Saying NO

An Interdisciplinary Conference

Anna Marie O. Troncales

February 24, 2011

MP

104 F resident of Steerehouse

Jan 2010, patient was living independently

with close support of family members

Hospitalized for an episode of syncope

secondary to bradycardia

Other noted co-morbidities were CKD and Chronic

Anemia attributed to UGIB possibly induced by

chronic NSAIDS use

MP

Admitted to SH for skilled nursing care as well as PT/OT

Discharged to home on March 2010

June 2010- another hospitalization for anemia requiring blood transfusion, UTI and C. difficile diarrhea

Second admission to SH for poor functional status

However she declined quickly and was noted to be SOB and with hypoxia

MP

June 2010 - Second admission to RIH (3rd

for patient) for HAP and hypervolemic CHF

Discharged back to SH with hospice which

was immediately discontinued

Steady decline to total care with ADLs,

incontinent of bladder and bowel, on house

pureed diet- she was transitioned to LTC

Blood transfusions became more frequent

MP

Nov 2010- admission to RIH after a regular check up revealed Hgb of 5.5

Asymptomatic

Family refused work up

Left neck ulcer with purulent discharge with evidence of cellulitis on left anterior neck that patient scratches

Family refused biopsy but agreed on PO antibiotics

MP

Since then blood transfusions have

become more frequent and mostly

based on family’s request or routine

CBC checks

No noted change from baseline

MP

PMH

Atrial fibrillation

Aortic Stenosis

CHF

Chronic Kidney

Disease

Chronic Anemia prob

from a slow UGIB

Medications: Amlodipine 10 mg PO

daily

Carvedilol 3.125 mg PO BID

Acetaminophen 325 mg PO BID and 650 mg PR PRN

Ferrous Sulfate 324 mg PO TID

Vitamin C 250 mg PO TID

MP Psychosocial History:

Born and raised in RI, 2nd of 5 children

3 children, 1 in Florida with whom patient lived with from 90-97 years old, a Daughter who lives next door and another deceased son

The past 3 years prior to repeated admissions, patient had increasing need for assistance with ADLS and IADLS and she was never left alone

3MS 44/90 and MMSE 18/29 which reflects knowledge of month and season with some difficulty stating year

Mood was pleasant and accepting of age and disabilities Feb 2010

MP

VSS

NAD, lying in bed and staring at TV

Alert, seems oriented to time and place

Pallor, EOMI intact

Dry mucous membranes

Supple, 2x2x1cm ulcer with clean base on left anterior neck with erythematous border

CTAB

S1S2 III-IV/VI sys murmur over base

Protruberant, NABS, soft and NT

Trace edema on dep areas

Atrophy

Question

When can we say “This is enough?”

How do you tell a patient “It is enough.”

Perspective

Patient- what is the limit to my self

determination?

Family- Under what conditions can our

cultural or religious values can be

disregarded?

Physicians- Under what conditions can MD

override wishes of a patient regarding

provision of new or ongoing tx when it felt to

be inappropriate?

Sibbald, 2008

Conflicts

Physicians resist inappropriate care because

of:

1. It is in the best interests of the patient

2. It contravenes their ethical code/ professional

values (do no harm)

3. Scarce Resources *

But….

#3 may conflict with #1

#2 may conflict with #1

Sibbald, 2007

Perceptions of futile care among

caregivers in the ICU

Involve the use of considerable

resources without reasonable hope that

the patient would recover to a state of

relative independence or be interactive

with their environment

Pain and suffering are not essential to

the definition but make cases difficult for

health care providers

AMA Website on Futility

When further intervention to prolong life

becomes futile, physicians have an

obligation to shift the intent of care

toward comfort and closure

AMA on Futility

Conflicts may interrupt satisfactory

decision-making and adversely affect

patient care, family satisfaction, and

physician-clinical team functioning.

AMA on Futility

To assist in fair and satisfactory

decision-making about what constitute

futile intervention:

All healthcare institutions should adopt a

policy on medical futility

Policies on medical futility should follow a

due process approach

Seven Steps to Declaring Futility

1. Earnest attempts should be made in

advance to deliberate over and

negotiate prior understanding between

patient, proxy and physician on what

constitutes futile care for the patient and

what falls within acceptable limits for the

physician, family and possibly also the

institution

Seven Steps to Declaring Futility

2. Joint decision making should occur

between patient/proxy and physician to

the maximum extent possible

3.Attempts should be made to negotiate

disagreements if they arise and to reach

resolution within all parties’ acceptable

limits with the assistance of consultants

as appropriate

Seven Steps to Declaring Futility

4. Involvement of an institutional committee

such as ethics committee should requested if

disagreements are irresolvable

5. If the institutional review supports the

patient’s position and physician remains

unpersuaded, transfer of care to another

physician within the institution may be

arranged

Seven Steps to Declaring Futility

6. If the process supports the physician’s

position and the patient/proxy remains

unpersuaded, transfer to another institution

may be sought and if done, should be

supported by the transferring and receiving

institution

7. If transfer is not possible, the intervention

need not be offered

Easing the Difficult Journey

Journal of Palliative Medicine

November 4, 2006

Volume 9

Guidelines on Shifting GOC

Adjustment to death and dying cannot be rushed

The needs of palliative care patient and family should be heard, honored and not questioned or challenged

The patient and family should remain as decision makers with Palliative team as guides and facilitators

Guidelines on Shifting GOC

Presenting accurate information to the

patient and family is important for

realistic goals to develop

Cultural issues should be considered

during difficult times

Guidelines on Shifting GOC

When clinicians are unable to successfully relay their opinion about appropriate or realistic GOC to patients and families, the journey at the end of patient’s life may seem endless

Relationship becomes strained and even adversial when extremes in GOC are developed by clinicians and families independently

Guidelines on Shifting GOC

Even though challenging, it is

responsibility of the team to support the

patient/family unit in their decisions,

unless issues on futility or ethics arise

that preclude clinicians to provide high

quality care

Guidelines on Shifting GOC

It is even more challenging for patients

and families who face great likelihood of

significant losses

Sensitivity to loss of hope when

treatments are withdrawn or removed

Response may be denial with new and

realistic GOC

In Their Own Time: The Family Experience

during the Process of Withdrawal of Life-

Sustaining Therapy (LST)

To understand the lived experience of

families participating in withdrawal of

LST from a family member with an

unexpected, life threatening illness or

injury

Table 1 Continuation

Results

17 of patients agree with HC provider to

withdraw LST (16 died after withdrawal,

1 died prior to withdrawal)

2 did not agree ( 1 died in ICU, 1 alive

after study and plan to LTC)

Results

This happens to other families

Time to understand the severity of illness or injury

Time to see if health would be restored

Riding a roller coaster

Family readiness

Willingness to consider withdrawal of LST as an option

One step at a time

Family readiness:Time to make a decision

Family will go on

Waiting for a miracle

Discussion

Family readiness

to have discussion regarding withdrawal of

LST as a possible option

to make decision regarding withdrawal of

LST

Discussion

In their own time This study found that approaching families before

they come to the point of understanding patient’s condition and prognoses were more resistant to withdrawal and opted for aggressive treatment

The End

Bibliography In Their Own Time: The Family Experience during the Process of Withdrawal of Life Sustaining Therapy,

Wiegand Debra Journal Of Palliative Medicine Vol 11 Nov 8,2008 115-1121

AMA Website on Medical Futility

Perceptions of “futile care” among caregivers in ICU Robert Sibbald MSc, et al CMAJ.JMAC 177 (10)1201;

2007

Moral Fictions and Moral Ethics, Frank Miller et. al, Bioethics Vol 24, Nov 2010 453-460

End Of Life Treatment Preferences Among Older Adults: An Assessment of Psychosocial Influences Debra

Carr NIH Public Access 2009

Prolonging life and delaying death:The role of physicians in the context of limited intensive care resources,

Robert McDermid et. al Philosophy, Ethics, and Humanities in Medicine Feb 2009