Ethics Case Conference

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  • ~15% survival rate overall typical of recent series; that number hasn’t changed in a long time.
  • Look at a rule like this and, whatever its usefulness, what one immediately sees is that any such rule must be qualified by numerous exceptions.
  • Sense here is the longer you go the less likely a good outcome, but not of a firm cutoff, certainly not at 10 minutes.
  • Furthermore, we know there are clinical settings in which prolonged efforts at cpr are very much worthwhile, such as drowning, hypothermia and electrical injury.
  • In medicine and in ethics, rules seem better suited to some sorts of issues/problems than others. there are some rules that are more or less exceptionless; in ethics you can think of these easily; most of the 10 commmandments would fit in here; don’t tell lies don’t steal; don’t kill the innocent in medicine there are some too; e.g. if the po2 is < 55, administer o2. but in medicine and ethics, there are situations or problems we face for which rules seem less than adequate. if the question is “should the patient be dnr or not?”, any rule we come up with is going to be less useful because there are going to be so many exceptions based upon the uniqueness of the individual case.
  • There are perhaps some absolute rules in medicine…e.g. if po2 is < 55, administer o2. But most problems in medicine are more like the present one; we bring rules to bear on them and find that they bear only imperfectly, because the case has features that make the rule inapplicable.
  • Autonomy as expressed by patient’s surrogate decision makers is not unimportant but in this case the patient’s interest demands that we give him what he needs.

Transcript

  • 1. To Code or Not to Code?? F. Amos Bailey MD Director, Palliative Care Birmingham VAMC
  • 2. Screw the Ethical Principles
    • This case is giving me a headache
    • The ethical principles don’t seem to be helpful
    • What I need is some sort of guidance
  • 3. Ethical Principles Screw UP
    • Autonomy – Cannot Get a Straight Answer
    • Offer to take responsibility for decision but ultimately no decision is made
    • Beneficence – Resuscitation cannot be helpful or beneficial
    • Non-Maleficence- Resuscitation has got to hurt particularly when there is no benefit to be gained
  • 4. Justice
    • Justice for Mr. XG?
    • Justice for the family?
    • Justice for the medical providers?
    • Justice for society?
  • 5. Slow Code
    • Don’t run; walk.
    • Faking it is as bad a lying.
    • New England Journal said it was a bad idea.
      • The Slow Code- Should Anyone
      • Rush to Its Defense
      • Gazelle, G. NEJM (1998)338:467-9
  • 6. Slow Code
    • Was the idea best option in the case of Mr. XG?
    • However, was admittedly, not satisfactory…
    • The scenario did not work out as planned and patient was coded when one was not attended…
    • What was needed was a rule…..
  • 7. Borrow a Bright Idea
    • Validation of a Rule for
    • Termination of Resuscitation
    • in Out-of-Hospital Cardiac Arrest.
      • Morrison LJ et al. NEJM (2006)335:478-87
      • Article discusses a Rule for TOR that if applied in the Toronto area would greatly reduce the numbers of resuscitation attempts with no “statistical” effect on number of survivors .
  • 8. Rule for Termination of Resuscitation
    • If it could work in the outpatient setting why not have one for codes in the hospital
    • Sick people come to the hospital and a lot of them die
    • A rule like this would have been helpful in the Case of Mr. XG when all the ethical principles failed us
    • Lets try to develop a Rule for TOR for the hospital
  • 9. Disclaimer
    • Cardiac Arrest not Respiratory Arrest
    • Respiratory Arrest much more likely to be survived and have beneficence with less risk on maleficence
    • Often confused in discussion of codes and if counted in gives a false sense of the successfulness, for cardiac arrest
    • “Mostly dead I can work with.” Max( Billy Crystal) resuscitating Wesley in the Princess Bride.
  • 10. Rule for Termination of Resuscitation
    • 1 Arrest is not witnessed - If the cardiac arrest is not witnessed or detected by telemetry such that the time between arrest and the when ACLS is initiated is unknown then resuscitation will not be provided, and if started, then will be discontinued.
    • 2. Asytole- Patients who have asytole at the time of arrest or develop asytole during resuscitation will not receive ACLS or have ACLS protocol discontinued
    • Murphy et al: Annals of Internal Medicine 1989; 111 (3): 199-205
    • van Walraven et al: Journal of American Medical Association 2001;285: 1602-06
    • Engdahl J;Am J Cardiol 2000 Sep 15;86(6):610-4
  • 11. Rule for Termination of Resuscitation
      • 3. DNI Order- Patients who have a Do Not Intubate order will not receive ACLS protocol since the initial step in ACLS is to secure airway and provide respiratory support. Since this cannot be reasonably done and honor the DNI order, ACLS will not be initiated and if it has been will be promptly discontinued.
      • Ethical Challenges of Partial Do-Not-Resuscitate (DNR) Orders: Placing DNR Orders... Berger Arch Intern Med. 2003; 163: 2270-2275.
  • 12. Rule for Termination of Resuscitation
      • 4. Return of spontaneous circulation - If spontaneous circulation is not restored within 10 minutes of initiation of ACLS protocol then resuscitation efforts will be discontinued.
      • 5. Defibrillation - Electrical defibrillation is an effective treatment for ventricular dysrhythmia. However, if defibrillation is not effective in restoring spontaneous circulation within 10 minutes then the ACLS will discontinued
    • In-hospital versus out-of-hospital presentation of life-threatening ventricular arrhythmias predicts survival Epstein, A. et al. J Am Coll Cardiol, 1999; 34:1111-1116 .
    • Bourke Arch Intern Med 2001;161:1751-1758.
    • Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Rea TD; Circulation 2003 Jun 10;107(22):2780-5.
    • Advanced cardiac life support in out-of-hospital cardiac arrest.
    • Stiell IG;N Engl J Med 2004 Aug 12;351(7):647-56
    • .
  • 13. Rule for Termination of Resuscitation
    • 6. Patients that reside in a nursing home would not receive resuscitation attempts.
    • 7. Patients 80 years and older would not receive resuscitation attempts .
    • Outcome and Cost-Effectiveness of Cardiopulmonary Resuscitation after In-Hospital Cardiac Arrest in Octogenarians Paniaguaa, D et al. Cardiology 2002;97:6-11
    • Age and Other Determinants of Survival After In-hospital Cardiopulmonary Resuscitation O'KEEFFE s. Q J Med 1991; 81: 1005-1010
    • In-hospital Cardiac Arrest and Resuscitation Outcomes: Rationale for Sudden Cardiac Death Approach Rakiae, D. Croat Med J 2005;46(6):907-912
    • Outcomes of cardiopulmonary resuscitation in nursing homes: can we predict who will benefit? Tresh DD,Am J Med. 1993 Aug;95(2):123-30.
  • 14. The Case of Mr XG; optimal outcomes
    • Had we had the rule: Mr XG’s family is educated that he will not benefit from resuscitation and a dnr order is written, if necessary, in spite of their disagreement.
    • Not having the rule (but in light of its correctness): Mr XG is coded, but briefly (slow code). This would have been the best course to take under the circumstances.
  • 15. The Case
    • Mr XG is 86 years old, is s/p bilateral cva and has multiple comorbidities and is sick.
    • He needs to be DNR but family cannot accept this, order cannot be written.
    • Dr Bailey’s instructions are not made completely clear but suggestion is that Mr XG is not meant to be coded.
    • Mr XG dies, is coded, would not have been if Dr Bailey had been on the ball.
  • 16. Amos’s Approach
    • Tough case  what’s the rule?  Action
    • This doesn’t work very well for this case.
    • Amos’s solution: devise a rule that fits the case
  • 17. CPR in the Hospital
    • Arrest rhythms
      • VF/VT 25%
      • Asystole/PEA 66%
    • Survival
      • Overall (to discharge) 17%
        • VF/VT 35%
        • Asystole/PEA 10%
    Peberdy et al., Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the national registry of cariopulmonary resuscitation. Resuscitation 58(2003): 297-308
  • 18. CPR in the Hospital; survivors
    • Before After d/c
    • Residence at home 84% 51%
    • Good Cerebral
    • performance 68% 59%
    • Good overall
    • performance 48% 37%
  • 19. Amos’s rule for cpr
    • Don’t if unwitnessed arrest of indeterminate duration
    • Don’t if asystole
    • Dni equals dnr
    • Stop after 10 minutes
    • Don’t if nursing home resident
    • Don’t if patient is > 80
  • 20. CPR and Code Duration
    • Survival is clearly more likely for …CPR durations of 15 minutes or less. Mortality increases from 44% for resuscitations less than 15 minutes in duration versus 95% for those that are longer. Survival is rare after 30 minutes of CPR.
    Ch 16 Cardiopulmonary Resuscitation; Cohn et al., Cardiac Surgery in the Adult (NY: McGraw Hill, 2003)
  • 21. CPR and Code Duration
    • Recent series:
      • “ The duration of the resuscitation attempt was not correlated with patient survival.”
    Danciu et al., A predictive model for survival after in-hospital cardiopulmonary arrest Resuscitation 62(2004): 35-42.
  • 22. Cpr and Asystole
    • Recent series/registries:
      • Survival in-hospital cpr attempts
        • 25% cases: Initial rhythm vt/vf; survival rate 25%
        • 66% cases: initial rhythm asystole/PEA; survival rate 10%
    Peberdy et al., Cardiopulmonary resuscitation of adults in the hospital: a report of 14720 cardiac arrests from the national registry of cariopulmonary resuscitation. Resuscitation 58(2003): 297-308
  • 23. CPR and Age
    • Recent series/registries:
      • age sometimes an independent predictor of survival…
      • and sometimes not….
    Cooper et al., A decade of in-hospital resuscitation: outcomes and prediction of survival? Resuscitation 68(2006): 231-37. Danciu et al., A predictive model for survival after in-hospital cardiopulmonary arrest Resuscitation 62(2004):
  • 24. Cpr and age
    • Recent expert opinion:
      • Advanced age was a negative prognostic indicator in several early series but has no independent predictive value when comorbidities are considered.
    Ch 16 Cardiopulmonary Resuscitation; Cohn et al., Cardiac Surgery in the Adult (NY: McGraw Hill, 2003)
  • 25. CPR and metastatic cancer
    • Recent metaanalysis:
      • Conclusions: Overall survival of CPR to hospital discharge in cancer patients compares favorably to survival rates in unselected inpatients. Improved outcomes in recent years in patients with metastatic disease are likely to reflect more selective use of CPR in cancer patients, with the sickest patients deselected.
    Reisfeld et al., Survival in cancer patients undergoing in-hospital resuscitation: a metaanalysis. Resuscitation 71(2006): 152-60.
  • 26. CPR and rules
    • Amos’s rule isn’t the right one.
    • One might use what we know about resuscitation outcomes to develop a rule for offering cpr.
      • – Any such rule would be tentative, more like a suggestion or a general guideline than a fixed rule.
    • Rules are most useful (easily applicable) when one doesn’t need them.
  • 27.
    • The most useful (directly applicable because generally exceptionless) rules are rules we tend not to need.
      • Ethics: the decalogue
      • Medicine: e.g. when po2 is <55, give o2.
    • Non-straightforward situations (for which we look for guidance) tend to be less amenable to clear direction from available rules
    Algorithms/“Rules”
  • 28.
    • The Bailey view of practice:
      • Rule  Case  Action
    • Realistic view of practice
      • Straightforward cases: Docs engage with cases  Action
        • Rules describe our practice but we don’t consult a rulebook; we see what the case demands and act.
      • More difficult cases; rules serve as aids to engagement
        • We turn to them not for primary guidance but to help us better grasp our more difficult cases (in what ways does it fit the rule, and in what ways not?)
  • 29. Algorithms/“Rules” in Medicine
    • Summarize our practice for situations of a given type (that share given properties)
    • Rules draw our attention to common properties of multiple cases
    • But individual cases involve multiple properties not taken cognizance of by a given rule.
  • 30.
    • Easy rules/cases
      • Property governed by the rule demands use of the rule in all (or virtually all) situations—no matter what the other aspects of the situation happen to be….
    • Hard rules/cases
      • Property governed by the rule may or may not demand its use depending upon other properties the situations bears.
      • i.e. : rules for hard cases are defeasible
    • “ rules are made to be broken”
    Algorithms/“Rules” in Medicine
  • 31. Algorithms/rules in medicine
    • Suitability for resuscitation is the kind of property that makes for a “hard case”; any rule we try to make for this issue will be defeasible.
  • 32.
    • Easy cases/properties: lets have rigid rules and live by them
    • Hard cases/properties: lets consider abstract information we have and make decisions after grappling with the case and grasping it in its full individuality.
    • Rigid rules for hard cases (such as suitability for resuscitation) are a recipe for disaster.
    Algorithms/rules in medicine
  • 33. Mr XG
    • It is clear that Mr XG, by the time he’s in Safe Harbor at BVAMC, needs to receive comfort care and be DNR.
    • The difficulty in the case is that his surrogate decision-makers, his family, haven’t gotten to this conclusion.
  • 34. Amos’s options that night
    • 1) Compassionately but firmly tell the patient’s family that Mr XG would receive everything he needed for comfort and would not be resuscitated in the event of an arrest.
  • 35. Amos’s options for that night
    • 2) Leave the patient without a DNR order and resign himself to the patient being coded in spite of that not being the right thing for Mr. XG.
  • 36. Amos’s actual choice
    • Defacto but concealed DNR order in the form of instructions to call him when the patient died.
      • Right thing for the patient
      • Leaves Amos compromised in regard to the family
    •  patient inadvertently coded; Amos gets the worst of possible worlds
  • 37. Tough cases
    • Engage  identify the difficulty
    • Consider abstract knowledge (rules) but realize that these will likely be less important than
      • a good grasp of the case
      • a good intention to resolve it in the patient’s interest.