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.