Intensive care limitations and end-of-life care framework

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Intensive care limitations and end-of-life care framework

  1. 1. LIMITATIONS AND END-OF-LIFE CARE FRAMEWORK Please complete this form if the decision to limit therapy is made and file at the front of the medical notes. At this time, it is also appropriate to consider the patient’s resuscitation status. Patient Name________________________ Hospital Number_______________________ DOB_______________________________ Sex__________________________________ If decision is made to actively withdraw care, please move on and complete pages 2-5. LIMITATION OF VENTILATION  For intubation or reintubation  For ventilatory escalation or reventilation  Have limits been placed for respiratory support? If so, please complete table below CMV FiO2 RR PC/Vt PEEP SIMV/BiLEVEL FiO2 RR PC/Vt Ps/high/ASB PEEP/Plow PS/CPAP ASB/ CPAP FiO2 RR Ps/high/ASB PEEP/Plow N/A  For non-invasive ventilation, please specify ____________________________________________ Any other limits, please specify: ___________________________________________________________________ LIMITATION OF INOTROPE/VASOPRESSOR SUPPORT Please state drug and limits for infusion Name of drug Infusion limits (mcg/kg/min, specify if different) Any other drug, please specify and include limits: ____________________________________________________ RENAL SUPPORT  Is renal replacement therapy appropriate?  Is diuretic therapy appropriate for fluid balance?  Is medical/pharmacological treatment for hyperkalaemia and/or pulmonary oedema appropriate? AUTHORISATION OF TREATMENT LIMITATIONS Decision made by Dr __________________________________ Grade _________________________________ Signature __________________________________________ Date __________________________________ Discussed with family and consultant; if so please state who ____________________________________________ Page 1 of 8 Sherren & Yoganathan 2009
  2. 2. REVERSAL OF DECISION (CROSS THROUGH PREVIOUS SECTION AND COMPLETE BELOW) Decision made by Dr __________________________________ Grade _________________________________ Signature __________________________________________ Date __________________________________ Discussed with family and consultant; if so please state who ____________________________________________ Reason for reversal ____________________________________________________________________________ ADDITIONAL COMMENTS _____________________________________________________________________________________________ ______________________________________________________________________________________________ Page 2 of 8 Sherren & Yoganathan 2009
  3. 3. END-OF-LIFE CARE FRAMEWORK Once the decision has been made to withdraw therapy, please use the framework below. The framework is designed as a prescription order; tick the boxes and prescriptions applicable to your withdrawal plan. Please note there will be instances when parts of this framework will not be appropriate / applicable. Please refer to the exclusion criteria at the end of this framework for details on who should NOT be included. Patient Name ________________________ Hospital Number _______________________ DOB _______________________________ Sex _________________________________ BASICS  Documentation in notes regarding withdrawal and reasons why Decision discussed with Family Intensive Care Consultant Named Consultant     Do not attempt resuscitation (DNAR) order signed  Remove all non-essential monitoring (e.g. CO monitoring / Manuel BP / SPO2 etc)  Discontinue non-essential observations (continue any required for pain assessment)  Discontinue all non-essential medications (including LMWH / Antibiotics / Gastric protection etc)  Discontinue renal replacement therapy  Ensure effects of neuromuscular blocking / paralytic agents (if used) no longer persist  Organ donation discussed with family / transplant coordinator and found not to be appropriate NB - If brain stem death is confirmed, please refer to exclusion criteria at end of framework CVS  Continue ECG / invasive BP (for pain assessment)  Discontinue inotropes once appropriately sedated and comfortable  Continue / Start intravenous fluids if not enterally/parenterally fed already. Once enteral/parenteral feed bag finished change over to intravenous fluid maintenance. Page 3 of 8 Sherren & Yoganathan 2009
  4. 4. SEDATION Select one of the below if required:  Midazolam infusion • Continue current rate if comfortable or start at specified dose ____ mg/Hr • Bolus ____ mg if there are signs of distress • +increase infusion rate by 25% every 15 mins if required  Propofol infusion • Continue current rate if comfortable or start at specified dose ____ mg/Hr • Bolus ____ mg if there are signs of distress • +increase infusion rate by 25%, every 15 mins if required  Other Sedatives at specified dose ____________________________________________________ _______________________________________________________________________________ ANALGESIA Select one of the below if required:  Morphine infusion • Continue at current rate if comfortable or start at specified dose ____ mg/Hr • Bolus ____ mg if there are signs of distress • +increase infusion rate by 25%, every 15 mins if required  Fentanyl Infusion • Continue current rate if comfortable or start at specified dose ____ mcg/Hr • Bolus ____ mcg if there are signs of distress • +increase infusion rate by 25%, every 15 mins if required  Alfentanil Infusion • Continue current rate if comfortable or start at specified dose ____ mcg/Hr • Bolus ____ mcg if there are signs of distress • +increase infusion rate by 25%, every 15 mins if required  Remifentanil infusion • Continue current rate if comfortable or start at specified dose ____ mcg/Hr • +increase infusion rate by 25%, every 15 mins if required. NB. - Primary importance is to ensure comfort of patient, concerns to respiratory depression is secondary. RESPIRATORY  Switch off Alarms  Document initial ventilatory parameters CMV FiO2 RR PC/Vt PEEP Page 4 of 8 Sherren & Yoganathan 2009
  5. 5. SIMV/BiLEVEL FiO2 RR PC/Vt Ps/high/ASB PEEP/Plow PS/CPAP ASB/ CPAP FiO2 RR Ps/high/ASB PEEP/Plow N/A (11  Document new ventilatory parameters to be achieved. Gradually reduce each parameter in turn over 10 minutes, titrating sedation/analgesia as required CMV FiO2 RR PC/Vt PEEP SIMV/BiLEVEL FiO2 RR PC/Vt Ps/high/ASB PEEP/Plow PS/CPAP ASB/ CPAP FiO2 RR Ps/high/ASB PEEP/Plow N/A (11  Once comfortable on new ventilatory parameters, select one of the following:  continue with current airway support (e.g. COETT) and ventilation  extubate to air  place on a T-piece / Swedish nose Page 5 of 8 Sherren & Yoganathan 2009
  6. 6. ADDITIONAL PRESCRIPTIONS (Hyoscine, anti-emetics etc) ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ OTHER COMMENTS ___________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ DOCTOR First Name: Last Name: __ Grade: Date: __ SIGNATURE: CONSULTANT First Name: Last Name: __ Date: SIGNATURE: NURSE First Name: _________________________ Last Name: ______________________________ Date: ______________________________ SIGNATURE: ___________________ Exclusion Criteria The following scenarios / situations should be excluded from the Withdrawal of Care Framework (unless otherwise specified by the Consultant in charge of care): 1. Patient is confirmed as brainstem dead 2. Patient is awaiting organ donation or a decision has yet to be made regarding this Page 6 of 8 Sherren & Yoganathan 2009
  7. 7. 3. Patient is undergoing CPR 4. Patient has not been discussed with / reviewed by a consultant 5. Patient is under 16 APPENDIX Withholding and withdrawing life-prolonging treatments: Good practice in decision- making (Good medical practice, 2006) 1. Doctors have a duty to protect the life and further the health of patients. A number of legal judgements on withholding and withdrawing treatment have shown that the courts do not consider that protecting life (the 'sanctity of life' principle) always takes precedence over other considerations. The case law identifies some circumstances where withholding or withdrawing a life-prolonging treatment would be lawful, and establishes the following principles (see endnotes for case references): • An act where the doctor's primary intention i is to bring about a patient's death would be unlawful ii. • Withholding or withdrawing treatment is regarded in law as an 'omission' not an 'act'. • A competent adult patient may decide to refuse treatment even where refusal may result in harm to themselves or in their own death iii. This right applies equally to pregnant women as to other patients, and includes the right to refuse treatment where the treatment is intended to benefit the unborn child iv. Doctors are bound to respect a competent refusal of treatment and, where they have an objection to the decision, they have a duty to find another doctor who will carry out the patient's wishes v. • Life prolonging treatment may lawfully be withheld or withdrawn from incompetent patients when commencing or continuing treatment is not in their best interests vi. • There is no obligation to give treatment that is futile and burdensome vii. • Where an adult patient has become incompetent, a refusal of treatment made when the patient was competent must be respected, provided it is clearly applicable to the present circumstances and there is no reason to believe that the patient had changed his/her mind viii. • For children or adults who lack capacity to decide, in reaching a view on whether a particular treatment would be more burdensome than beneficial, assessments of the likely quality of life for the patient with or without the particular treatment may be one of the appropriate considerations ix. • In the case of patients in a permanent vegetative state (PVS), artificial nutrition and hydration constitute medical treatment and may be lawfully withdrawn in certain circumstances x28. However, in practice, a court declaration should be obtained xi. • Final responsibility rests with the doctor to decide what treatments are clinically indicated and should be provided to the patient, subject to a competent patient's consent or, in the case of an incompetent patient, any known views of that patient prior to becoming incapacitated and taking account of the views offered by those close to the patient xii. 2. Case law also suggests that: • Where a patient's capacity to consent to or refuse a treatment remains in doubt after appropriate steps have been taken to assess their capacity, or where differences of opinion about a patient's best interests cannot be resolved satisfactorily, legal advice should be sought about applying to the courts for a ruling. • When the Court is asked to reach a view on whether it is in an incompetent patient's best interests to withhold or withdraw a treatment, it will have regard to whether what is proposed is in accordance with a responsible body of medical opinion. But the Court will determine for itself whether treatment or non-treatment is in the patient's best interests xiii. 3. It is also important to note that the Human Rights Act 1998 may have implications for this area of medical decision making by incorporating into English law the European Convention on Human Rights. Notably under that Convention, Article 2 requires that a person's right to life be protected by law; Article 3 prohibits inhuman and degrading treatment; and Article 8 requires respect for private and family life. As relevant case law emerges, the exact scope of these rights and how they may be balanced against one another will become clearer. At present the case law confirms that the existing common law principles are consistent with the European Convention on Human Rights xiv. It is also clear Page 7 of 8 Sherren & Yoganathan 2009
  8. 8. that doctors' decisions are likely to be subject to greater scrutiny and the decision making process will need to be open, transparent and justifiable. 4. Other legislative changes affecting patients' rights, such as provisions in the Adults with Incapacity (Scotland) Act 2000, mean that the legal position in Scotland, Northern Ireland, England and Wales could diverge significantly in future years. Such changes reinforce the importance of doctors obtaining up to date advice and guidance on the legal as well as clinical issues affecting their practice in this area. i R v Cox (1992) 12 BMLR 38. ii For a very rare exception in the case of conjoined twins see Re: A (Children) (Conjoined twins: surgical separation) [2000] 4 All ER 961. iii Airedale NHS Trust v Bland [1993] 1 All ER 821 at page 860 per Lord Keith and page 866 per Lord Goff. Also Re JT (Adult: Refusal of Medical Treatment) [1998] 1 FLR 48 and Re AK (Medical Treatment: Consent) [2001] 1 FLR 129. iv St George's Healthcare Trust v S (No 2). R v Louise Collins & Others, Ex Parte S (No 2) [1993] 3 WLR 936. v Re Ms B v a NHS Hospital Trust [2002] EWHC 429 (Fam). vi Airedale NHS Trust v Bland [1993] 1 All ER 821. vii Re J (A Minor) (Wardship: Medical Treatment) [1990] 3 All ER 930. viii Airedale NHS Trust v Bland [1993] 1 All ER 821 at page 860 per Lord Keith and page 866 per Lord Goff. Also Re T (Adult: Refusal of Treatment) [1992] 4 All ER 349 and Re AK (Medical Treatment: Consent) [2001] 1 FLR 129. ix Re B [1981] 1 WLR 421; Re C (A Minor) [1989] All ER 782; Re J (A Minor) (Wardship: Medical Treatment) [1990] 3 All ER 930; Re R (Adult: Medical Treatment) [1996] 2 FLR 99. x Airedale NHS Trust v Bland [1993] 1 All ER 821; Law Hospital NHS Trust v Lord Advocate 1996 SLT 848. xi Airedale NHS Trust v Bland [1993] 1 All ER 821; Law Hospital NHS Trust v Lord Advocate 1996 SLT 848. Also refer to Practice Note (Official Solicitor: Declaratory Proceedings: Medical and Welfare Decisions for Adults Who Lack Capacity) [2001] 2 FLR. xii Re J (A Minor) (Child in Care: Medical Treatment) [1992] 2 All ER 614; and Re G (Persistent Vegetative State) [1995] 2 FCR 46. xiii Re A (Male Sterilisation) [2000] FCR 193; and Re S (Adult: Sterilisation) [2000] 2 FLR 389. xiv A National Health Trust v D (2000) 55 BMLR 19; NHS Trust A v M and NHS Trust B v H (2000) 58 BMLR 87. Withholding and withdrawing life-prolonging medical treatment. Guidance for decision- making (British Medical Association, 1999) Where the patient’s imminent death is believed to be inevitable, artificial nutrition and hydration may be withheld or withdrawn if it not considered to be a benefit to the patient. In these final stages, active treatment and provision of artificial nutrition and hydration may become unnecessarily intrusive and merely prolong the dying process rather than offering a benefit to the patient. Oral/intravenous hydration can be considered if it is thought to be necessary for the patient’s comfort. Page 8 of 8 Sherren & Yoganathan 2009

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