ethical dilemmas in intensive care
TRANSCRIPT
“The primary goals of intensive care medicine are to help patients survive acute threats to their lives while preserving and restoring the quality of those lives”
Truog R, et al. Critical Care Medicine 2008; 36: 953-963
Issues with changing goals of care
Most patients have a deep desire not to be dead.
Medicine cannot predict the future, and cannot give patients a precise, reliable prognosis about when death will come.
If death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle”
Truog R, et al. Critical Care Medicine 2008; 36: 953-963
•Beneficence: the physicians’ duty to help patients whenever possible
•Non-maleficience: the obligation to avoid harm
•Justice: the fair allocation of medical resources
•Autonomy: the patients’ right to self-determination
Underpinning concepts•Withholding and withdrawing life
support are equivalent•There is an important distinction
between killing and allowing to die•The doctrine of “double effect” - ethical
rationale for providing symptom control even when this may have the foreseen (but not intended) consequence of hastening death
Challenges•Competing demands for limited
resources•Futility•Quality of life•Burnout•Therapeutic nihilism•Fatalism
a medical intervention that had not been useful in the last 100 cases OR interventions that merely preserve permanent unconsciousness or dependence on intensive medical care
“Treatments should be defined as futile only when they will not accomplish their intended (physiologic) goal”.
“Treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit may be considered inappropriate and hence inadvisable, but should not be labeled futile”.
Futility
How do we know...?•Who should be admitted?
•What are the indicators that we shouldn’t admit?
•How much illness is too much?•When should we say enough is enough?•How can we be certain?
Quality indicators for end-of-life care•Patient and family-centred decision-making
•Communication with family and patient•Communication within team•Continuity of care•Emotional and practical support for
patient/family•Symptom management and comfort care•Spiritual support for patient/family•Emotional/organisational support for ICU
clinicians
Scenario 1•Spinal cord injury:
• quadriplegia• ventilator dependence• prolonged pressure sore• difficult access to rehab bed
•Is a prolonged ICU stay appropriate?•What about other patients rights to care?•What are you using to inform your
decisions?
Scenario 2• Elderly patient with significant comorbidity• Profound septic shock and MSOF and no
improvement in 48 hours of maximum therapy• Outlook bleak...discussion with family...patient
would not want treatment that will not get her better....would not want CPR etc
• Agreement to DNAR and no escalation with clear plan to withdraw the following day if no MAJOR improvement (definition given)...family content with plan and communicated to extended family
•Change of consultant the next day•New consultant gets verbal hand-over of
decision making process and outcome•New consultant not happy to withdraw•Family upset and angry with change in
plan•Patient treated aggressively for further
48 hours before withdrawal and death
Scenario 2