End-of-life Care in the ICU: Practical and Ethical Issues

Mazen Kherallah, MD, FCCP

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Case Scenario

• An 85-year-old man with New York Heart Association class IV heart failure, hypertension, and moderate Alzheimer’s disease is admitted to the hospital after a hip fracture.

• His postoperative course is complicated by pneumonia, delirium, and pressure ulcers on his heels and sacrum.

• Respiratory status is worsened with severe shortness of breath and hypoxemia requiring high flow O2 .

• A decision for intubation and mechanical ventilation needs to be made

What would you do next:

A. Intubate the patient and place on MVB. Do not intubate and Inform the family that

prognosis is bad based on his previous conditionC. Meet with the family and ask them what they want

to do and proceed based on their wishes D. Meet the family and help in making decision:

shared decision making11%11%11%11%

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Palliative care within the experience of illness, bereavement, and risk.

Risk-reducing Care

Risk Diagnosis Death

Bereavement CareSymptom Management/Supportive Care

Curative

Hospice Palliative Care

Life Closure(Planning for Death)

Last Hours of Life Care (Dying)

Risk Illness Bereavement

PatientFamily

End of Life Care

One in Five Deaths in the U.S. Occur in the ICU

Angus, Crit Care Med 2004; 32:638

Proportion of Deaths Preceded by CPR for Patients > 65 years old

Ehlenbach, NEJM, 2009; 361:22

Variability in Withholding and Withdrawing Life Support in the US

n = 6303 deaths, 131 ICU’s, 110 hospitals, 38 states

Prendergast, Am J Resp Crit Care Med, 1998. 158:1163

OUTLINE

Shared decision-makingTools for communicating with familiesInterdisciplinary communicationRole of culture and ethnicityWithdrawing life support

Shared Decision-making About End-of-life Care

Clinician decision

Family decision

Carlet, Intensive Care Med 2004; 30:770

Treatments that are indicatedPrognosis

Level of certaintyPatient/family: patient values & preferences

Family Preferences for Role in Decision-making

n=1123 families of patients in 6 ICU’s

Heyland, Intens Care Med, 2003; 29:75

Symptoms of PTSD Higher with Discordance in Decision-making Role

p=0.005p=0.10p=0.06

Gries, Chest 2010; 137:280

Parentalism or Doctor Decides

Autonomy or “Informed Choice”

Shared Decision Making

Default Starting Place

Family preferencePrognosis and Certainty

New Paradigm for “Right Approach” to Parentalism vs. Autonomy

DirectiveProvide some infoMake decision

InformativeProvide infoMake no recommendationShared Decision

Making

FacilitativeElicit patient valuesPlace in context

CollaborativeElicit patient valuesOffer recommendation

White, submitted, 2008

New Paradigm for “Right Approach” to Parentalism vs. Autonomy

White, Arch Intern Med, 2007, 167:461

OUTLINE

Shared decision-makingTools for communicating with familiesInterdisciplinary communicationRole of culture and ethnicityWithdrawing life support

Case Scenario

• 69 year old with PMH of HTN, DM, and COPD• Admitted with pneumonia and required to be

intubated and placed on MV• Condition is worsened with shock, renal

failure requiring dialysis, DIC, severe ARDS and lactic acidosis (LA 8.9)

What would you do next:

A. Continue current level of support, do not dialyze and no escalation of inotrops

B. Discontinue all life support modalities and provide comfort care

C. Escalate therapies, start hemodialysis, and do everything possible.

D. Arrange for family conference and discuss the current condition, prognosis and expectation with the family and make a shared decision

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Study of ICU Family Conferences

• Daily screen of all ICUs in 4 hospitals• If conference planned, contact attending:

– Is discussion of withholding or withdrawing life support likely?

– Willing to have conference recorded?

• Consent/survey all participants• 51 family conferences recorded (46%)

McDonagh, Crit Care Med, 2004, 32:1484

Duration of Family Conferences and Proportion of Family Speech

McDonagh, Crit Care Med, 2004, 32:1484

Proportion Family Speech Correlates with Family

Satisfaction

McDonagh, Crit Care Med, 2004, 32:1484

Clinician Statements Associated with Increased Family Satisfaction

• Assure family that patient will not be abandoned prior to death

• Assure family that patient will be kept comfortable and not suffer prior to death

• Provide support for family around decisions to withdraw or continue life support

• Answer questions, clarify and follow up on family statements• Acknowledge and address emotions• Explore patient preferences• Affirm non-abandonment

Stapleton, Crit Care Med, 2006; 43:1679

VALUE: 5-step Approach to Improving Communication in ICU with Families

• V… Value family statements• A… Acknowledge family emotions• L… Listen to the family• U… Understand patient as a person• E… Elicit family questions

Curtis, J Crit Care, 2002; 17:147

Lautrette, N Engl J Med 2007;356:469-78

Randomized Trial of Communication Strategy

Lautrette, NEJM, 2007; 356:469

Randomized 126 patients if attending believed “patient would die in a few days”

Proactive family conference using VALUE strategy

63 patients

Usual practice atCenter

63 patients

Intervention Control

Family Member Outcomes: Clinically Significant Morbidity at 3 Months

p<0.02 for all

Lautrette, NEJM, 2007; 356:469

OUTLINE

Shared decision-makingTools for communicating with familiesInterdisciplinary communicationRole of culture and ethnicityWithdrawing life support

A meeting is scheduled, whom do want to be present?

A. Yourself and patient’s wifeB. Yourself, wife and closed relativesC. Yourself, wife, closed relatives and the

primary physicianD. Yourself, wife, closed relatives, primary

physician and the nurseE. Yourself, wife, closed relatives, primary

physician, the nurse and a religious person

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Physician-Nurse Collaboration in the ICU

• Interdisciplinary collaboration associated with decreased– ICU mortality– ICU length of stay– ICU readmission rates– Physician and nurse conflict– Job stress for nurses

Doctor and Nurse Ratings of Interdisciplinary Communication

p<0.001 for all

Reader, Br J Anaesth, 2007; 98:347

Percent of Decisions with Physician-Nurse Collaboration in Decision-making

Ferrand, Am J Resp Crit Care Med, 2003; 167:1210

Percent of Physicians Involving Nurses in Decisions about Withdrawal

Yaguchi, Arch Intern Med, 2005; 165:1970

How do you assess the physician collaboration? (Nurses only)

A. PoorB. AverageC. GoodD. Very goodE. Excellent

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How do you assess the nurses collaboration? (Physicians only)

A. PoorB. AverageC. GoodD. Very goodE. Excellent

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OUTLINE

Shared decision-makingTools for communicating with familiesInterdisciplinary communicationRole of culture and ethnicityWithdrawing life support

Case Scenario

• 54 year old male with 30 years of smoking history who was recently diagnosed with metastatic lung cancer

• The wife request not to inform the patient with his diagnosis or prognosis

What would you do next?

A. Tell the wife that it is his right to know the diagnosis and prognosis and inform the patient

B. Respect the wife’s wish and tell the patient that he has pneumonia and treatment will be given to him

C. Inform the wife to follow with other physician as you would not be able to carry on with her wish but do not inform the patient

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In your opinion, should a patient be told of a cancer Dx?

A. YesB. No

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In your opinion, should a patient decide about withdrawing life support treatment?

A. YesB. No

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YesYesYesYes

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NoNoNoNo

Cultural Differences: Survey of 800 Patients in LA

Should a patient:

Blackhall, JAMA, 1995; 274:820

OUTLINE

Shared decision-makingTools for communicating with familiesInterdisciplinary communicationRole of culture and ethnicityWithdrawing life support

A decision is made to withdraw LST, how would you

do it?A. Do not escalate treatment, do no labs and

continue with meds, fluids and feedingB. Do no labs, stop all medications except

sedatives and analgesia and stop fluids and feeding

C. Stop everything, sedate patient and extubateD. Stop everything, sedate patient and do

terminal wean

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Needs of the Patient

• Receiving adequate pain and symptom management.

• Avoiding inappropriate prolongation of dying• Achieving a sense of control• Relieving burden• Strengthening relationships with loved ones.

Needs of Families

Components of the Withdrawal of Life Support Form

• Preparation– DNAR order; document discussion with family;

discontinue prior orders

• Ventilator withdrawal protocol• Analgesia and sedation

– Infusion with broad range; no maximum dose; document reason for increase

• Principles of withdrawing life support

Treece, Crit Care Med, 2004; 32:1141

Terminal Withdrawal of the Ventilator

Full ventilatory support

Remove supplemental O2 and PEEP

Reduce set rate or PS gradually

•Titrate sedation to ensure comfort•Takes 5 minutes

•Titrate sedation to ensure comfort•Takes 5 minutes

•Titrate sedation to ensure comfort•Takes 5-20 min

Should Patients Be Extubated After Withdrawing Mechanical Ventilation?

A. YesB. No

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YesYesYesYes

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NoNoNoNo

Should Patients Be Extubated After Withdrawing Mechanical Ventilation?

• Little evidence to guide decisions• Clinicians often have strong opinions • Recent study suggests family ratings of care

higher if patient extubated• Case-based judgment based on

– Family preferences– Level of support, amount of secretions, level of

consciousness

Glavan, Crit Care Med, 2008; 36:1138

Tips for Talking with Family About Withdrawal of Life Support

• When life support is withdrawn, stress– “Care” will not be withdrawn– Aggressive palliation will be used– avoid making firm predictions– about the patient’s clinical course – Time to death variable

• Offer option of family being present– Family presence associated with higher PTSD

• Describe process so they know what to expect

Kross, AJRCCM, 2009; abstract

Summary: Ethical and Practical Issues in End-of-life Care in the ICU

• Decision-making about end-of-life care common in the ICU and should start early

• Shared decision-making at the default– Need to adapt to individual patient and family

• Interdisciplinary communication essential• Incorporate and honor cultural difference• Withdrawal of life support is a clinical

procedure