alexandra Hospital, Singapore
GUEST FACULTY ➺ Prof Chandra M Kumar
SENIOR LECTURERS AND LECTURERS
MEDICAL DEGREE PROGRAMME (PRE–CLINICAL & CLINICAL)
The Depts. of Anaesthesia and Ophthalmology &
Visual Sciences, Alexandra Hospital, National
Healthcare Group, Singapore, will organise the
Ophthalmic Anaesthesia Course and Workshop in
Alexandra Hospital, Singapore.
• ANATOMY
• MEDICAL MICROBIOLOGY
• BIOCHEMISTRY
• PHARMACOLOGY
• PHYSIOLOGY
• PATHOLOGY
• MEDICINE
• SURGERY
• PSYCHIATRY
• PARASITOLOGY
• PUBLIC HEALTH
• OBSTETRICS & GYNAECOLOGY
Applicants must possess the following :
1. A medical qualification registrable with Medical Council.
2. Possess a recognised higher qualification (fellowship, membership or masters) in the
relevant specialty in medicine.
3. Interest and ability to teach at undergraduate and postgraduate levels.
4. Experience and exposure in medical related research activities and teaching.
5. All applicants must forward letters of references from 2 referees.
TARGET GROUPS
Anaesthetists, ophthalmologists, doctors-in training,
nurses and paramedical staff involved in the
perioperative care of ophthalmic patients.
PROGRAMME HIGHLIGHTS
• Current trends and controversies in ophthalmic
anaesthesia.
• Updates on perioperative anaesthetic management
of routine and complex ophthalmic surgeries.
• Techniques of regional ophthalmic blocks.
• Anaesthetic considerations for special situations in
ophthalmic surgery e.g. ocular trauma, vitreoretinal
surgery, paediatric ophthalmic surgery.
Remuneration will commensurate with experience and qualifications. All applicants for
the above position are required to send in their full resume with information on
qualifications, experience, area of expertise, current and expected salary, passport-sized
photograph (n.r.), contact telephone number(s), e-mail and postal addresses to :
SECRETARIAT
Chief Executive Officer
PERAK COLLEGE OF MEDICINE (477486-U)
No. 3, Jalan Greentown, 30450 Ipoh, Perak Darul Ridzuan
Tel : (605) 243 2635 Fax : (605) 243 2636
Website: www.perakmed.edu.my
Attn: Ms Alice How, Ophthalmic Anaesthesia
Course and Workshop, c/o Departments of
Anaesthesia and Ophthalmology & Visual Sciences,
Alexandra Hospital, 378 Alexandra Road,
Singapore 159964, Singapore
Tel: (65) 6379 3741
Fax: (65) 6379 3540
Email: Alice_HOW@alexhosp.com.sg
Only short-listed candidates will be notified
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News from the College of Anaesthesiologists
by Prof Ramani Vijayan
Consensus on Withdrawal and Withholding
of Life Support in the Critically Ill
The College of Anaesthesiologists will be holding a national workshop on the above:
Date
Venue
Time
Chairperson
Target Audience
:
:
:
:
:
25 September 2004
Ballroom, KL Hilton, KL Sentral
4.30 pm
Dato’ Dr K Inbasegaran
Physicians, Surgeons, Anaesthesiologists, Intensive Care Nurses,
Hospital Administrators and all those involved in managing critically ill patients.
Given below is the draft consensus. Doctors who are interested in attending the national workshop are
requested to RSVP to the Academy Secretariat before 15 August 2004.
the demand for intensive care which is becoming very expensive to
provide. Although economic factors are not a criteria for limiting therapy,
it is also justifiable for the medical community to have a consensus as
to the kind of patients who will truly benefit and those who will not
benefit from intensive care therapy.
INTRODUCTION
One of the major advances in medicine occurred soon after the last World
War when life supporting technologies were developed and continued
throughout the 20th century. Intensive care units were developed which
with life support technology could save many ill patients as well as allow
major procedures in ill patients to be carried out. Before the mid sixties,
the goal of medicine was to use whatever it takes to preserve life.
However, it became apparent to most caregivers in the intensive care
setting that significant numbers of patients would eventually die because
of the underlying disease and all that these new technologies were doing,
was to prolong the process of dying. In the nineties, the concept of a
dignified death and the helping of the dying, became more acceptable.
The medical community again, particularly in the West, learnt to accept
that caregivers have to actively help patients to come to terms with
terminal illnesses and minimise aggressive intervention such as CPR and
ventilation in many of these cases.
Scope of guideline – This consensus statement is directed at adult
patients who are critically ill and are being treated by various means in
critical care or intensive care units. The consensus statement is not
directed at children and patients undergoing palliative therapy in homes
or nursing homes. There is also a category of critically ill patients who
may be receiving life support therapy in conventional wards due to a lack
of intensive care beds, and this consensus statement can also be applied
to them.
Definition – Life support treatment or life prolonging treatment refers to
all treatment which has the potential to postpone the patient’s death and
includes cardiopulmonary resuscitation, artificial ventilation, specialised
treatments for particular conditions such as dialysis, vasoactive drugs,
antibiotics when given for a potentially life-threatening infection and
artificial nutrition and hydration. It will also include pacemakers when
used to treat life threatening arrythmias .
GOALS OF MEDICINE AND INTENSIVE CARE
The primary goal of medical treatment is to benefit the patient by
restoring or maintaining the patient's health as far as possible,
maximising benefit and minimising harm. If treatment fails, or ceases to
give a net benefit to the patient (or if the patient has competently refused
the treatment), that goal cannot be realised and the justification for
providing the treatment is removed. Unless some other justification can
be demonstrated, treatment that does not provide net benefit to the
patient may, ethically and legally, be withheld or withdrawn and the goal
of medicine should shift to the palliation of symptoms.
Artificial nutrition and hydration refers specifically to those techniques
for providing nutrition or hydration which are used to bypass a pathology
in the swallowing process. It includes the use of nasogastric tubes,
percutaneous endoscopic gastrostomy (PEG feeding) and total parenteral
nutrition.
PRINCIPLES OF WITHDRAWAL OR WITHHOLDING LIFE SUPPORT
The goal of intensive care is to treat reversible life threatening conditions
so that patients can recover and continue to enjoy a reasonably good
quality of life. In many of the developed societies and broad consensus
has emerged during the past 30 years that it is appropriate to withhold or
withdraw life support therapy in many clinical situations. The consensus
did not come about easily. There had been much debates and
controversies within the medical community. It had also raised numerous
societal, ethical, religious, legal and economic issues in the last two
decades. Up to 90% of Western critical care unit deaths in the present
day result from caregivers limiting or withholding therapy. In many of the
consensus guidelines, there is no moral difference between the decision
to withhold or to withdraw life support as the intention is the same.
Withholding or withdrawal of life support is the process by which various
medical interventions are either withdrawn or withheld with the
expectation that the patient will die of the underlying disease. Palliation
is the prevention or treatment of pain, dyspnea and other kinds of
suffering and providing basic care for patient comfort and must be
provided to all patients in whom withdrawal of life support is being
considered. Both these closely related processes must be supported by
ethical principles in medicine.
The principles of withholding or withdrawal of life-support should be
based on the basic principles of medical ethics. These are:
1. Preservation of life which is frequently tempered by the second
principle.
2. Relief of suffering – This covers distressing symptoms such as pain,
distress caused by anxiety, etc.
3. “First do no harm” – Non maleficence
In Malaysia, the medical profession is still a little behind in accepting
many of the concepts that lead to the limitation or withdrawal of
intervention in certain categories of patients. However, with the rapid
growth of both public and private health care, there is also an increase in
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4. Respect the autonomy of patients – Patients have the right to
informed choices in treatment and have the right to refuse or accept
a given mode of treatment.
5. Concept of a just allocation of medical resources – This is a concept
that it must be good for the majority in society. Allocating scarce and
expensive resources like intensive care for potentially nonsalvageable patients limits the amount that can be spent on potential
survivors. Increasing medical costs also make some form of rationing
inevitable. Intensive care is extremely expensive and economic
considerations form part of the consideration in ethical discussion
regarding intensive care management.
6. To be truthful to the patients and family or surrogates as to the
prognosis of their loved ones.
OTHER DECISION–MAKING
WITHHOLDING
R
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WITHDRAWAL
OR
Quality of Life – Patients in intensive care who are unlikely to regain
some form of meaningful life as we know it pose a particularly
challenging problem. Quality of life has to be taken in the context of other
factors mentioned above as well as the possibility of further rehabilitation
and family support. Most intensivists have resisted managing such
patients in the ICU as there is no meaning in prolonging the life of these
individuals. At the same time, it will be an easier decision not to admit
these patients to an intensive care unit rather than taking them out of
one.
1. A patient with imminent death
A patient facing imminent death has an acute illness whose reversal
or cure would be unprecedented and will certainly lead to death
during the present hospitalisation within hours or days, without a
period of intervening improvement. This is a patient who is clearly not
responding to therapy, and is reasonably unlikely to survive with
continued therapy. Futility will be determined by prolonged multiple
organ system failure. Further intensive care management with four or
more organ systems failure is futile as shown by most studies and
reports.
2. A patient with terminal condition
A patient with a terminal condition has a progressive, unrelenting
terminal disease incompatible with survival longer than 3-6 months.
Life support treatment should be provided to treat superimposed,
reversible condition only with clear and achievable goals in mind.
Cardiopulmonary resuscitation should not be instituted in such
patients with terminal, irreversible illness whose death is expected
and in whom resuscitation represents a violation of the right to die
with dignity.
3. A patient with severe and irreversible condition impairing
cognition and consciousness but death may not occur for
many months
This category includes patients with permanent vegetative state or
severe dementia. Permanent vegetative states is usually diagnosed
in patients with severe cerebral injury after a month of assessment
for non traumatic injury and three months following a traumatic
injury. In many of these cases who are nursed in wards, the decision
is often not to initiate CPR or other resuscitative measures in the
event of a downturn in the patients condition.
4. A competent patient who has stated his/her wish not to initiate
or who has stated his/her wish to have life support withdrawn
This will include patients who, when competent, have given clear
wishes before the present episode of illness in the form of a written
Advanced Medical Directive (AMD). The principle of patient
autonomy requires that physicians respect the decision to forego
life-sustaining treatmentof a patient who possesses decision-making
capacity. The medical team however, has to be very certain that this
is indeed the case and in the case of doubt should disregard previous
wishes.
5. A patient who is brain dead
Brain death is now recognised as death in many countries including
Malaysia and it is perfectly legitimate and legal to withdraw all forms
of life support from such patients once a diagnosis is made. Organ
support is only continued in the event where consent for organ
procurement is needed.
E
IN
Scoring systems – Recently, various scoring systems have gained
increasing importance as decision-making aids. Among the multitude of
predictors available, the best known is perhaps the APACHE (Acute
Physiological and Chronic Health Evaluation) which is now available in
version III. There are also others such as SAPS (Severe Acute
Physiological Score), TISS (to indicate the number of interventions),
Trauma scores and many more. Regardless of the accuracy of these
predictors of outcome, these can only aid decision-making. They should
not replace conscientious medical decision-making taking other factors
into account.
C ATEGORIES OF PATIENTS TO BE CONSIDERED FOR WITHDRAWA L
OR WITHHOLDING OF LIFE SUPPORT
B
AIDS
STEPS IN DECISION-MAKING TO WITHDRAW OR WITHHOLD LIFE
S U P P O RT
1. Medical consensus – It is essential that the primary physician and the
intensive care team have agreed on a consensus before any decision
is taken. In certain cases, more than one primary team may be
involved and it is essential to have the consensus of all the
caregivers. In the event of absence of medical consensus, active
treatment is continued. A further time period of active treatment is
set and subsequent review of management plan. The primary
physician in our context refers to the specialist or consultant under
whose department the patient is admitted.
2. Nursing consensus – Nurses play a key role in intensive care and are
in continuous contact with patients and relatives. The sense of
sympathy for the patient is often stronger and it is essential that they
also support the decision to withhold or withdraw therapy.
3. Communication – In the unfortunately rare event that the patient is
fully rational, awake and competent, the communication should be
with the patient. More often in the intensive care setting the
discussion is with the relatives. A clear and honest medical opinion
should always be given to the family. To avoid any seeming conflict of
opinion, it is best that a single resource person deal with the family,
while the others can be present. The physician orchestrating discussion
with either the family or patient, must be someone who is involved in
the active care of the patient. This key person must be someone who
has been frequently communicating with the family and has a rapport
with them. This task should be done by a senior medical staff and
should never be left to the most junior doctor in the unit.
4. The family should be given time to come to terms with the impending
loss of the their loved ones. They should be allowed to ventilate their
feelings and be as often as possible with the patient.
5. Time limited goals should be established by the clinical team and this
must be based on clinical judgement and best medical evidence.
Families will usually agree to discontinuation of life support systems
after a reasonable trial of therapy has demonstrated failure.
In the event of disagreement between the physician and the patient or
family, the assistance of an individual consultant and a patient
representative is often helpful to reach resolution amongst all parties.
An institutional committee such as an ethics committee, may be involved
if disagreements are not resolvable. In dealing with the family, they
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should not be rushed as the mental shift from hope and cure to accepting
the inevitable will not occur quickly. All explanations should be kept as
simple as possible (in a manner easily understood by lay persons).
Facilities for discussion such as a private counselling room, must be made
available and the designated staff should help them with any
clarifications if needed. The decision and processes taken, must not be
conflict with the laws of the country. Although active termination of life
i.e. euthanasia or assisted suicide may be acceptable legally in some
countries, it is unlawful here.
MANAGEMENT PLAN FOR WITHDRAWAL OF LIFE SUPPORT
There is no significant difference in patient comfort between the two
methods. However, the endotracheal tube should generally be left in
place while ventilatory support is reduced for the patients with difficulty
in clearing their secretions or protecting their airways. Regardless of the
method, frequent assessment of the patient’s comfort during and after
withdrawal of the ventilator is most important. Intravenous opioids and
benzodiazepines should be used liberally to relief dyspnoea and other
discomfort. The alarms on the monitors should be disabled. The family
should be allowed to be with the patient if they choose to. The physician
should be present to ensure the patient’s and family’s comfort during
withdrawal of mechanical ventilation.
While the medical team puts its plan for withdrawal into operation, the
exact mechanics of this, need not be told to the family or patient. It is
however, important to emphasise that the patient will be comfortable and
will not be in distress or pain, etc, during the process. There should be
great sensitivity to cultural norms and dignity to the dying patient. There
should be five main objectives for ensuring a good end of life care;
a. Receiving adequate pain relief and relief of any other distressing
symptom such as dyspnoea.
b. Avoidance of prolongation of dying.
c. Active sense of control over events.
d. Strengthen relationship among loved ones.
e. Relief of “burden” amongst caregivers and the loved one.
Withdrawal of life support is lawful at the patient’s request at common
law and in a few countries by legal statute. It is more common to
withdraw life support because the therapy is perceived to be of little
benefit or not in the patient’s best interests or the therapy is futile. In
Malaysia, there is very little case law and no legislation to direct the
decision of whether to withdraw life sustaining therapy on grounds of
futility or the patients best interests although these are available in the
UK and in the US. The decision to withdraw therapy, usually places
responsibility on the doctor/doctors in charge of the patient. Much weight
is, however, placed on the wishes of the family or legal guardians.
MEDICO-LEGAL IMPLICAT I O N S
THE PLAN FOR WITHDRAWAL WILL GENERALLY HAVE THE
FOLLOWING COMPONENTS
i.
ii.
iii.
iv.
v.
CONCLUSIONS
Today, the medical technology available has made it possible for many
patients in intensive care to be successfully treated and given an
acceptable quality of life. At the same time, the intensive care teams and
other caregivers have recognised that in many cases, one should be
aware of the limitations or futility of trying to achieve a cure and
turn towards allowing the patient a dignified and peaceful death.
This paradigm change in thinking amongst doctors, has taken many years
and is here to stay. Although these are difficult decisions, discussion
amongst doctors and other caregivers on this issue should constantly be
encouraged to allow acceptance of a consensus on limitation or
withdrawal of life support therapy.
All basic support such as pain control, hydration and nutrition, patent
airway and freedom from breathlessness, must be ensured to keep
the patient comfortable.
All life support must be continued until the patient and his family had
enough time together.
Removal of life sustaining therapy are removed in an escalating
fashion after ensuring the patient is both pain free and free from any
form of discomfort.
Support therapies such as inotropes and other medications are
withdrawn first. Usually, in a patient with multi organ failure, this
alone may sometimes result in death.
Relief of pain and discomfort – At this stage, most ICU patients are
already receiving some form of sedation and analgesia. These drugs
are continued, often at higher doses.
REFERENCES
1. American Medical Association Guidelines on Withholding or Withdrawing
Life sustaining treatment. June 1994.
2. BMJ Guideline on End of Life; BMJ Publishing Group October 14th 2000.
3. Recommendations for end of life care in the Intensive care unit; The Ethics
Committee of the Society of Critical Care Medicine; Critical Care Medicine
2000 Vol 2; 9; No 12 Pg 2332-2349.
4. Increasing incidence of withholding and withdrawal of life support from the
critically ill. Am J of Respir.Crit Care Med; Vol 155.No 1. Jan 1977; 15-20.
5. Ethical issues in Anaesthesia - Edited by Michael Vickers, Wendy Scott;
published by Butterworth Heinemann 1994.
6. John Edward Ruarn; Thomas Alfred Raffin; Stanford University Medical
Center Committee on Ethics; Initiating and Withdrawing Life Support –
Principles and Practice in Adult Medicine; NEJM; Jan 7th 1988; Vol 318; Pgs
25-30.
7. John Luce; Making Decisions about the Forgoing of life sustaining therapy;
Am J. Resp Crit. Care Med; 1997;Vol 156 pp 1715-1718.
8. Statement on the Limitations of Life Sustaining Therapy in the Intensive Care
Unit; Intensive Care Committee of the Hong Kong College of
Anaesthesiologists; 9th January 2002.
9. R.J. Young; A. King; Legal Aspects of withdrawal of Therapy. Anaesth and
Intensive Care 2003: 31:501-508.
Opioids are the most useful drugs for relieving pain in terminally or
critically ill patients. Morphine is the most common opioid and there is no
maximum dose when used in these situations. In patients who have not
previously received opioids, it should be titrated and rapidly increased
until symptoms of pain and dyspnoea are relieved. Benzodiapines should
be used to treat anxiety until during the dying process. In the event where
relatives wish for their loved ones to pass away at home, the caregivers
may assist with the necessary arrangements for the patient to be
transported home. This will depend on the local logistics and practices.
D I S C O N T I N U ATION OF MECHANICAL VENTILAT I O N
Withdrawal of mechanical ventilation is probably viewed as more
problematic than withdrawal of other interventions. Discontinuing
mechanical ventilation does not differ morally from forgoing dialysis or
cardiopulmonary resuscitation.
There are two strategies for the withdrawal of mechanical ventilation
1. Terminal weaning i.e. gradually reducing the ventilator rate, positive
end-expiratory pressure, oxygen levels or tidal volume while leaving
the endotracheal tube in place.
2. Extubation after appropriate suctioning.
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News from the College of Pathologists
Heading towa rds a National
Ac c re d i tation Scheme for
Medical Te sting Labor a to ri e s
by Prof Looi Lai Meng
Further on the Memorandum of Understanding signed in
late 2002 between the College of Pathologists (CPath) and
the Department of Standards Malaysia (DSM) of the
Ministry of Science, Technology and Innovation, activities
towards the realization of a National Accreditation
Scheme for Pathology Laboratories have been progressing
rapidly. A Steering Committee chaired by Professor
L M Looi and comprising Professor Victor Lim, Dr Halimah
Yahaya, Dr Roshida Hassan, Dr Jamilah Baharom,
Dr Rohani Md Yasin, has met several times with the
Accreditation Division of the Department of Standards
to plan the schedule for development of such a scheme.
To date, the following key events have been jointly
organized by DSM and CPath and have been successfully
carried out:
1. A Public Forum on Laboratory Accreditation, at the
Quality Hotel, Shah Alam on 15 December 2003.
This forum was to increase awareness of the need for
Laboratory Accreditation and to explain the rationale
for the adoption of ISO15189 as the standards for
Pathology Laboratories.
6. Formation of 6 Medical Expert Panels (on
Histopathology,
Cytopathology,
Haematology,
Chemical Pathology, Medical Microbiology and
Virology) chaired by various members of the Steering
Committee, on 3 April 2004. These panels, comprising
pathologists, scientists and medical laboratory
technologists, will develop the Specific Technical
Requirements for the various specialities of Pathology
to supplement the ISO 15189 requirements.
7. To enhance the efficiency of collaboration with DSM,
CPath has been successfully registered with the
Ministry of Finance in April 2004, and can now
officially bid for projects with the Government.
8. CPath has officially signed a contract with DSM on
4 June 2004, to provide the professional input towards
development of the National Accreditation Scheme.
This project, costing RM500,000, will include field
training for lead assessors, training of technical
assessors and finalization of the Specific Criteria and
Specific Technical Requirements for the National
Scheme. We aim at the launch of the Scheme by
December 2004.
2. An Introductory Course on “Medical Laboratories –
Particular requirements for Quality and Competence
(ISO/IEC 15189)” for Lead Assessors, at the Quality
Hotel, Shah Alam. 16 – 18 December 2003. This was
conducted by Mr Phil Barnes, Programme Manager for
Medical Laboratories, International Accreditation New
Zealand (IANZ).
Commitment towards the development of this scheme by
CPath members has been steadfast and most encouraging.
Many members, though not directly being trained as
assessors, have been contributing through Committees
formed to develop Guidelines on Laboratory Practices
(e.g, Retention of Pathology Records and Materials;
Laboratory Design and Safety, etc) which will have
important bearing on Laboratory Accreditation Standards
for Malaysia.
3. A Training Course (ISO/IEC 15189) for 20 Lead
Assessors (comprising pathologists and DSM
nominees), at the Department of Standards, Putrajaya,
22 – 26 March 2004 by Dr Max Robertson (IANZ) and
Mr Shaharul Sadri Alwi (DSM).
4. A Workshop on Traceability and Uncertainty of
Measurement, at the Putrajaya Convention Centre,
30 – 31 March 2004, by Dr Max Robertson (IANZ)
at the DSM.
5. Formation of the Technical Working Group, chaired by
Professor Looi and comprising Members of the Steering
Committee from CPath and members of DSM,
to develop the Specific Criteria for the DSM standards
in accordance with ISO 15189, on 3 April 2004.
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Dr Max Robertson conducting the lead assessors course at DSM.
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