1 / 29

Just How Far Is Too Far? Ethics and Transitions From Technology To Support

Just How Far Is Too Far? Ethics and Transitions From Technology To Support. John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University Medical Center. Learning Objectives. Appreciate ethical dilemmas.

roxy
Download Presentation

Just How Far Is Too Far? Ethics and Transitions From Technology To Support

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Just How Far Is Too Far?Ethics and Transitions FromTechnology To Support John R. Stone, MD, PhD Center for Health Policy and Ethics Creighton University Medical Center

  2. Learning Objectives • Appreciate ethical dilemmas. • Explain ethical features of deciding about transitions from life-saving devices to supportive care. • Describe discussion strategies about advance directives and turning off implanted devices.

  3. Terminology • AD: Advance Directive (e.g., living will, power of attorney for health care or generally) • CIED: Cardiovascular Implantable Electronic Devices • ICD: Implanted Cardioverter Defibrillator

  4. Story • Progressive Alzheimer’s and a pacemaker for intermittent heart block and syncope

  5. Decision Process Spouse Patient made wishes clear AD? Children

  6. StoryCongestive Heart Failure AD? H H H ICD AD? AD? H Quality of Life H Turn off ICD? Time

  7. ICDs/End-of-Life • “In the last weeks of their lives, twenty percent of ICD patients receive shocks which are painful and known to decrease quality of life and which greatly contribute to the distress of patients and their families.” Lampert et al. 2010, p. 1008

  8. Physicians/End-of-Life Discussions • “Studies show that many physicians report uneasiness with conversations addressing device management as patients near the end of their lives.” Lampert et al. 2010, p. 1008

  9. Ethics & Deciding: Rescue to Comfort • Promote early ADs and related discussions • Establish a moral space for good decisions and helpful dialogue • Respectful • Comfortable • Caring • Supporting • Continue dialogue over course of the illness

  10. Questions • Encourage patients to execute ADs? • Advise to consider conditions for turning off CIEDs in ADs? • Why? • When? • How?

  11. Questions If a patient with decision-making capacity or, if legally declared incompetent, a legal surrogate requests turning off a CIED: • Is it ethically permissible? • Is it euthanasia or physician-assisted suicide? • Is it permissible to refuse?

  12. CIEDs: Legal/Ethical • “A patient with decision-making capacity has the legal right to refuse or request the withdrawal of any medical treatment or intervention, regardless of whether s/he is terminally ill, and regardless of whether the treatment prolongs life and its withdrawal results in death.” Lampert et al. 2010, p. 1009

  13. CIEDs: Legal/Ethical • “When a patient lacks capacity, his/her legally-defined surrogate decision-maker has the same right to refuse or request the withdrawal of treatment as the patient would have if the patient had decision-making capacity.” Lampert et al. 2010, p. 1009

  14. CIEDs: Legal/Ethical • “Ethically and legally, there are no differences between refusing CIED therapy and requesting withdrawal of CIED therapy.” • “Advance directives should be encouraged for all patients with CIEDs.” Lampert et al. 2010, p. 1009

  15. CIEDs: Legal/Ethical • “Legally, carrying out a request to withdraw life-sustaining treatment is neither physician-assisted suicide nor euthanasia.” Lampert et al. 2010, p. 1009

  16. CIEDs: Legal/Ethical • “Ethically, CIED deactivation is neither physician-assisted suicide nor euthanasia.” Lampert et al. 2010, p. 1009

  17. CIEDs: Legal/Ethical • “A clinician cannot be compelled to carry out an ethically-and legally-permissible procedure (i.e., CIED deactivation) that s/he personally views in conflict with his/her personal values. In these circumstances, the clinician cannot abandon the patient but should involve a colleague who is willing to carry out the procedure.” (Underline added) Lampert et al. 2010, p. 1009

  18. Surrogate Decision-Making • If insufficient capacity/ declared incompetent • Must respect patients’ AD choice of surrogate • If no AD surrogate, “clinicians must identify the legally recognized appropriate surrogate” as per their state. Lampert et al. 2010, p. 1010

  19. Questions • Encourage patients to execute an advance directive (AD)? • Should patients be advised to include conditions for turning off CIEDs in their ADs? • Why? • When? • How?

  20. Worries • If we introduce the idea of withdrawal of pacer/ICD support, are we giving the patient and family the message that • we are giving up or • their outlook is worse than we say? • Will we destroy their hope? • How avoid such messages or outcome?

  21. Question • How should we introduce the discussion about future termination of pacemaker or ICD life support?

  22. ADs, CIEDs, & Hope Discussions • Setting: Calm, Caring, Privacy, Comforting, Positive • Perception: Patient’s, Provider’s (comfort with death, dying, and the discussion) • Invitation • Knowledge • Empathy • Summarize/Strategize • Guide (Documents, navigation) Adapted from Henning & Carlson 2010

  23. Background Forces Rescue Support Comfort

  24. Background Forces Rescue Long-term Care Support Comfort Acute Care Technical Imperative

  25. Ethics and Choices Withdraw CIED Requests withdrawal Has capacity Requests withdrawal Respect for Autonomy AD Directive, values, preferences Respect for Persons Lacks Capacity/legally declared incompetent Substituted Judgment AD Surrogate Lampert et al. 2010, p. 1009

  26. Ethics and Choices Withdraw CIED No AD, values & preferences unclear Requests withdrawal Best Interests Respect for Persons Protect & promote best interests Lacks Capacity/legally declared incompetent Legal Surrogate

  27. Sharing Bad News • Avoidance: Responsible, practice failure, adverse reactions, unresolved personal issues about death and dying • SPIKES Protocol* • Setting • Perception • Invitation • Knowledge • Empathy • Summarize & Strategize *Henning & Carlson 2010

  28. References/Resources-1 • Butler, Katy. (2010, June 14). What Broke My Father’s Heart. The New York Times. • Goldstein N, Carlson M, Livote E, Kutner JS. (2010) Management of Implantable Cardioverter-Defibrillators in Hospice: A Nationwide Survey. Annals of Internal Medicine,152 (5), 296-299. • Henning, Kevin S; Carlson, Margi. (2010, April). Delivering Bad News: Helpful Guidance that Also Helps the Patient. National Hospice and Palliative Care Organization. Newsline. http://www.nxtbook.com/nxtbooks/nhpco/newsline_201004/#/0 • Kramer, D. B., Ottenberg, A. L., Gerhardson, S., Mueller, L. A., Kaufman, S. R., Koenig, B. A., & Mueller, P. S. (2011). "Just because we can doesn't mean we should": Views of nurses on deactivation of pacemakers and implantable cardioverter-defibrillators. Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmias and Pacing, 32(3), 243-252. doi: 10.1007/s10840-011-9596-7 • Lampert, R., Hayes, D. L., Annas, G. J., Farley, M. A., Goldstein, N. E., Hamilton, R. M., . . . Zellner, R. (2010). HRS expert consensus statement on the management of cardiovascular implantable electronic devices (CIEDs) in patients nearing end of life or requesting withdrawal of therapy. Heart Rhythm: The Official Journal of the Heart Rhythm Society, 7(7), 1008-1026. doi: 10.1016/j.hrthm.2010.04.033 • Matlock, D. D., Nowels, C. T., Masoudi, F. A., Sauer, W. H., Bekelman, D. B., Main, D. S., & Kutner, J. S. (2011). Patient and cardiologist perceptions on decision making for implantable cardioverter-defibrillators: A qualitative study. Pacing and Clinical Electrophysiology : PACE, 34(12), 1634-1644. doi: 10.1111/j.1540-8159.2011.03237.x; 10.1111/j.1540-8159.2011.03237.x

  29. References/Resources-2 • Mueller, P. S., Ottenberg, A. L., Hayes, D. L., & Koenig, B. A. (2011). "I felt like the angel of death": Role conflicts and moral distress among allied professionals employed by the US cardiovascular implantable electronic device industry. Journal of Interventional Cardiac Electrophysiology: An International Journal of Arrhythmias and Pacing, 32(3), 253-261. doi: 10.1007/s10840-011-9607-8 • National Hospice and Palliative Care Organization. Talking About Treatment Options and Palliative Care: A Guide for Clinicians. http://www.nhpco.org/i4a/pages/index.cfm?pageID=6412 • Phend, Crystal. (2010, May 14). HRS: Cardiac Device Deactivation Not Euthanasia, Society Says. Medpage Today. http://www.medpagetoday.com/MeetingCoverage/HRS/20119 • Raphael, C. E., Koa-Wing, M., Stain, N., Wright, I., Francis, D. P., & Kanagaratnam, P. (2011). Implantable cardioverter-defibrillator recipient attitudes towards device deactivation: How much do patients want to know? Pacing and Clinical Electrophysiology: PACE, 34(12), 1628-1633. doi: 10.1111/j.1540-8159.2011.03223.x; 10.1111/j.1540-8159.2011.03223.x • Russo, J. E. (2011). Original research: Deactivation of ICDs at the end of life: A systematic review of clinical practices and provider and patient attitudes. The American Journal of Nursing, 111(10), 26-35. doi: 10.1097/01.NAJ.0000406411.49438.91 • Waterhouse, E., & Ahmad, F. (2011). Do implantable cardioverter defibrillators complicate end-of-life care for those with heart failure? Current Opinion in Supportive and Palliative Care, 5(4), 307-311. doi: 10.1097/SPC.0b013e32834d2cce

More Related