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STEFANO NAVA Pneumologia e Terapia Intensiva Respiratoria Ospedale Sant’Orsola Malpighi BOLOGNA

Ethics and end-of-life issue in RICU A European perspective. ANTALYA 5/4/2032. STEFANO NAVA Pneumologia e Terapia Intensiva Respiratoria Ospedale Sant’Orsola Malpighi BOLOGNA. “ I just want to give a meaning to a situation that has no meaning“ (Vasco Rossi). The facts.

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STEFANO NAVA Pneumologia e Terapia Intensiva Respiratoria Ospedale Sant’Orsola Malpighi BOLOGNA

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  1. Ethics and end-of-life issue in RICU A European perspective ANTALYA 5/4/2032 STEFANO NAVA Pneumologia e Terapia Intensiva Respiratoria Ospedale Sant’Orsola Malpighi BOLOGNA

  2. “ I just want to give a meaning to a situation that has no meaning“ (Vasco Rossi)

  3. The facts More and more patients are placed on mechanical ventilation (MV) Who is going to decide when and why: - the time is come to suspend MV - someone does NOT “merit” MV - who is involved in the decision

  4. Publications on End-of-Life issues YEARS n. publications

  5. “I am not afraid to die. I just don't want to be there when it happens ” Woody Allen

  6. INTRODUCTION • In most Western countries, about 1% of the population dies every year • Advances in medicine have greatly improved possibilities to treat seriuosly ill chronic patients and to prolong life • There is increasing recognition that extension of life might not always be an appropriate goal of medicine • Medical end-of-life decisions can take place in any setting at which patients die, that is in hospital, nursing homes, hospices and at home

  7. death • (World Health Organization 2002)

  8. 4 items were identified : • Correct Information • Symptoms control • Mobility • Relief of burden

  9. Communications

  10. Do WE KNOW HOW TO SPEAK WITH RELATIVES ? % J.Gen.Intern.Med. 1995;10:436

  11. Do WE KNOW HOW TO SPEAK WITH RELATIVES ? % Overall >50% of speak J.Gen.Intern.Med. 1995;10:436

  12. Do WE KNOW HOW TO SPEAK WITH RELATIVES ? % Overall >50% of <50% of speak speak J.Gen.Intern.Med. 1995;10:436

  13. “And we [family members] had another concern my mother specifically wanted to mention, the way they would talk about these issues [DNR decision] within hearing range of my father. And we felt like he could hear, even if he could not respond, and it might hurt his chances for recovery to hear us talking about him. My mother would have to motion to go into the hall.”

  14. 42% were considered COMPETENT Total North EU South EU

  15. Symptoms control

  16. Drugs used in the last month of life Only about 50% of patients achieved control of symptoms % of patients

  17. Family’s burden

  18. Where do the end-stage respiratory patients die ?

  19. Family’s burden

  20. Decisions

  21. DEFINITIONS • Withholding : a planned decision not to institute therapies that were otherwise warranted (i.e. intubation, renal replacement therapy, increased doses of vasopressor infusions, surgery, transfusion, nutrition, hydration). • Withdrawal: discontinuation of treatments that had been started (i.e decreasing FiO2 21%, extubation, turning off the ventilator, suspend the vasopressors….) • Euthanasia : from eu and anatos = good death. A doctor intentionally killing a person who is suffereing unbearably and hopelessly at the latter’s voluntary, explicit, repeated, well-considered and informed request

  22. WHO is THE CANDIDATE for end-of-life decision ? Decision to withhold or withdraw life-sustaining treatment are often hindered by prognostic uncertainly, since it is usually difficult to identify at an early stage, and without resonable doubt those patients who will inevetably die. Typically the prognosis only becomes obvious late in the evolution of the acute or chronic illness. Unfortunately the available severity scoring systems do not predict outcome in individual patients with sufficient accuracy to be useful in end-of-life decision making.

  23. BMJ 2000 20% of predictions were accurate 63% were overoptimistic 17% overpessimistic.

  24. Preferences

  25. Carico assistenziale Acuto (i.e. ETI) Outcome clinico

  26. N Engl J Med 1996; 334:1578-82 “Real” < 50%

  27. Anticipatory planning in severe COPDCarlucci et al. n. Carlucci et al

  28. NIV non-users NIV users Anticipatory planning in severe COPDCarlucci et al. n. Carlucci et al

  29. Anticipatory planning in severe COPDCarlucci et al. % patients 20% “I trust everything the physicians say” “I do not feel like talking about these issues” Carlucci et al

  30. NIV as a ceiling treatment:UNIQUE feature of the pulmonologists ?

  31. The problem of the “pain of breathing” (i.e. dyspnea) in terminally ill patients

  32. A systematic review of oxygen and airflow effect on relief of dyspnea at rest in patients with advanced disease of any cause This systematic review found low-grade scientific evidence that oxygen improve dyspnea at rest in some patients with advanced disease. However, there is no evidence to identify which patients will benefit from supplemental oxygen. Gallagher & Roberts J Pain Palliat Care Pharmacother. 2004;18(4):3-15.

  33. Total North EU South EU *

  34. survived died 44% of the patients survived the episode of ARF

  35. Observational trial 23 patients with solid malignancies

  36. Practicalities: the dying patient receiving MV including NIV Opiates Anticholinergic patches Physio, cough adjuncts Adjustment of ventilator settings Consider removing MV when patient comatose, replace with O2 via nasal cannulae to prevent terminal hypoxic fits

  37. General Principles Treat the treatable: exacerbations, CCF, PE etc. Explore advance directives: involve family and care team – this is just part of a management plan Continued and intensive efforts to palliate symptoms Recognise the inevitable Facilitate care in accordance with patient’s wishes where possible

  38. Conclusions When is “getting dark, too dark to see”: TALK with your patients and relatives with THEIR languages and LISTEN because we have one mouth and two ears CONSIDER their preferences (i.e. control the symptoms, use drugs and/or NIV, organize a home care program to relief their burden) IMAGINE TOGETHER their future and TAKE in ADVANCE the right decision about End-of-Life Do not unduly PROLONG life and suffering

  39. TALK and LISTENHable con ella(Pedro Almodovar)CONSIDER THE PATIENT’S NEEDS Through a glass darkly (Ingmar Bergman)TAKE TOGETHER the DECISIONMar adentro (Alejandro Amenábar) DO NOT PROLONG SUFFERINGLes invasions barbares(Denys Arcand)

  40. Le scaphandre et le papillon(Julian Schnabel)Johnny got his gun(Dalton Trumbo) Million dollars baby (Clint Eastwood)

  41. “Today medicine can and must relief my pain. If this will not happen, I will kill myself, but this should not be considered suicide butfailure in duty of care ” Prof. Sandro Bartoccioni, Cardiochirurgo Cittta’ di Castello, 25 agosto 1947 – Città di Castello, 2 giugno 2006

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