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Ethics and end-of-life issue in RICU A European perspective. ANTALYA 5/4/2032. STEFANO NAVA Pneumologia e Terapia Intensiva Respiratoria Ospedale Sant’Orsola Malpighi BOLOGNA. “ I just want to give a meaning to a situation that has no meaning“ (Vasco Rossi). The facts. - PowerPoint PPT Presentation
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STEFANO NAVAPneumologia e Terapia Intensiva RespiratoriaOspedale Sant’Orsola MalpighiBOLOGNA
Ethics and end-of-life issue in RICU A European perspective
ANTALYA 5/4/2032
“ I just want to give a meaning to a situation that has no meaning“
(Vasco Rossi)
The facts
•More and more patients are placed on mechanical ventilation (MV)•Who is going to decide when and why: - the time is come to suspend MV - someone does NOT “merit” MV - who is involved in the decision
Publications on End-of-Life issues
0
20
40
60
80
100
120
80-90
90-00
00-08
n. publications
YEARS
“I am not afraid to die. I just don't want to be there when it happens ”Woody Allen
INTRODUCTION
• In most Western countries, about 1% of the population dies every year
• Advances in medicine have greatly improved possibilities to treat seriuosly ill chronic patients and to prolong life
• There is increasing recognition that extension of life might not always be an appropriate goal of medicine
• Medical end-of-life decisions can take place in any setting at which patients die, that is in hospital, nursing homes, hospices and at home
(World Health Organization 2002)
death
• Correct Information
• Symptoms control
• Mobility
• Relief of burden
4 items were identified :
Communications
Do WE KNOW HOW TO SPEAK WITH RELATIVES ?
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
p h y s c i a n s p e a k
f a m i l y s a t i s f a c t i o n
%
J.Gen.Intern.Med. 1995;10:436
Do WE KNOW HOW TO SPEAK WITH RELATIVES ?
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
p h y s c i a n s p e a k
f a m i l y s a t i s f a c t i o n
%
Overall >50% of speak
J.Gen.Intern.Med. 1995;10:436
Do WE KNOW HOW TO SPEAK WITH RELATIVES ?
0
1 0
2 0
3 0
4 0
5 0
6 0
7 0
8 0
9 0
p h y s c i a n s p e a k
f a m i l y s a t i s f a c t i o n
%
Overall >50% of <50% of speak speak
J.Gen.Intern.Med. 1995;10:436
“And we [family members] had another concern my mother specifically wanted to mention, the way they would talk about these issues [DNR decision] within hearing range of my father. And we felt like he could hear, even if he could not respond, and it might hurt his chances for recovery to hear us talking about him. My mother would have to motion to go into the hall.”
42% were considered COMPETENTTotalNorth EUSouth EU
Symptoms control
0
10
20
30
40
50
Resp. D. Heart D. Pain D. Anx D. Sedatives morphine other
Drugs used in the last month of life
% of patients
Only about 50% of patients achieved control of symptoms
Family’s burden
0
1 0
2 0
3 0
4 0
5 0
h o m e G e n D e p . R e s pD e p .
IC U R e h . D e p . N H
Where do the end-stage respiratory patients die ?
0
1 0
2 0
3 0
4 0
5 0
6 0
F a mily F a m+p ub .
S e r v ic e
Pr iva t e
A s s is t a nc e
ot h e r
Family’s burden
Decisions
DEFINITIONS
• Withholding : a planned decision not to institute therapies that were otherwise warranted (i.e. intubation, renal replacement therapy, increased doses of vasopressor infusions, surgery, transfusion, nutrition, hydration).
• Withdrawal: discontinuation of treatments that had been started (i.e decreasing FiO2 21%, extubation, turning off the ventilator, suspend the vasopressors….)
• Euthanasia : from eu and anatos = good death. A doctor intentionally killing a person who is suffereing unbearably and hopelessly at the latter’s voluntary, explicit, repeated, well-considered and informed request
WHO is THE CANDIDATE for end-of-life decision ?
Decision to withhold or withdraw life-sustaining treatment are often hindered by prognostic uncertainly, since it is usually difficult to identify at an early stage, and without resonable doubt those patients who will inevetably die.
Typically the prognosis only becomes obvious late in the evolution of the acute or chronic illness.
Unfortunately the available severity scoring systems do not predict outcome in individual patients with sufficient accuracy to be useful in end-of-life decision making.
BMJ 2000
20% of predictions were accurate63% were overoptimistic17% overpessimistic.
Preferences
Outcome clinicoCarico assistenziale
Acuto (i.e. ETI)
N Engl J Med 1996; 334:1578-82
“Real” < 50%
0102030405060708090
100
does not exactly know thedisease
never discussed E-o-L issues
Carlucci et al
n.
Anticipatory planning in severe COPDCarlucci et al.
0
10
20
30
40
50
60
70
80
90
100
Decisions
ETI
O2 andmorphineceling NIV
Carlucci et al
n.
Anticipatory planning in severe COPDCarlucci et al.
NIV users
NIV non-users
0
2
4
6
8
10
12
14
16
18
decision
refused
accept
Carlucci et al
% p
atie
nts
“I trust everything the physicians say”“I do not feel like talking about these issues”
Anticipatory planning in severe COPDCarlucci et al.
20%
NIV as a ceiling treatment:UNIQUE feature of the
pulmonologists ?
The problem of the “pain of breathing” (i.e. dyspnea) in
terminally ill patients
A systematic review of oxygen and airflow effect on relief of dyspnea at rest in patients
with advanced disease of any cause
Gallagher & Roberts J Pain Palliat Care Pharmacother. 2004;18(4):3-15.
This systematic review found low-grade scientific
evidence that oxygen improve dyspnea at rest in some
patients with advanced disease. However, there is no
evidence to identify which patients will benefit from
supplemental oxygen.
*
TotalNorth EUSouth EU
44% of the patients survived the episode of ARF
surviveddied
DYSPNEA INDEX
0
1
2
3
4
5
6
7
8
9
10
ADMISSION NIV 1 hr
*
Observational trial 23 patients with solid malignancies
Practicalities: the dying patient receiving MV
including NIV• Opiates• Anticholinergic patches• Physio, cough adjuncts• Adjustment of ventilator settings• Consider removing MV when
patient comatose, replace with O2 via nasal cannulae to prevent terminal hypoxic fits
• Opiates• Anticholinergic patches• Physio, cough adjuncts• Adjustment of ventilator settings• Consider removing MV when
patient comatose, replace with O2 via nasal cannulae to prevent terminal hypoxic fits
General Principles
• Treat the treatable: exacerbations, CCF, PE etc.
• Explore advance directives: involve family and care team – this is just part of a management plan
• Continued and intensive efforts to palliate symptoms
• Recognise the inevitable• Facilitate care in accordance with patient’s
wishes where possible
• Treat the treatable: exacerbations, CCF, PE etc.
• Explore advance directives: involve family and care team – this is just part of a management plan
• Continued and intensive efforts to palliate symptoms
• Recognise the inevitable• Facilitate care in accordance with patient’s
wishes where possible
ConclusionsWhen is “getting dark, too dark to see”: TALK with your patients and relatives with THEIR languages and LISTEN because we have one mouth and two ears CONSIDER their preferences (i.e. control the symptoms, use drugs and/or NIV, organize a home care program to relief their burden) IMAGINE TOGETHER their future and TAKE in ADVANCE the right decision about End-of-Life Do not unduly PROLONG life and suffering
TALK and LISTEN Hable con ella (Pedro Almodovar)
CONSIDER THE PATIENT’S NEEDS Through a glass darkly (Ingmar Bergman)
TAKE TOGETHER the DECISION Mar adentro (Alejandro Amenábar)
DO NOT PROLONG SUFFERINGLes invasions barbares (Denys Arcand)
Le scaphandre et le papillon (Julian
Schnabel)
Johnny got his gun (Dalton Trumbo)
Million dollars baby (Clint Eastwood)
“Today medicine can and must relief my pain.If this will not happen, I will kill myself, but this shouldnot be considered suicide but failure in duty of care ”
Prof. Sandro Bartoccioni, Cardiochirurgo
Cittta’ di Castello, 25 agosto 1947 – Città di Castello, 2 giugno 2006