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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

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

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

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

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.

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

Withdrawal 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 Treatment • Not initiating a therapy that has a disproportionate burden without achieving reasonable clinical goals

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.

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.

Withdrawal 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 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 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 Ventilation • Not predictors: • age • severity of illness • organ dysfunction

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

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

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

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

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

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?

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

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.”

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?

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.

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.

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

“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” • What would you do? • PA cath • CPR • Dialysis

“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 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

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

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

Non-medically Beneficial Treatment(Futile Care) • Would you offer dialysis? • If so, why? • If not, why not?

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.”

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.”

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

Legal Issues • Cruzan - principle that a competent person’s right to forgo treatment, including nutrition and hydration, protected under 14th amendment

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

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

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

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

CPR • Physically and emotionally traumatic • Significant likelihood of iatrogenic injury • Disrupts the care of the living • Communicates false hope to the families

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

CPR • Predictors of outcome: • Favorable • respiratory arrest • unexpected • witnessed • Unfavorable (no survival to discharge) • not witnessed • pulseless electrical activity • asystole

CPR • Age is not a major predictor of outcome. • Underlying medical conditions are a predictor. • CPR greater than 10 minutes - no survivors

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

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

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.

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