Transcript Ethics in the Intensive Care Unit

PROPERTIES
Allow user to leave interaction:
Show ‘Next Slide’ Button:
Completion Button Label:
Anytime
Show always
View Presentation
Ethics in the
Intensive Care Unit
Christine C. Toevs, MD
Trauma/ Critical Care Surgeon
MA Bioethics
21 Dec 2009
™
Care at the End of Life
• Cassell, 2003; Critical Care Medicine
• Ethnographic study of three ICUs
• Surgeons - most important goal is defeating death
• Intensivists - scarce resources and quality of life
™
Page 3
Care at the End of Life
• Surgeons - covenantal ethics:
– surgeons define their relationship to the patient as a
promise to battle death on behalf of the patient
– choice is simple-life or death
– quality of that life not an issue
™
Page 4
Care at the End of Life
• New Zealand
– Critical care physicians have legal authority and
mandate to determine who is admitted to ICU
– Decision to redirect treatment toward comfort
measures is purely medical
– Does not require assent of family or surgeon
™
Page 5
Care at the End of Life
• New Zealand rations by limiting care to those judged
able to benefit from such care
• United States - largely indigent population has to “wait
their turn” for access to care (ethic of scarce resources)
• US rations by limiting those who care for ICU patients
™
Page 6
Goals of Healthcare
• Restore health
• Relieve suffering
• These goals are not incompatible. The treatment being
offered must be defined within the context of the goals.
™
Page 7
Geriatric ICU Care
• 50% ICU admissions over age 65
• 60% of all ICU days
• ICU/hospital mortality for age > 60 = 70%
• 11% Medicare recipients spend > 7 days in ICU within 6
months before death
• 30% of Medicare costs in last year of life, 52% during
last 60 days
™
Page 8
Withdrawal of Treatment
• Discontinuing a therapy that has disproportionate burden
without achieving reasonable clinical goals
• Withdrawing treatment is distinguishable from purposely
hastening death (intent)
™
Page 9
Withholding of Treatment
• Not initiating a therapy that has a disproportionate
burden without achieving reasonable clinical goals
™
Page 10
Withdrawing vs. Withholding
• Withholding a treatment is viewed as equivalent to
withdrawing an intervention.
• Distinction between failing to initiate and stopping
therapy is artificial.
• Justification that is adequate for not commencing
treatment is sufficient for ceasing it.
™
Page 11
Withdrawal vs. Withholding
• No presumption that, once begun, no matter how futile,
the treatment must be continued.
• No difference between withdrawal and withholding.
• Not “care” but treatment. We still care for the patient but
do not offer or continue non-medically beneficial
treatment.
™
Page 12
Withdrawal and Withholding
• 1988 - 50% of ICU deaths preceded by decision to
withdraw or withhold treatment
• 1993 - 90% of ICU deaths
• Includes DNR orders
™
Page 13
Withdrawal of Mechanical Ventilation
• N Engl J Med, 2003
• 15 ICUs
• Examine clinical determinants associated with
withdrawal of mechanical ventilation
• 851 patients:
– 539 weaned (63.3%)
– 146 died (17.2%)
– 166 withdraw (19.5%)
™
Page 14
Withdrawal of Mechanical Ventilation
• Need for inotropes or vasopressors
• Physician’s prediction of survival < 10%
• Physician’s prediction of limitation of future cognitive
function
• Physician’s perception that patient did not want life
support used
™
Page 15
Withdrawal of Mechanical Ventilation
• Not predictors:
– age
– severity of illness
– organ dysfunction
™
Page 16
Withdrawal of Mechanical Ventilation
• Emphasize that life-sustaining therapy was not able to
reverse the underlying disease.
• Removal of life-sustaining therapy is allowing disease to
take its natural course.
• Aggressive palliative treatment
™
Page 17
Principle of Double Effect
• Ensuring adequate palliation while differentiating
clinician actions from active hastening of death
• Distinction based on intent of action
• Use of pain medicines to relieve pain and suffering
™
Page 18
Active Euthanasia
• Actively shortening the dying process
• Performing an act with the specific intent of shortening
the dying process
• Overdose of narcotics, anesthesia, paralytics, etc.
• It is not the absolute dose of narcotics, but a change in
the dose
™
Page 19
Decisional Capacity
• Understand relevant information and decision at hand
• Appreciate significance and relate it to own life
• Reason through options and outcomes
• Make and articulate a choice
™
Page 20
Surrogate Consent
• Patient lacks decisional capacity
• Apply substituted judgment
• Promote patient’s wishes and express beliefs of the
patient
• “What would your loved one do in this situation?”
• Avoid implication of “pulling the plug”
• Not ending life but avoiding prolonged suffering
™
Page 21
Withholding Treatment
• Case scenario:
– 60-year-old male
– Widely metastatic colon cancer
– S/p exp lap, bypass of obstructing lesion
– Develops SOB on floor, transferred to ICU
– Minor distress, unable to give consent, no family at
all
• Would you intubate him?
™
Page 22
Withholding Treatment
• Options:
• Intubate him
– Trial of 5 - 7 days to see is he improves on vent
– Continue intubation until he dies in ICU
• Do not intubate him
– Several MDs document that mechanical ventilation
will not benefit him medically
– Continue to provide comfort therapy
™
Page 23
Withholding Treatment
• “For a patient with metastatic cancer and liver failure,
respiratory support on a ventilator does not even have to
be offered because it will only prolong a death rather
than provide treatment of the disease.”
™
Page 24
Non-medically Beneficial Treatment
(Futile Care)
• Is patient autonomy really the utmost ethical guideline?
• Do we not have a responsibility to use the medical
decision-making skills that we have?
™
Page 25
Non-medically Beneficial Treatment
(Futile Care)
• It is well established in medical ethics and law that it is
appropriate to withhold medical intervention when such
interventions provide no reasonable likelihood of benefit
to the patient.
™
Page 26
Non-medically Beneficial Treatment
(Futile Care)
• “There is no duty to offer a cancer patient access to
Laetrile or other unproven forms of therapy and no duty
to offer a patient a futile surgical intervention.
™
Page 27
Rule of Rescue
• Hadorn, 1991
• Powerful human tendency to act to save an endangered
life
• Implies that available technology be used when even
small chances of cure are possible
™
Page 28
“Everything Done”
• Case scenario:
– 85-year-old male, MVC, pelvic fx and facial
– “Codes” in CT
– CPR for 20 minutes
– Brought to ICU
– On 2 pressors with BP in 70s
– Family “wants everything done”
™
Page 29
fx
“Everything Done”
• What would you do?
– PA cath
– CPR
– Dialysis
™
Page 30
“Everything Done”
• Determine what the family means by “everything done.”
• Most families want reassurances that their loved one did
not have a survivable incident and all appropriate
medical therapy was offered/done.
• Are not obligated to provide care that we believe to be
non-medically beneficial
• Family present at interventions (resuscitations)
™
Page 31
Non-medically Beneficial Treatment
(Futile Care)
• How is medical futility defined?
– Disease must be terminal
– Disease must be irreversible
– Death must be imminent
– Merely preserves permanent unconsciousness or
cannot end dependence on intensive medical care
– Clear legal definition does not exist
™
Page 32
Non-medically Beneficial Treatment
(Futile Care)
• Reasons for clinician distress
– want to minimize suffering
– reluctance to provide care that they would not want
for themselves or family
– not a good use of resources
– lack of trust that family not following
recommendations
– feelings of distaste at inflicting physical abuse on
dead or dying people
™
Page 33
Non-medically Beneficial Treatment
(Futile Care)
• Case scenario:
– 85-year-old male
– MVC, rib fx
– Vent.-dependent for 6 months
– Wife continues to “want everything done”
– Develops renal failure
™
Page 34
Non-medically Beneficial Treatment
(Futile Care)
• Would you offer dialysis?
• If so, why?
• If not, why not?
™
Page 35
Non-medically Beneficial Treatment
(Futile Care)
• “Physicians are not obligated to provide care they
consider physiologically futile even if a patient or family
insists. If treatment cannot achieve its intended purpose,
then to withhold it does not cause harm. Nor is failure to
provide it a failure of standard of care.”
™
Page 36
Non-medically Beneficial Treatment
(Futile Care)
• “Physicians are not ethically obligated to deliver care
that, in their best professional judgment, will not have a
reasonable chance of benefiting their patients. Patients
should not be given treatments simply because they
demand them. Denial of treatment should be justified by
reliance on openly stated ethical principles and
acceptable standards of care, not on the concept of
‘futility,’ which cannot be meaningfully defined.”
™
Page 37
Legal Issues
• Competent adult has the right to refuse life-sustaining
treatment
• Quinlan - substituted judgment
• Medical interventions not distinguished by
“extraordinary” and “ordinary”
• Medical interventions evaluated by benefits and burdens
offered
™
Page 38
Legal Issues
• Cruzan - principle that a competent person’s right to
forgo treatment, including nutrition and hydration,
protected under 14th amendment
™
Page 39
Legal Issues
• Only clear legal rule on medically futile treatment is
traditional malpractice test
• Likely to get better legal results when refuse to provide
nonbeneficial treatment and then defend position in court
as consistent with professional standards than when
seek advance permission from court to withhold
treatment
™
Page 40
CPR
• Developed in 1960s
• Intended for victims of unexpected death:
– drowning
– drug intoxication
– heart attacks
– asphyxiation
• 75% survival on television
• 15% survival of hospitalized patients
™
Page 41
CPR
• Not intended as a routine at time of death to include
cases of irreversible illness for which death was
expected
• Unclear how it became the “standard of care”
• Unique among medical interventions as it requires a
written order to preclude its use
™
Page 42
CPR
• “A physician’s decision supported by consultants to
withhold CPR is a medical decision and cannot be
overridden. Patient autonomy and consumerism does
not extend to medically futile care.”
Weil, 2000
™
Page 43
CPR
• Physically and emotionally traumatic
• Significant likelihood of iatrogenic injury
• Disrupts the care of the living
• Communicates false hope to the families
™
Page 44
CPR
• Moral, ethical, and legal justification for a physician’s
refusal to perform CPR when there is medical consensus
that CPR will not be beneficial
™
Page 45
CPR
• Predictors of outcome:
– Favorable
• respiratory arrest
• unexpected
• witnessed
– Unfavorable (no survival to discharge)
• not witnessed
• pulseless electrical activity
• asystole
™
Page 46
CPR
• Age is not a major predictor of outcome.
• Underlying medical conditions are a predictor.
• CPR greater than 10 minutes - no survivors
™
Page 47
CPR
• Greek study, Resuscitation, 2003
• CPR in general adult ICU
• 111 patients
• CPR performed in 98.2% within 30 seconds
• 24-hour survival - 9.2%
• Survival to discharge - 0
™
Page 48
DNR
• “DNR orders only preclude resuscitative efforts in the
event of cardiopulmonary arrest and should not influence
other therapeutic interventions that may be appropriate
for the patient.
AMA
™
Page 49
Summary
• Death is a process, not an event.
• Dignity in dying is as important as preserving life.
• Palliative treatment is a crucial part of ICU care.
• Withdraw and withholding are equivalent.
• Early and frequent communication with families is
important.
™
Page 50
Conclusion
• ICUs have 2 major goals:
– Save lives by intensive and invasive therapies.
– Provide a peaceful and dignified death when death is
inevitable.
™
Page 51
Review
The follow are question to help you review the key points of
this presentation.
Review Quiz
Skip
™
Page 52
PROPERTIES
On passing, 'Finish' button:
On failing, 'Finish' button:
Allow user to leave quiz:
User may view slides after quiz:
User may attempt quiz:
Goes to Next Slide
Goes to Next Slide
At any time
At any time
Unlimited times
References
•
Cassell, et al. Surgeons, Intensivists, and the Covenant of Care:
Administrative Models and Values Affecting Care at the End of Life. CCM
2003. 31:1551-1559
•
Civetta, Taylor and Kirby’s Critical Care. 4th Edition. 2009. Lippincott
•
Gries, et al. Family Member Satisfaction with End-of-Life Decision Making in
the ICU. Chest 2008. 133:704-712
•
Halpern, Pastores. Critical Care Medicine in the United States 2000-2005:
An Analysis of Bed Numbers, Occupancy Rates, Payer Mix, and Costs.
CCM 2010. 38:65-71
•
Lubitx and Riley. Trends in Medicare Payments in the Last Year of Life.
NEJM 1993. 328:1092-1096
•
Mitchell, et al. The Clinical Course of Advanced Dementia. NEJM 2009.
61:29-38
•
Tamura, et al. Functional Status of Elderly Adults before and after Initiation
of Dialysis. NJEM 2009. 1539-47
™
Page 54