THE END OF LIFE

1. THE END OF LIFE AARTI RAGHU, M.D.

2. “…. death, a necessary end, will come when it will come.” - William Shakespeare

3. What we’re going to talk about.. • Issues with End of Life Care • The numbers • How are we doing? • Ethical Issues • Determining goals of care - Informed consent • Advance directives • Communication - Housestaff and communication • Withdrawal of Medical care and Legal Issues • Euthanasia • Futility • Physician withdrawal from patient care • When a patient dies- impact on physicians • Websites for patients

4. Why talk about it? • A century ago, most people with traumatic injuries, serious infections, heart disease or cancer had little expectation of a long life after diagnosis • Most people expected little more than comfort measures from doctors. • Today, death is often seen as an event that can be deferred indefinitely rather than as an intrinsic part of life. • Medical procedures commonly extend the lives of people who have such diseases as heart disease, cancer, stroke, chronic obstructive pulmonary disease, pneumonia, and dementia, often giving them many years in which quality of life and function are quite good but not always so. • Talking about the likely outcomes of illness, including death and dying, is an important part of health care. • Health care providers vary in their comfort levels discussing end of life issues. • There is a lack of formal education for providers regarding end of life

5. Societal Attitudes As a society - we do not accept death. We have deformed the process of dying. • Death is a failure • Death is often taboo • Mastery over nature • Legal paranoia • Palliative care is giving up • Fear of addiction (drugs) • Lack of reimbursement for palliative care • Health care system focuses on and reimburses for acute care interventions

6. What are some of the problems Vanishing line between old age & death - old age is a disease to be conquered/controlled • live for years with chronic illnesses • biomedicalization of aging has replaced the cultural understanding of aging (religion, nature, family) • we can orchestrate & control the timing of death Gulf between lay & medical worlds - new frontier - vast gulf between medical knowledge & lay - family members make decisions based on medical world of aging & death/ not the patients life experience The technological imperative - success reinforces use of technology - death can be conquered - goal of medicine - cure - implicit moral imperative to “do something” Lack of clarity with treatment goals - “everything done” - Goals are not clarified within patient values & quality of life

7. “What is needed to bring about change is something more fundamental, that is a hard look at a medical culture in which doctors have access to splendid life saving technology & feel obligated both morally and legally to use it.” Daniel Callahan Director, International Program _ Co-Founder of The Hastings Center The Hastings Center is an independent, nonpartisan, and nonprofit bioethics research institute founded in 1969 to explore fundamental and emerging questions in health care, biotechnology, and the environment.

8. New Goals Death is expected Care of the dying is integral to health care Palliative Care Active total care which embraces the notion of alleviating and easing symptoms in lieu of continuing to attempt a “cure” Palliative care affirms life and regards dying as a normal process Palliative care is not giving up or losing hope. Palliative care is aggressive caring! Palliative care is aggressive symptom management

9. More reasons to talk about it… • In one study, elderly patients with chronic illnesses were more satisfied with their primary care physicians and outpatient visits when advanced directives were discussed. (1) • Apparent severity of chronic illness does not necessarily predict patient desire for EOL discussions. One study found that patients at later stages of chronic lung disease were no more or less interested in such discussions than patients with earlier stage chronic lung disease. (2) Among all the patients studied, 85 percent desired EOL discussions.

10. The statistics % of institutional deaths (NCHS, CDC 1998 data) • 56% in a hospital, clinic, or medical center; • 19% in a nursing home; • 21% of people died at home. (3) Almost half of those who die in the hospital have been cared for in an intensive careunit (ICU) within 3 days prior to their death. (4) Trends and Patterns in Place of Death,1989-2000 Jay S. Buechner, PhD Rhode Island Department of Health, Office of Health Statistics:Turning numbers into knowledge Vol. 4, No. 9 September 2002

11. In the ICUs of tertiary care centers, the withdrawal or withholding of life support precedes death in 65% to 90% of all deaths.(4)

12. The prevalence of written Advance directives is about 25% and did not significantly increase after the passage of the Patient Self Determination Act (5) End-of-life care consumes 10% to 12% of all health care expenditures and 27% of Medicare expenditures in the United States. In 1999, terminal hospitalizations accounted for 7.5% of all inpatient costs. Studies have shown that the amount that might be saved by reducing the use of aggressive life-sustaining treatment for dying patients is 3.3% of total national health expenditures. (4)

13. The incremental cost per QALY of providing rather than withholding ventilator support and restorative care increase across prognostic strata in terminally ill patients (SUPPORT study) The cost was $24,000 per QALY among low-risk patients, $44,000 per QALY among medium-risk patients, $110,000 per QALY among high-risk patients. Although treatment of low- and medium-risk patients appeared to be cost-effective, the incremental cost per QALY for those patients with a less than 50% chance of surviving at least 2 mo after diagnosis did not compare favorably with other medical interventions, such as therapy for severe hypertension or coronary artery bypass surgery. Schapira and colleagues - fewer than ¼ of cancer patients who were mechanically ventilated for acute respiratory failure survived the ICU or spent more than 3 mo at home before dying. Overall, the cost per year of life gained at home was $95,142 for patients with solid tumors and $449,544 for patients with hematologic malignancies. (6) Wachter and coworkers - analysis of patients with the acquired immunodeficiency syndrome (AIDS) who received mechanical ventilation for severe Pneumocystis carinii pneumonia (PCP). The cost of ICU admission of subsequent hospitalization for the 25% of patients who left the ICU alive averaged $174,787 per year of life saved over the 10 yr of this study. (7)

14. End of Life Care- How are we doing? The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995 Nov 22-29;274(20):1591-8 • OBJECTIVES--To improve end-of-life decision making and reduce the frequency of a mechanically supported, painful, and prolonged process of dying. • DESIGN--A 2-year prospective observational study (phase I) with 4301 patients followed by a 2-year controlled clinical trial (phase II) with 4804 patients and their physicians randomized by specialty group to the intervention group (n = 2652) or control group (n = 2152). • SETTING--Five teaching hospitals in the United States. • PATIENTS--A total of 9105 adults hospitalized with one or more of nine life-threatening diagnoses; an overall 6-month mortality rate of 47%. • INTERVENTION--Physicians in the intervention group received estimates of the likelihood of 6-month survival for every day up to 6 months, outcomes of cardiopulmonary resuscitation (CPR), and functional disability at 2 months. A specifically trained nurse had multiple contacts with the patient, family, physician, and hospital staff to elicit preferences, improve understanding of outcomes, encourage attention to pain control, and facilitate advance care planning and patient-physician communication.

15. RESULTS The phase I observation documented shortcomings in communication, frequency of aggressive treatment, and the characteristics of hospital death: only 47% of physicians knew when their patients preferred to avoid CPR 46% of do-not-resuscitate (DNR) orders were written within 2 days of death 38% of patients who died spent at least 10 days in an intensive care unit (ICU) and for 50% of conscious patients who died in the hospital, family members reported moderate to severe pain at least half the time

16. During the phase II intervention, patients experienced no improvement in patient-physician communication ( 37% of control patients and 40% of intervention patients discussed CPR preferences) or in the five targeted outcomes, ie, incidence or timing of written DNR orders (adjusted ratio, 1.02; 95% confidence interval [CI], 0.90 to 1.15), physicians' knowledge of their patients' preferences not to be resuscitated (adjusted ratio, 1.22; 95% CI, 0.99 to 1.49), number of days spent in an ICU, receiving mechanical ventilation, or comatose before death (adjusted ratio, 0.97; 95% CI, 0.87 to 1.07), or level of reported pain (adjusted ratio, 1.15; 95% CI, 1.00 to 1.33). The intervention also did not reduce use of hospital resources (adjusted ratio, 1.05; 95% CI, 0.99 to 1.12). CONCLUSIONS— The phase I observation of SUPPORT confirmed substantial shortcomings in care for seriously ill hospitalized adults. The phase II intervention failed to improve care or patient outcomes. Enhancing opportunities for more patient-physician communication, although advocated as the major method for improving patient outcomes, may be inadequate to change established practices. To improve the experience of seriously ill and dying patients, greater individual and societal commitment and more proactive and forceful measures may be needed.

17. ETHICAL ISSUES Autonomy and beneficence • The principle of autonomy dictates that the patient has the right to choose among offered therapies and the right to refuse any treatment even though this decision may result in the patient's death. • In contrast, the principle of beneficence dictates that medical personnel have the obligation to help further the patient's own legitimate interests. • Since preservation of life is a legitimate interest of the patient, the refusal of life-prolonging therapy creates the potential for conflict. • Allowing the patient to die can be viewed as a violation of beneficence, while forcing the patient to undergo heroic supportive measures is a violation of his or her autonomy. • In the United States a consensus has been achieved that autonomy takes precedence over other considerations. Autonomy and nonmaleficence — Nonmaleficence can be defined simply as not inflicting evil or harm • The principle of nonmaleficence requires that persons refrain from providing interventions, which in their judgment, are likely to be of more harm than benefit. • Often, patients request interventions which are without benefit and are harmful or dangerous. • It can be argued that nonmaleficence is a right of the physician (or other health care provider) to refuse to participate in practices which are judged to be harmful to the patient.

18. Non-abandonment and nonmaleficence — Judgments made regarding the appropriateness of a specific intervention are not always unanimous On the one hand, the physician is obliged to refrain from providing treatments that he or she feels are inappropriate; on the other, the physician must not abandon the patient. The physician is obliged to help the patient or surrogate understand the issues but, if this fails and the physician feels it would be morally wrong to continue to be involved with the care plan, then it is imperative that he or she attempt to find another physician willing to continue care of the patient in the prescribed manner. The physician must continue to care for the patient until such a physician is found. The patient may refuse other physicians, wanting to continue with the current physician; this does not mean that the physician is in any way obligated to perform the disputed intervention. Disclosure and beneficence — Physicians have an obligation to disclose relevant medical information to patients and families. A few patients (13 percent in one study (8) ) do not want to participate in end-of-life decisions. One survey of critical care physicians found that 14 percent reported that they had withdrawn care from patients without informing the patient's family. (9) Fair allocation of societal resources —society does not have unlimited financial resources to provide the "best possible" health care for all. Duty to an individual patient and to society as a whole may conflict in cases in which limited resources are disproportionately consumed by a critically ill individual. cost of cardiopulmonary resuscitation alone has been estimated at nearly $500,000 per life saved. End of life care consumes 10 to 12 percent of all healthcare expenditures and 27 percent of all Medicare expenditures. (10, 11)

19. Case Scenario 56 yo male 5 months s/p palliative choledochoenterostomy for metastatic Ca of the head of the pancreas >30 lb. weight loss since operation and increasing weakness/fatigue (esp. last 2 months) Postprandial vomiting for last 3 weeks Very large distended stomach with mass obstructing proximal duodenum - endoscopist unable to stent Patient asks you to “fix it!” (When Do We Stop and How Do We Do It? Medical Futility and Withdrawal of Care Daniel B.Hinshaw, M.D.,FACS, Ann Arbor,MI. www.facs.org/education/congress2002)

20. Case Scenario – continued What should you do next? 1) Tell the patient: “ It’s hopeless. There’s nothing more that can be done.” 2) Place a PEG for gastric decompression. 3) Determine the patient’s understanding of the problem. What does he mean by “fix it”? 4) Encourage endoscopist to reattempt stenting of the obstructed segment of duodenum. 5) Institute NG decompression in anticipation of performing a palliative gastrojejunostomy.

21. Case Scenario – continued • What is the problem here? • Is it about a series of inadequate treatment options? • It’s really about • Defining the goals of care (i.e., the patient’s • goals) even before entering the ICU • • Advanced Care Planning • Communication

22. Determining the Goals of Care Ask the informed patient. The patient’s goals of care should always be a central feature of informed consent. Remember the context. What is realistic under the circumstances? Set achievable goals with the patient (eg. reduce vomiting to once/day and control nausea).

23. Informed consent • Upto the1970s- medical decisions were made by the physician without participation from the patient. • This paternalism emphasized beneficence to the exclusion of other principles, particularly autonomy. • Studies show physicians are not always able to determine what is in their patients' best interests – their own preferences may be a bias.(12) • and biases are unavoidable.(13, 14)

24. By the mid-1980s- emphasis was on patient autonomy due to increased valuing of patient autonomy by society at large questioning of the assumption of physician beneficence in an era of cost containment Physicians began to act as impartial agents for their patients who were considered "clients" with the power to chose any therapy they desired. Even giving advice was considered exerting an inappropriate influence. This overemphasis on autonomy still exists in many ways. Patients or family members are often made to feel that they have to "make the decision" regarding decisions to resuscitate. Often poorly informed patients are confronted with an open-ended request to tell the medical team what "they want to have done." Often their response was to have "everything done" and this was accepted by the physician as a request for cardiopulmonary resuscitation when the physician, in fact, thought that this would be a mistake. In this scenario, the physician abandoned his or her traditional responsibility to protect the patient against inappropriate therapy in favor of complete autonomy. This diminished autonomy by depriving patients of expert advice. Therapy was chosen based on unrealistic beliefs; silence by the physicians interpreted as tacit approval. The pendulum has begun to swing back from absolute autonomy toward a more balanced approach. These models have been termed - enhanced autonomy - the fiduciary role A model based solely on one principle (such as autonomy) is no better than one based solely on another (eg, beneficence).

25. Who gives consent? The patient is the primary decision maker if he has….. • The ability to communicate • The ability to understand the proposed treatment and alternative interventions - ask the patient to paraphrase • The ability to grasp the consequences of accepting and of declining the suggested treatment • The ability to reason. Exceptions… • Depression- preferences are clouded by their mood disorder - Overriding the wishes of a seemingly capable patient who is depressed is a serious matter and is one situation in which psychiatric involvement should be sought. • Cultural issues- in patients who are members of various ethnic groups, decision-making is customarily delegated to other family members. - most patients, at least those who have cancer, want to be informed if their illness is terminal, while family members' opinions may differ. (15) - ask patients directly whether they wish to be involved.

26. Informed Consent- Principles • How much information does the patient require? Three possible standards by which the adequacy of information provided may be judged: • The professional community standard: comparisons with other physicians; established by national professional organizations. • The reasonable person standard: information desired by a well-reasoning individual who is free of mental or physical illness and no conflicting interests - subjective, variable factors related to cultural and educational background. • The subjective standard: requires the physician to use experience and judgment to decide - information tailored for a specific clinical situation, by the physician, leaves one open to criticism

27. Does the patient understand the information? —ask the patient to summarize what has just been said and to correct as needed. Is there a conflict of interest? —especially if surrogate decision makers Informed consent is in place only when adequate information, adequate understanding, and lack of coercion have been verified. Incompetent patients (patients lacking decision making capacity) —patients do not lose their autonomy when they become incompetent -the medical team and persons who are well acquainted with the patient attempt to reconstruct the patient's judgment by analyzing prior statements and his or her overall values and beliefs. This is referred to as "substituted judgment." >90 percent of patients prefer that, if incapacitated, family members make medical decisions for them along with their physicians. (16)

28. Opinions of the physician — The renewed emphasis on informed consent has created the temptation for physicians to shift the decision-making process entirely to patients or their families. This is an incorrect approach, because informed consent is a process that requires the involvement of both the patient and the health care team. It is not only acceptable but also required for the physician to render an opinion regarding what he or she believes is the proper course of action. It is unacceptable for a set of facts to be merely presented to the patient without additional professional input and advice. Decisions of this gravity are best made jointly by those who have an in-depth knowledge of the patient's wishes and philosophy combined with those who understand the details of the pertinent medical issues.

30. Case Scenario 2 81 y/o female with advanced, widely metastatic breast cancer refractory to therapy presents in the ED with progressive SOB and debility. A two year old advanced directive exists stating her desire to “live as long as I have a meaningful quality of life and heroic measures are acceptable as long as there is a chance of recovery.”

31. You would next: 1) Invoke her advanced directive and admit her to a general care ward for “comfort measures” only. 2) Ask the patient, “if your heart should stop or you are unable to breathe on your own, would you want us to do everything possible to get your heart started again and keep you breathing?” 3) Invoke the advanced directive and admit her to the ICU for workup and potential ventilatory support. 4) Discuss with the patient and her family their understanding of the situation, its meaning in relation to her disease process and clarify her goals of care.

32. Advanced Directives Advanced directives direct physicians on what type of care patients do and do not want if unable to make a decision. Living Will - comes into effect when a patient is terminally ill and has less than 6 months to live. Limited by their vagueness; they do not specify what interventions are to be avoided and are generally applicable only to a dying patient. Durable Power of Attorney for Health Care – a kind of advance directive that selects a proxy decision maker- 2 types - permanent - springing DNR order Only 28% have prepared an advance directive (The George H. Gallup International Institute, Spiritual Beliefs and the Dying Process, A Report of a National Survey Conducted for the Nathan Cummings Foundation and Fetzer Institute,October 1997, p. 47).

33. Use a form-from physician/health dept. Patient writes down wishes in own language By a lawyer Use software package for legal documents. Ensure state laws are followed and review with physician/lawyer, notarize, distribute to PCP/family Can be revoked verbally/in a legal document. How to write an Advance Directive

34. Do Advanced Directives Make A Difference? UNC study - patients interviewed prospectively about preferences regarding aggressive measures to sustain life and then followed for six months. No significant association between patient willingness to receive aggressive Rx and whether the patients actually received aggressive Rx when they were critically ill. (17) Survey done of physicians using six hypothetical clinical scenarios. Cases contained an explicit advance directive with a potential conflict between the directive and prognosis, wishes of family/friends, or QOL. -Physicians' choices differed from the patients' stated advance directives in 65 percent of cases, suggesting that they viewed the advance directive as only part of the information needed to make treatment decisions. (18)

35. Instructional directive — to compensate for the limitations of the original living wills. One such instrument, the Medical Directive, asks patients to decide in advance which of a dozen possible interventions they would favor in the event of any of four potential scenarios: Coma with virtually no chance of recovery Coma with a small chance of recovery, probably to an impaired state Advanced dementia plus a terminal illness Advanced dementia The interventions include cardiopulmonary resuscitation, respirator support, artificial nutrition and hydration, major surgery, dialysis, chemotherapy, minor surgery, invasive diagnostic tests, blood transfusions, antibiotics, simple diagnostic tests, and pain medications. Problems - does not address considerations that may be given to limitation of treatment, such as moderate dementia or physical frailty. - no discussion of the goal of the interventions, the directive does not allow the individual to distinguish between short-term use of an intervention for a potentially reversible illness, and long-term treatment for a chronic condition. - it is a formidable document which may be quite intimidating in an older impaired population. a randomized trial of a complex advance directive was able to demonstrate that nursing homes that used the directive had decreased hospitalization rates and lower costs. (19) Instructional directives may significantly improve the ability of hospital-based physicians to ascertain patients' preferences. (20)

36. Values history — The values history seeks to ascertain which facets of life are most important to a given individual in the hope that this will help define how they wish to die. The questionnaire asks patients to state their religious background, their views of dependency, and attitudes towards physicians. Combined directive — Increasingly, advance-planning documents are being developed that include components of the living will, the values history, and the instructional directive, while also designating a surrogate decision-maker. A popular example is the Five Wishes, which is legally accepted in many states.

37. DNR orders… Death - the “D” word has to come out of the closet. Instead of asking: “ if your heart stops, would you want us to start it again…,” try: “when (if) you die from this illness an attempt to resuscitate your body will happen (by default). Would you want this to occur? It may not change anything but potentially be disturbing for those caring for you and your loved ones who might witness it.” In a study of Medicare admissions to SNFs, 32% of residents had DNR directives whereas < 2% had DNH directives. Factors associated with either directive included older age, cognitive impairment, functional dependence Caucasian ethnicity, being a resident at a rural or government facility. (21) In a questionnaire study at a community cancer center – Only 34% of patients correctly understood the meaning of DNR 66% thought DNR was administered only to prolong life without realizing that a DNR decision would result in no intervention even in potentially reversible conditions. (22)

38. Case Scenario A 79 y/o WM with severe COPD, CHF, CAD and A Fib is admitted to your service with LE cellulitis. He is incidentally noted to have a lump in the neck which proves to be metastatic carcinoma. MRI shows a nasopharyngeal mass. The diagnosis is communicated to him appropriately, oncology is consulted and he is scheduled for outpatient biopsy of the nasopharyngeal mass and dental extraction prior to radiation. At the time of discharge, the patient reports that his cellulitis “feels worse” after being switched to PO antibiotics and is very upset about the discharge plans and wants to fire his primary team. You will…. • Restart IV antibiotics • Request a colleague to assume care • Tell him “ there is no indication for change of therapy or continued inpatient care” • Ask him “ How do you feel about your diagnosis?”

39. Communicating Bad News Find a quiet, private place – minimize interruption Make sure the timing is right for the patient (and that there is enough time) Give the news in person - sit close to the patient; avoid bad body language - don’t cross legs, lean forward toward the patient (+/- comforting touch) If possible (and if wanted by the patient), have support network present (family, friends) Clarify the patient’s understanding of the situation - listen to the patient. Reduce the element of shock - fire a “warning shot” - e.g., “ I’m afraid I have bad news.”

40. Tell the truth - but give the patient a chance to indicate how much s/he wants to know - don’t force information on someone who is not ready for it. Silence is good - pause after delivering the news so that patient can absorb it and react appropriately. Cultural differences exist (e.g., in some cultures, family will control flow of information). Convey hope (if not for cure, at least for relief of pain and other symptoms and for the best possible quality of life remaining) Reassure the patient that s/he will not be abandoned! (Ptacek, JT and Eberhardt, TL Breaking Bad News: A Review of the Literature, JAMA 276: 496-502, 1996)

41. SPIKES—A Six-Step Protocol for Delivering Bad News: Application to the Patient with Cancer (Bailea et al. The Oncologist, Vol. 5, No. 4, 302-311, August 2000) STEP 1: S—SETTING UP the Interview • Arrange for some privacy. • Involve significant others. • Sit down. • Make connection with the patient. • Manage time constraints and interruptions. STEP 2: P—ASSESSING THE PATIENT'S PERCEPTION STEP 3: I—OBTAINING THE PATIENT'S INVITATION STEP 4: K—GIVING KNOWLEDGE AND INFORMATION TO THE PATIENT STEP 5: E—ADDRESSING THE PATIENT'S EMOTIONS WITH EMPATHIC RESPONSES STEP 6: S—STRATEGY AND SUMMARY

43. David Guidry, I ICU Nurse >> “ When you are involved in someone’s end of life care, they (the family) will never forget you…. …… do it poorly and they’ll never forgive you.”

44. Training Housestaff on communication • A self- administered questionnaire was given to 3 consecutive cohorts (1996-98) of incoming interns (n=162, n=155 U.S. graduates) of which 152 completed it. They reported very little classroom teaching, clinical observation, or clinical experience with end-of-life communication during medical school. Clinical observation and experience with caring for and communicating with dying patients were associated with greater perceived comfort and skill, whereas classroom teaching was not. (23) • The Palliative Care Clinical Evaluation Exercise (CEX) is an experience based intervention to teach communication skills in giving bad news and discussing code status. It allows faculty to observe, evaluate and give feedback to housestaff in their discussions with patients and families. Completed by 44 residents at University of Pittsburg’s Categorical IM Residency program- included pre-discussion counselling, resident-patient discussion and feedback (total avg. 49.5 mins.) Self- ratings showed improvement in 1 week. (24)

45. Case scenario A 56 y/o African-American woman is admitted with SOB. She has extensive metastatic carcinoma with an unknown primary, b/l hydronephrosis s/p nephrostomy tubes with anuric renal failure, severe acidosis, volume overload, anasarca, hyperkalemia, poor po intake, depression. Her diagnosis and prognosis are explained to her and she voices understanding. When you attempt to address objectives of care, she insists on aggressive treatment and refuses DNR orders. She develops hypotension and hypoxic respiratory failure and is intubated and started on pressors. Her daughter who is next of kin refuses to withdraw care and wants her mothers’ wishes followed. You would.. • Keep her code status as full code • Tell your cross cover to perform a “slow code” • Declare the patient incompetent with another physician and put in place a DNR order • Call an ethics committee meeting

46. Withdrawal of Care When to withdraw? • death is felt to be inevitable despite continued treatment. • dysfunction in three or more organ systems persists or worsens despite active treatment • At the patient’s/family’s request- when advance directives become available These decisions remain difficult because of the paucity of data on different clinical scenarios. Whatever the definition of futility used, the physicians must act as advocates for the patient. This requirement has, however, been criticized as paternalistic. The advance refusal of treatment is legally binding provided certain conditions are met.

48. Goldman: Cecil Textbook of Medicine, 22nd ed.

49. Problems with withdrawal of care • The referring team request continued futile therapy Explain the rationale and offer a second opinion. If conflict still remains, treatment cannot be withdrawn. The family should not be informed of a decision to withdraw that is then rescinded because of interteam conflicts. It will reduce their faith in subsequent decisions + undermine confidence in the predicted outcome. • The patient's family requests continued futile therapy Guilt usually plays a part, although religious and cultural factors may also contribute. Agreement can usually be obtained by explaining the rationale again and offering a second opinion from within or outside the intensive care team. It is best not to withdraw treatment if there is conflict. However, the final decision rests with the primary care team. This underlines the need for good communication. • The family requests inappropriate discontinuation of therapy The rationale behind the therapy and the reasons why continuing treatment is thought appropriate should be explained. The duty of care is to the patient, not the family. Again, a second opinion can be offered. • The patient requests discontinuation of therapy Explain to the patient the rationale for the treatment and that, in the opinion of the primary team, a chance of recovery exists. It may be appropriate to offer a short term contract for treatment (for example, 48 hours then review). Ultimately, the competent patient has the right to refuse treatment even if that treatment is life saving.

50. Case Scenario continued…. The patient in the previous case scenario goes into Ventricular Fibrillation… The daughter still wants a full code… The ethics committee is still debating the case… Would you.. • Perform CPR • Try a “slow code” • Hold CPR and institute a 2 physician DNR order stat • Call the code citing futility