Ethics Case Conference

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  • In the absence of evidence, we have no hard and fast rules about when to recommend PEG outside of a few scenarios (e.g. dysphagic stroke pt longterm); we make judgments
  • So what we have to do seems clear: allow patients to refuse tube feeds, or to discontinue them. But the courts seem a bit inconsistent, right? As this seems like suicide…(see next slide)
  • Courts rationales work in certain situations; when therapy is a)more clearly medical e.g. ventilation or dialysis b)more clearly burdensome Seems theres a difference between ordinary stuff we have to do to survive and medical treatments for disease; is it so clear that food/h2o through a tube is the latter? Certainly discontinuing it doesn’t seem to “allow disease to take its course” in any obvious way…….
  • If patients say death is my good, then they’re wrong; they make the mistake of milton’s satan (evil be thou my good)
  • Ethics Case Conference

    1. 1. Mr H; refusing treatment, tube feeding, and physician obligation Amos Bailey And Tom Huddle 4 December 2007
    2. 2. Mr H Autonomy, Patient Welfare and Tube Feeding <ul><li>What we know about tube feeding </li></ul><ul><li>Patient welfare and patient autonomy; what about when they conflict? </li></ul><ul><ul><li>Legal constraints: what we must do </li></ul></ul><ul><ul><li>Morality: what we ought to do </li></ul></ul>
    3. 3. Tube Feeding Efficacy Koretz Metaanalysis Am J Gastro Feb 07 <ul><li>Enteral nutrition (EN) and volitional nutritional support (VNS) </li></ul><ul><li>Conditions for which RCTs available: </li></ul><ul><ul><li>Perioperative </li></ul></ul><ul><ul><li>Cancer </li></ul></ul><ul><ul><li>Liver disease </li></ul></ul><ul><ul><li>Acute pancreatitis </li></ul></ul><ul><ul><li>IBD </li></ul></ul><ul><ul><li>COPD </li></ul></ul><ul><ul><li>Stroke </li></ul></ul>
    4. 4. <ul><li>Strong evidence </li></ul><ul><ul><li>EN doesn’t help in dysphagic stroke pts in 1 st week </li></ul></ul><ul><ul><li>VNS doesn’t help non-dysphagic stroke pts in long term </li></ul></ul>Tube Feeding Efficacy Koretz Metaanalysis Am J Gastro Feb 07
    5. 5. <ul><li>“ reasonable evidence” </li></ul><ul><li>Malnourished geriatric pts </li></ul><ul><ul><li>EN  no benefit re mortality/pressure ulcers in a hip fx elderly population </li></ul></ul><ul><ul><li>VNS  benefit in pts who could consume supplements </li></ul></ul>Tube Feeding Efficacy Koretz Metaanalysis Am J Gastro Feb 07
    6. 6. <ul><li>“ some” evidence (low quality rcts) favors EN or VNS for: </li></ul><ul><ul><li>Perioperative </li></ul></ul><ul><ul><li>Critically ill </li></ul></ul><ul><ul><li>Liver disease </li></ul></ul>Tube Feeding Efficacy Koretz Metaanalysis Am J Gastro Feb 07
    7. 7. Tube Feeding Efficacy <ul><li>Dementia: </li></ul><ul><ul><li>No rcts </li></ul></ul><ul><ul><li>Trials we do have suggest no benefit (see Finucane JAMA 282(1999): 1365-70) </li></ul></ul>
    8. 8. Decisions re tube feeding <ul><li>In most cases, the clinician “will have to rely on an understanding of the patient’s clinical condition and anticipated outcome, a judgment as to the patient’s ability to tolerate undernutrition, and an appreciation of the desires and needs of the patient and his or her family.” </li></ul>Koretz, Am J Gastroenterology 2007;102:429.
    9. 9. Tube Feeding plausible scenarios <ul><li>Clinical situations such as those in which there is a mechanical problem with eating but the patient would eat if they could physically seem to have the most benefit </li></ul><ul><ul><li>Tumor blocking swallowing </li></ul></ul><ul><ul><li>Short Bowel Syndromes (TPN) </li></ul></ul><ul><ul><li>Accident, Surgery with possible recovery of eating </li></ul></ul>
    10. 10. Tube Feeding Usual Approach <ul><li>Consider tube feeding as a medical intervention </li></ul><ul><li>Consider benefits and burdens of tube feeding in the individual case </li></ul><ul><li>Trial of tube feeding may clarify burdens and benefits </li></ul>
    11. 11. Mr H Autonomy, Patient Welfare and Tube Feeding <ul><li>What we know about tube feeding </li></ul><ul><li>Patient welfare and patient autonomy; what about when they conflict? </li></ul><ul><ul><li>Legal constraints: what we must do </li></ul></ul><ul><ul><li>Morality: what we ought to do </li></ul></ul>
    12. 12. Patient autonomy vs patient welfare: legal setting <ul><li>Courts have held: </li></ul><ul><ul><li>Suicide is forbidden </li></ul></ul><ul><ul><li>Patients have a right to refuse treatment; exceptions: </li></ul></ul><ul><ul><ul><li>Preserve ethical integrity of docs—no. </li></ul></ul></ul><ul><ul><ul><li>Preservation of life—no. </li></ul></ul></ul><ul><ul><ul><li>Patient has kids, there’s noone else to take care of them—yes. </li></ul></ul></ul><ul><ul><ul><li>(when tx is food/h2o, courts have agonized, but pts can still refuse) </li></ul></ul></ul>Kay, “Causing Death for Compassionate Reasons in American Law” Am J Comp Law Fall 06
    13. 13. Patient autonomy vs patient welfare: legal setting <ul><li>Refusing treatment is not suicide: rationales in legal opinions: </li></ul><ul><ul><li>Wanting to end therapy isnt the same as wanting to end life </li></ul></ul><ul><ul><li>Suicide is an affirmative act vs discontinuing treatment is allowing disease to take its course </li></ul></ul><ul><li>Both of these seem questionable when the treatment is food/h2o by tube feeding </li></ul>
    14. 14. Patient autonomy vs patient welfare: what ought docs to do? <ul><li>Patient autonomy tells us to let the patient make the decision </li></ul><ul><li>Our responsibility as doctors to further the patient’s interest (construed as biological/psychological wellbeing) tells us to resist any decision that appears, in effect, to be suicide. </li></ul>
    15. 15. <ul><li>Human flourishing is best understood in terms of autonomous decision making; human dignity is reflected in unconstrained autonomous choices. </li></ul><ul><ul><li>The fact of choice is more important than what is chosen </li></ul></ul><ul><li>Physician: purveyor of drugs/technology in the service of patient wishes </li></ul>Patient autonomy above all
    16. 16. Patient autonomy above all <ul><li>If patient choice trumps other considerations, its hard to draw a line with suicide on the other side of it </li></ul><ul><li>Doc’s responsibility is to further patient wishes (even if these include acts tantamount to suicide) </li></ul>
    17. 17. <ul><li>Docs anyway kill patients (effectively) when they do things that hasten death e.g. </li></ul><ul><ul><li>opiates in the endstage COPD patient </li></ul></ul><ul><ul><li>Withdrawal of support in the terminal icu patient </li></ul></ul><ul><li>So what’s so awful about doing something similar when it goes with what the patient wants??? </li></ul>Patient autonomy above all
    18. 18. <ul><li>What to do with Mr H: </li></ul><ul><ul><ul><li>Treat depression if present; but if Mr H has capacity and his wishes continue to be for removal of his feeding tube as a means of ending his life, his physician should not protest or resist and should simply pull the tube. </li></ul></ul></ul>Patient autonomy above all
    19. 19. Traditional Hippocratic view: Patient welfare comes first <ul><li>Patient well-being is construed along lines of biological/psychological flourishing </li></ul><ul><li>Exercise of autonomy is part of human flourishing but not if exercised in opposition to one’s well-being. </li></ul><ul><li>Patient wishes are partly constitutive of patient welfare, but not necessarily determinative in all cases (such as when patients wish to commit suicide) </li></ul>
    20. 20. Traditional Hippocratic view and sucide <ul><li>If killing oneself is wrong, doctors killing patients is doubly wrong (contrary to our aim of furthering patient well-being) </li></ul><ul><li>Physician imperative is to preserve life (although not at any cost) </li></ul><ul><ul><li>This is where the hippocratic view has evolved somewhat in the past 50 years </li></ul></ul>
    21. 21. <ul><li>Welfare trumps autonomy; then how far may autonomy be interfered with; </li></ul><ul><ul><li>fifty years ago many docs would have said coercion toward the end of patient welfare was justifed  force Mr H to keep his feeding tube. </li></ul></ul><ul><ul><li>Modified Hippocratic view of today would draw the line at coercion. </li></ul></ul><ul><ul><ul><li>We’re more aware of the burdens of treatment; </li></ul></ul></ul><ul><ul><li>But; other things being equal, life is good! </li></ul></ul>Traditional Hippocratic view: Patient welfare comes first
    22. 22. <ul><li>intention behind an act trumps effect of the act in determining its character </li></ul><ul><li>Physician action that seems be killing is not so </li></ul><ul><ul><li>Opiates in COPD; principle of double effect </li></ul></ul><ul><ul><ul><li>Death (if occurs) is a side effect of an act intended to relieve discomfort </li></ul></ul></ul><ul><ul><li>Withdrawal of support; is indeed ceasing a burdensome treatment and allowing disease to take its course (unlike w/drawal of food and h2o when these are not burdensome) </li></ul></ul>Traditional Hippocratic view: Patient welfare comes first
    23. 23. Traditional Hippocratic view: Mr H <ul><li>Tube feedings are here not a burdensome treatment </li></ul><ul><li>Mr H’s desire for w/drawal of tube feedings amounts to intended suicide </li></ul><ul><li>Our task as physician is to further Mr H’s welfare and is thus to discourage such an intention, (without coercing Mr H); not coercing is right, as: </li></ul><ul><ul><li>This is the law </li></ul></ul><ul><ul><li>This is also what’s right (with which many physicians would have disagreed fifty years ago) </li></ul></ul>
    24. 24. <ul><li>What to do with Mr H: </li></ul><ul><ul><li>Treat depression, sensitively ascertain Mr H’s wishes; presuming he has capacity, be willing to go along with his wish to discontinue the feeding tube, even if this is his means of shortening his life; but be an advocate with Mr H for his welfare—urge him to reconsider such a determination. </li></ul></ul>Traditional Hippocratic view: Patient welfare comes first

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