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Ethics in the Ethics in the Intensive Care UnitIntensive Care Unit
Christine C. Toevs, MDChristine C. Toevs, MDUniversity of Mississippi Medical Center
April 15, 2005
Care at the End of LifeCare 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
Care at the End of LifeCare 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
Care at the End of LifeCare 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 care toward comfort measures is purely medical
Does not require assent of family or surgeon
Care at the End of LifeCare 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
Goals of HealthcareGoals of Healthcare
Restore health
Relieve suffering
These goals are not incompatible. The treatment being offered must be defined within the context of
the goals.
Geriatric ICU CareGeriatric ICU Care
70% ICU admissions over age 60
ICU mortality for age > 60 = 70%
11% Medicare recipients spend > 7 days in ICU within 6 months before death
77% of Medicare costs in last year of life
Withdrawal of TreatmentWithdrawal of Treatment
Discontinuing a therapy that has disproportionate burden without achieving reasonable clinical goals
Withdrawing treatment is distinguishable from purposely hastening death (intent)
Withholding of TreatmentWithholding of Treatment
Not initiating a therapy that has a disproportionate burden without achieving
reasonable clinical goals
Withdrawing vs. WithholdingWithdrawing 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.
Withdrawal vs. WithholdingWithdrawal 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.
Withdrawal and WithholdingWithdrawal and Withholding
1988 - 50% of ICU deaths preceded by decision to withdraw or withhold treatment
1993 - 90% of ICU deaths
Includes DNR orders
Withdrawal of Mechanical VentilationWithdrawal 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%)
Withdrawal of Mechanical VentilationWithdrawal 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
Withdrawal of Mechanical VentilationWithdrawal of Mechanical Ventilation
Not predictors:• age
• severity of illness
• organ dysfunction
Withdrawal of Mechanical VentilationWithdrawal 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
Principle of Double EffectPrinciple 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
Active EuthanasiaActive 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
Decisional CapacityDecisional 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
Surrogate ConsentSurrogate 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
Withholding TreatmentWithholding 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?
Withholding TreatmentWithholding 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
Withholding TreatmentWithholding 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.”
Hening, 2001
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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?
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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.
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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.”
Weil, 2000
Rule of RescueRule 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
““Everything Done”Everything Done”
Case scenario:• 85-year-old male, MVC, pelvic fx and facial fx
• “Codes” in CT
• CPR for 20 minutes
• Brought to ICU
• On 2 pressors with BP in 70s
• Family “wants everything done”
““Everything Done”Everything Done”
What would you do?• PA cath
• CPR
• Dialysis
““Everything Done”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)
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(Futile Care)
Reasons for clinician distress (Curtis, 2003):• 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
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(Futile Care)
Would you offer dialysis?
If so, why?
If not, why not?
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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.”
Luce, 2001
Non-medically Beneficial TreatmentNon-medically Beneficial Treatment(Futile Care)(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.”
AMA
Legal IssuesLegal 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
Legal IssuesLegal Issues
Cruzan - principle that a competent person’s right to forgo treatment, including nutrition and hydration, protected under 14th amendment
Legal IssuesLegal 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
CPRCPR
Developed in 1960s
Intended for victims of unexpected death:• drowning• drug intoxication• heart attacks• asphyxiation
75% survival on television
15% survival of hospitalized patients
CPRCPR
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
CPRCPR
“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
CPRCPR
Physically and emotionally traumatic
Significant likelihood of iatrogenic injury
Disrupts the care of the living
Communicates false hope to the families
CPRCPR
Moral, ethical, and legal justification for a physician’s refusal to perform CPR when there is medical consensus that CPR will not be beneficial
CPRCPR
Predictors of outcome:
Favorable• respiratory arrest• unexpected• witnessed
Unfavorable (no survival to discharge)• not witnessed• pulseless electrical activity• asystole
CPRCPR
Age is not a major predictor of outcome.
Underlying medical conditions are a predictor.
CPR greater than 10 minutes - no survivors
CPRCPR
Greek study, Resuscitation, 2003
CPR in general adult ICU
111 patients
CPR preformed in 98.2% within 30 seconds
24-hour survival - 9.2%
Survival to discharge - 0
DNRDNR
“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
SummarySummary
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.
ConclusionConclusion
ICUs have 2 major goals:
1. Save lives by intensive and invasive therapies.
2. Provide a peaceful and dignified death when death is inevitable.
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