WVUH Ethics Committee & Ethics Consultation

1. WVUH Ethics Committee &Ethics Consultation  Palliative Care Consultation Alvin H. Moss, MD Barb Mulich, RN, FNP, CHPN

2. “She wants to be a full code.” A frail 96-yr old woman is admitted in pulmonary edema. She is known to have inoperable severe aortic stenosis and 3 ° HB treated with a pacemaker. She has had a recent MI. Prior to the MI, her EF was 15%. This is her third hospitalization in six months. Shortly after admission, she becomes hypotensive and oliguric. She is started on a Levophed drip to keep her systolic pressure above 80 mmHg. She remains tachypneic. Workup reveals a new massive MI with troponin level of 4.5. Her BUN and Creatinine rise to 53 and 1.7, and a nephrology consultation is requested. Nephrology declines to dialyze the patient because she is too unstable. The family gets irate and requests dialysis, full code status, and mechanical ventilation if needed. They claim age discrimination. The patient is asking for CPR, but it is hard to determine her understanding secondary to her hearing deficit. What should you do?

3. Ethics Consult orPalliative Care Consult?

4. Objectives • Provide an example of ethics consultation • Identify the indications for an ethics consultation • Present the most common reasons for ethics consultation • Highlight the Advance Directive, Do Not Resuscitate, and Health Care Surrogate laws • Present an example of palliative care consultation • Introduce the Palliative Care Service and the CHIP DNR/comfort screen

5. Indications for Ethics Consultation • An impasse with the patient/family in medical decision making, i.e., there is conflict. • Disagreement within the health care team about the appropriate management of a patient, i.e., there is conflict. • An unusual, unprecedented, or very complex case ethically. • The patient lacks decision-making capacity and has no advance directive or identifiable surrogate to assist in decision-making for the patient.

6. Most Common Reasons for Ethics Consultation • Assistance with decision-making about the withdrawal of life support, especially when there is conflict • Assistance with decision-making about CPR status, MV, and feeding tubes • Interpretation of advance directives

7. Decision-Making for Patients without Capacity • Based on Advance Directives • with MPOA representative if named • according to the Living Will • Based on Best Interests • with MPOA representative if named • with health care surrogate

8. DiagramHealth Care Decision-makingfor Adults

9. Does the patient have a medical power of attorney? If not, what should you do?

11. Would you be surprised if the patient died in the next year?

13. The POST Form into West Virginia Code • a STANDARD form • LEGALLY recognized DNR identification • legal PROTECTION--health care providers are not subject to civil or criminal liability for good faith compliance with or reliance upon POST • protocol for interinstitutional TRANSFERS

14. Use of POST Form • Discharge of patients to… • Nursing Homes • Hospice • Home Health

16. Palliative Care Consultation

17. “I want to die at home.” A Palliative Care consult was requested for a 68 yr. old man w/ end-stage heart disease and CKD. He was admitted 3 wks earlier for heart failure. Each time he would get close to being discharged, he got worse. The case manager suggested a palliative care consult to the cardiologist. The patient had been in the hospital four times in the previous month. The pt had asked his wife "why did you bring me in?” The patient wanted to die at home.

18. “I want to die at home.” The patient was afraid of suffocating, but ready to die. Shortness of breath and swelling were main symptoms.The patient wanted to say good-bye to his brothers and sisters who were out of town. He lived with his wife and a daughter. The daughter was not reconciled to the patient's dying, requesting dialysis and home monitoring of O2 saturation. His wife was willing to honor the patient's wishes. What should you do?

19. Aspects of Palliative Care • Pain and symptom management • Advance care planning • DNR • Advance Directives • Psychosocial and spiritual support • Cultural support

20. Definition Palliative care is comprehensive, interdisciplinary care of patients and families facing a chronic or terminal illness focusing primarily on comfort and support. Billings JA. Palliative Care. Recent Advances. BMJ 2000:321:555-558.

21. Curative / Remissive Therapy Presentation Death Hospice Palliative Care Source: EPEC

22. Reasons for Palliative Care Consultation • pain and sx assessment and management • assistance in making difficult decisions, usually about continued use or withdrawal of life-sustaining treatment • assistance in planning for the most appropriate care setting to meet patient/family goals • provision of psychosocial and spiritual support to patients, families, and the health care team

24. WHO 3-stepLadder 3 severe Morphine Hydromorphone Methadone Levorphanol Fentanyl Oxycodone ± Adjuvants 2 moderate A/Codeine A/Hydrocodone A/Oxycodone A/Dihydrocodeine Tramadol ± Adjuvants 1 mild ASA Acetaminophen NSAIDs ± Adjuvants

25. CHIP Master Guide • Comfort/Treatment Limits • CPR status • Treatment Limitations • Comfort Measures • Pain/Other Symptoms • Spiritual/Emotional • Hospice/Home Health • Advance Directives/Surrogate

26. Obtaining Consults • CHIP • Paging • Ethics – beeper 0857 M-F 8-4:30 • Paging operator nights/weekends for ethics advice • Palliative Care – beeper 0857 M-F 8-4:30

27. www.wvendoflife.org Toll-free 1-877-209-8086

28. www.wvendoflife.org • Downloadable living will and MPOA • Downloadable surrogate selection form • Request DNR and POST forms • Request Hard Choices for Loving People