Sick Patients, Grieving Families, and a Selection of Issues in Ethics

Allen Roberts, MDProfessor of Clinical Medicine

Georgetown University Hospital

“On that day, men will gather in great mead halls and sing of the day when physicians, like giants, walked the earth.”

- Richard Selzer Notes on the Art of Surgery

A day in the life of the intensivist…RoundsCodesFamily meetingsAdmissionsProceduresAcademic conferences

The ICU TeamPhysiciansNursesRespiratory therapistsNutrition specialistsClinical pharmacologists

Available:Pastoral CarePalliative CareInternational Services

The week of February 25…175 ICU patient visits, ventilator adjustments, miscellaneous

interventions and procedures. Most will survive, but…

37 year old man with rapidly progressive pneumonia, respiratory failure, septic shock, died.

48 year old man with severe streptococcal infection of the major muscle groups of both legs. Septic shock, respiratory failure; emergent surgery to remove non-viable tissue. Will survive, but with extensive rehab.

29 year old man with influenza A, complicated by pneumonia, respiratory and kidney failure, died.

Three patients with liver failure of various causes. All died while awaiting a transplant.

The cords of death encompassed me; the torrents of destruction assailed me…Psalm 18:4

ICU Glossary: basicsIntubation and mechanical ventilationPressorsRenal-replacement therapy:

dialysis, continuous vs intermittent

Prognosis, severity of illness, APACHE

“Full Code” vs “DNR”“Comfort measures”

Withdrawal of Care

Pastoral Care and Clinical Medicine: IntersectionsFamily meetings:

DiagnosisPrognosisWhat’s changed now that the patient is in the ICURealistic goals of careFamily & social supportFaith tradition

Preparation for death

Family care following death

Ministry in the Unit:Meeting with the Family

Early-on after ICU admissionPurpose:

- inform the family and establish goals of carediagnosis, prognosis, statistics v gestalt - establish who is the spokesperson - identify family dynamics encourage unity - establish a follow-up meeting

Meeting the FamilyMost meetings go smoothly

- include residents, nurses & medical students

Mentality: - family is in tsunami-mode - spectrum: concerned <–> distraught <–> openly hostile

Gage need for “Security”Focus on problems at handSit close to the door

Ethical Issues in the ICUMost ethics issues

center around the beginning or the end of life

Ethical dilemmas at the end of life are the necessary consequence of advanced, life saving and life-sustaining medical care.

End-of Life ScenariosThe natural end-point of a terminal disease

- malignancy - liver failure - neuromuscular disease

Extreme old agechronological vs physiological age

Complication of long-term careSevere, acute illness which advances

relentlessly despite aggressive, multi-modality measures - age non-specific

Medical-Pastoral Questions Keep everything going and wait for recovery?

Wait for God to intervene with a miracle?

Allow natural death/shift to providing comfort?

What would the patient want?

What does the family want?

What’s ‘the right thing?’

How to make a decision that everyone can live with ….?

When is continuing care futile?

A Selection of Ethical IssuesThe Georgetown mantra:

beneficence, non-maleficence, autonomy, and justice

The evolution of patient (family ) autonomyWhat’s technically possible vs what’s the

right thing to do (or not do)Concept of futility vs ‘no benefit’

Principles of End-of-Life Counseling in the ICUConfidence in the diagnosis and prognosisProvide for comfort and consolationProvide for pastoral care, if desiredThat which ends the patient’s life is the

underlying disease process, NOT the withdrawal of biological life-sustaining measures

Medical decisions made by MDs in close dialogue with family

“Let’s make decisions we can look back on 10 years form now and know we did right.”

Withdrawing CareMorphine

concept of the “double-effect”Dose to relieve evidence of distress

(not dosed to end life)Shut off all pressorsRemove the ventilatorAllow the family proximity, if desired

Georgetown Ethics InitiativesIdentify clinical data points which suggest

that survival in the ICU is unlikelyIf these criteria are met, establish a “Goals of

Care” meeting with family early, with Pastoral Care and Palliative Care presence

Establish who will serve as the surrogate decision maker for the patient

Time limits on interventions of questionable benefit

Ethics Community monitoring of all ICU “comfort-measure” deaths

Contemporary Ethics IssuesPatient/family autonomy vs physician’s right of

conscience - lessons learned from the abortion debate - Christian Medical/Dental Association lobby

Physician-assisted suicide - legal in Oregon, Montana, Nevada - getting press time in professional journals

Transplantation ethics - technical success way ahead of ethics dialogue - the vetting process for living donors

The perfect storm….

Other things to think about…“Spirituality” in medicineSharing Jesus with our patientsPraying with patientsChristian medical professionalismMedical errors and complications

- full disclosure