Death, Hope and Uncertainty
in ICU Decision-making
Frank Chessa, Ph.D.
David Seder, MD
June 10, 2009
The owl of Minerva
flies only at night.
Plato
?
The owl of Minerva
flies only at night.
Plato
Translation –
You only need philosophy
when there is a problem
Objectives
 Explore how the concepts of hope,
uncertainty and medical futility influence
clinician and family approaches ...
Focus on Uncertainty
 Prognostic Uncertainty
 Communicative Uncertainty
Results in
 Ethical Uncertainty
 What is enoug...
Background
 Always wanted to be a rural family
practitioner
 Very concerned about medical spending,
excessive and inappr...
Background
 11 years training in internal medicine,
pulmonary medicine, critical care medicine,
and neurocritical care
 ...
Case One
 54 yo woman suffered OHCA
 15 minutes “down time”
 Therapeutic hypothermia
 Hospital day #3: low grade fever...
Case One
 HD #4
 Withdraws to pain stimulus, eyes closed
 Treated for pneumonia
 HD #5
 Awakens, tracks with eyes, do...
Case Two
 76 yo Russian man admitted to CICU after
being intubated with respiratory distress in his
home
 Per EMS – Poli...
Case Two
 Arrangements made for withdrawal of the
endotracheal tube and transition to “comfort
measures”
 15 yo grandson...
Case Two
 Rapid clinical improvement
 Patient extubated on clinical grounds, hospital
day #3
 When he could speak (thro...
Case Three
 51 yo man admitted to OSH
with BP 240/120 and
headache
 Rapidly progressive loss of
consciousness and
develo...
Case Three
 HD #2:
 Quadiplegic with no head or facial movement
 Volitional control of blinking, downgaze, weak
upgaze
...
Three dimensions of EOL decision
Making
 Active vs. Passive
 Knowledge of patient’s preferences
 Prognosis
Three dimensions of EOL decision
Making
 Active vs. Passive
 The more active the means of providing death,
the more cont...
Active vs. Passive
 Withholding
 Withdrawing
 DNR
 Food and Fluids
 Withdrawing during/after surgery
 Double effect ...
Active vs. Passive
 Withholding
 Withdrawing
 DNR
 Food and Fluids
 Withdrawing during/after surgery
 Double effect ...
Three dimensions of EOL decision
Making
 Active vs. Passive
 Knowledge of patient’s preferences
 The more certain that ...
Three dimensions of EOL decision
Making
 Active vs. Passive
 Knowledge of patient’s preferences
 Prognosis
 Good progn...
Three dimensions of EOL decision
Making
 Active vs. Passive
 Knowledge of patient’s preferences
 Prognosis
Autonomous
Active
Passive
Non-autonomous
Good Prognosis
Poor Prognosis
Communicating about choices and
preferences
 Patient has capacity. Ask the patient.
 Patient lacks capacity.
 Substitut...
Determining Capacity
 Applebaum and Grisso (NEJM, 1988)
 the ability to communicate choices;
 the ability to understand...
Who makes decisions for a patient
who lacks capacity?
In order of priority:
1. Power of attorney (unless revoked)
2. Court...
Maine Law: Surrogacy (Title 18A §5-805)
Priority of surrogates
(1) The spouse, unless legally separated;
(1-A) An adult wh...
Uncertainty about patient choices and
preferences
 Since 1966, there have been 16 studies that tested
the accuracy of sur...
Advance Directives –
The answer to uncertainty
1. Designate Power of Attorney for Health
Care Decisions
2. Provide patient...
Old Maine Form
I do or do not want my life prolonged if
(1) I have an incurable and irreversible condition that will resul...
New Maine Form
I do not want treatment to keep me alive if my
physician decides any of the following is true
(1) I have an...
New Maine Form
I want to be kept alive as long as
possible within the limits of generally
accepted health care standards, ...
Time for Discussion!
Thank you
Frank Chessa, Ph.D.
Director, Clinical Ethics
Maine Medical Center
chessf@mmc.org
207-662-3...
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  • Appelbaum, Paul S and Thomas Grisso, Assessing Patients’ Capacities to Consent to Treatment, NEJM 319(25) (Dec. 22, 1988): 1635-1638.)
  • Hope, Death, Uncertainty in ICU (.ppt)

    1. 1. Death, Hope and Uncertainty in ICU Decision-making Frank Chessa, Ph.D. David Seder, MD June 10, 2009
    2. 2. The owl of Minerva flies only at night. Plato ?
    3. 3. The owl of Minerva flies only at night. Plato Translation – You only need philosophy when there is a problem
    4. 4. Objectives  Explore how the concepts of hope, uncertainty and medical futility influence clinician and family approaches to end of life decision making for the critically ill;  Explain how the substituted judgment and best interest ethical standards form the basis of current approaches to end of life decision making in the ICU;  Be thoughtful and provocative so that we more deeply explore ethical challenges in provision of palliative care
    5. 5. Focus on Uncertainty  Prognostic Uncertainty  Communicative Uncertainty Results in  Ethical Uncertainty  What is enough and what is too much
    6. 6. Background  Always wanted to be a rural family practitioner  Very concerned about medical spending, excessive and inappropriate resource utilization  No religious affiliation, but a heavy utilizer of modern world literature  Initially thought the ICU was the worst place in the world
    7. 7. Background  11 years training in internal medicine, pulmonary medicine, critical care medicine, and neurocritical care  Clinical and research interest in severe brain injuries  Saving and rehabilitating patients with previously “unsurvivable” brain injuries  Great “saves”  Occasional terrible outcomes
    8. 8. Case One  54 yo woman suffered OHCA  15 minutes “down time”  Therapeutic hypothermia  Hospital day #3: low grade fever  Opens eyes to pain stimulus, no movement of extremities, does not orient to voice or follow commands  Neurology consultant: “dismal prognosis… suggest pursue family discussion regarding goals of care”
    9. 9. Case One  HD #4  Withdraws to pain stimulus, eyes closed  Treated for pneumonia  HD #5  Awakens, tracks with eyes, does not follow commands  HD #6  Extubated, minimally communicated  HD #7  Follows commands and converses in spanish  Discharged home with normal cognitive function
    10. 10. Case Two  76 yo Russian man admitted to CICU after being intubated with respiratory distress in his home  Per EMS – Police had to restrain the patient’s wife while the medics worked – she had tried to block them out of the apartment  Wife arrived (Russian speaking) and through translator described the patient’s vision (several months earlier) of lying dead on a bed of roses with the calendar on the present month.
    11. 11. Case Two  Arrangements made for withdrawal of the endotracheal tube and transition to “comfort measures”  15 yo grandson arrived with one of his teachers and asked that we reconsider, said that the information from his grandmother was wrong  SW consult revealed prior APS involvement (we never got the story) with family.  Decision making delayed
    12. 12. Case Two  Rapid clinical improvement  Patient extubated on clinical grounds, hospital day #3  When he could speak (through the translator), stated his wife was “crazy” and “wanted him dead”  Profound religious differences between patient and wife
    13. 13. Case Three  51 yo man admitted to OSH with BP 240/120 and headache  Rapidly progressive loss of consciousness and development of brainstem deficits, intubated  CT suggested pontine stroke  MRI at MMC showed bilateral pontine infarction
    14. 14. Case Three  HD #2:  Quadiplegic with no head or facial movement  Volitional control of blinking, downgaze, weak upgaze  Answered questions briskly by yes-no system of blinks and downgaze  Diagnosis: locked-in syndrome
    15. 15. Three dimensions of EOL decision Making  Active vs. Passive  Knowledge of patient’s preferences  Prognosis
    16. 16. Three dimensions of EOL decision Making  Active vs. Passive  The more active the means of providing death, the more controversial and (generally) the less ethically acceptable.
    17. 17. Active vs. Passive  Withholding  Withdrawing  DNR  Food and Fluids  Withdrawing during/after surgery  Double effect of pain medication  PAS  Active Killing
    18. 18. Active vs. Passive  Withholding  Withdrawing  DNR  Food and Fluids  Withdrawing during/after surgery  Double effect of pain medication  PAS  Active Killing
    19. 19. Three dimensions of EOL decision Making  Active vs. Passive  Knowledge of patient’s preferences  The more certain that you are do what the patient wants (or would want) the less controversial the decision.  The less certain you are, the more controversial the decision
    20. 20. Three dimensions of EOL decision Making  Active vs. Passive  Knowledge of patient’s preferences  Prognosis  Good prognosis: withdrawing life-sustaining care from a patient with a good prognosis is suspect.  Very bad prognosis: not withdrawing futile care wastes resources and increases suffering.
    21. 21. Three dimensions of EOL decision Making  Active vs. Passive  Knowledge of patient’s preferences  Prognosis
    22. 22. Autonomous Active Passive Non-autonomous Good Prognosis Poor Prognosis
    23. 23. Communicating about choices and preferences  Patient has capacity. Ask the patient.  Patient lacks capacity.  Substituted Judgment: Determine what the patient would have wanted were they able to understand relevant information and make a choice.  Search for evidence  POA  Family  Advance Directive (Living Will)  Medical Record  Other providers (PCP)  If sufficient evidence from these sources of evidence is not available, move to best interest standard
    24. 24. Determining Capacity  Applebaum and Grisso (NEJM, 1988)  the ability to communicate choices;  the ability to understand relevant information;  the ability to rationally manipulate information;  the ability to appreciate the situation and its consequences.  Maine State Law (18§5-101)  "Incapacitated person" means any person who is impaired by reason of mental illness, mental deficiency, physical illness or disability, chronic use of drugs, chronic intoxication, or other cause except minority to the extent that he lacks sufficient understanding or capacity to make or communicate responsible decisions concerning his person
    25. 25. Who makes decisions for a patient who lacks capacity? In order of priority: 1. Power of attorney (unless revoked) 2. Court appointed guardian 3. Family member acting as surrogate. 4. Others who know the patient
    26. 26. Maine Law: Surrogacy (Title 18A §5-805) Priority of surrogates (1) The spouse, unless legally separated; (1-A) An adult who shares an emotional, physical and financial relationship with the patient similar to that of a spouse; (2) An adult child; (3) A parent; (4) An adult brother or sister; (5) An adult grandchild; (6) An adult niece or nephew, related by blood or adoption; (7) An adult aunt or uncle, related by blood or adoption; or (8) Another adult relative…, related by blood or adoption, who is familiar with the patient's personal values and is reasonably available for consultation. (c)  If none of the individuals eligible to act as surrogate [above] is reasonably available, an adult who has exhibited special concern for the patient, who is familiar with the patient's personal values and who is reasonably available may act as surrogate.
    27. 27. Uncertainty about patient choices and preferences  Since 1966, there have been 16 studies that tested the accuracy of surrogate decision-makers  Compare surrogate and patient responses to hypothetical end-of-life scenarios  151 scenarios; 2595 surrogate-patient pairs; 19,526 responses.  Overall accuracy?  68% Shalowitz et.al., The Accuracy of Surrogate Decision Makers, Archives Internal Medicine 166 (Mar 13, 2006)
    28. 28. Advance Directives – The answer to uncertainty 1. Designate Power of Attorney for Health Care Decisions 2. Provide patient directives regarding medical care if unable to speak POA required to make decisions consistent with patient’s written directive
    29. 29. Old Maine Form I do or do not want my life prolonged if (1) I have an incurable and irreversible condition that will result in my death within a relatively short time; (2) If I become unconscious and to a reasonable degree of medical certainty I will not regain consciousness; or (3) The likely risks and burdens of treatment would outweigh the expected benefits
    30. 30. New Maine Form I do not want treatment to keep me alive if my physician decides any of the following is true (1) I have an illness that will not get better, cannot be cured, and will result in my death quite soon (sometimes reffed to as a terminal condition), Or (2) I am no longer aware (uncounscious) and it is very likely that I will never be conscious again (sometimes referred to as a persistent vegetative state).
    31. 31. New Maine Form I want to be kept alive as long as possible within the limits of generally accepted health care standards, even if my condition is terminal or I am in a persistent vegetative state.
    32. 32. Time for Discussion! Thank you Frank Chessa, Ph.D. Director, Clinical Ethics Maine Medical Center chessf@mmc.org 207-662-3589 David Seder, M.D. Assistant Professor of Medicine Tufts University School of Medicine Medical Director of Neurocritical Care Maine Medical Center sederd@mmc.org 207-662-2179
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