Ethical Dilemmas in Intensive CareDr. Andrew Ferguson
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 livesTruog 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 struggleTruog R, et al. Critical Care Medicine 2008; 36: 953-963
FutilityQuality of lifeAutonomyJusticeBeneficenceNon-maleficenceUtilityEquity
Beneficence: the physicians duty to help patients whenever possibleNon-maleficience: the obligation to avoid harmJustice: the fair allocation of medical resourcesAutonomy: the patients right to self-determination
Paternalistic decision-making = physicianDeterminative decision-making = shared
Underpinning conceptsWithholding and withdrawing life support are equivalentThere is an important distinction between killing and allowing to dieThe doctrine of double effect - ethical rationale for providing symptom control even when this may have the foreseen (but not intended) consequence of hastening death
ChallengesCompeting demands for limited resourcesFutilityQuality of lifeBurnoutTherapeutic nihilismFatalism
What is futility?
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
What is quality of life?
Elements of Quality of LifePhysicalPsychologicalSocial
Whose life is it anyway?
How do we know...?Who should be admitted?What are the indicators that we shouldnt 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 carePatient and family-centred decision-makingCommunication with family and patientCommunication within teamContinuity of careEmotional and practical support for patient/familySymptom management and comfort careSpiritual support for patient/familyEmotional/organisational support for ICU clinicians
Scenario 1Spinal cord injury: quadriplegiaventilator dependenceprolonged pressure soredifficult access to rehab bedIs a prolonged ICU stay appropriate?What about other patients rights to care?What are you using to inform your decisions?
Scenario 2Elderly patient with significant comorbidityProfound septic shock and MSOF and no improvement in 48 hours of maximum therapyOutlook bleak...discussion with family...patient would not want treatment that will not get her better....would not want CPR etcAgreement 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 dayNew consultant gets verbal hand-over of decision making process and outcomeNew consultant not happy to withdrawFamily upset and angry with change in planPatient treated aggressively for further 48 hours before withdrawal and death