Ethical Dilemmas in Intensive Care

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Ethical Dilemmas in Intensive Care Dr. Andrew Ferguson

Transcript of Ethical Dilemmas in Intensive Care

Ethical Dilemmas in Intensive Care

Dr. Andrew Ferguson

“The primary goals of intensive care medicine are to help patients survive acute threats to their lives while preserving and restoring the quality of those lives”

Truog R, et al. Critical Care Medicine 2008; 36: 953-963

Issues with changing goals of care

Most patients have a deep desire not to be dead.

Medicine cannot predict the future, and cannot give patients a precise, reliable prognosis about when death will come.

If death is the alternative, many patients who have only a small amount of hope will pay a high price to continue the struggle”

Truog R, et al. Critical Care Medicine 2008; 36: 953-963

Futility

Quality of life

Autonomy

Justice

Beneficence

Non-maleficence

Utility Equity

•Beneficence: the physicians’ duty to help patients whenever possible

•Non-maleficience: the obligation to avoid harm

•Justice: the fair allocation of medical resources

•Autonomy: the patients’ right to self-determination

•Paternalistic decision-making = physician

•Determinative decision-making = shared

Underpinning concepts•Withholding and withdrawing life

support are equivalent•There is an important distinction

between killing and allowing to die•The doctrine of “double effect” - ethical

rationale for providing symptom control even when this may have the foreseen (but not intended) consequence of hastening death

Challenges•Competing demands for limited

resources•Futility•Quality of life•Burnout•Therapeutic nihilism•Fatalism

What is futility?

a medical intervention that had not been useful in the last 100 cases OR interventions that merely preserve permanent unconsciousness or dependence on intensive medical care

“Treatments should be defined as futile only when they will not accomplish their intended (physiologic) goal”.

“Treatments that are extremely unlikely to be beneficial, are extremely costly, or are of uncertain benefit may be considered inappropriate and hence inadvisable, but should not be labeled futile”.

Futility

What is quality of life?

Elements of Quality of Life

Physical Psychological Social

Whose life is it anyway?

How do we know...?•Who should be admitted?

•What are the indicators that we shouldn’t admit?

•How much illness is too much?•When should we say enough is enough?•How can we be certain?

Quality indicators for end-of-life care•Patient and family-centred decision-making

•Communication with family and patient•Communication within team•Continuity of care•Emotional and practical support for

patient/family•Symptom management and comfort care•Spiritual support for patient/family•Emotional/organisational support for ICU

clinicians

Scenario 1•Spinal cord injury:

• quadriplegia• ventilator dependence• prolonged pressure sore• difficult access to rehab bed

•Is a prolonged ICU stay appropriate?•What about other patients rights to care?•What are you using to inform your

decisions?

Your thoughts?

Scenario 2• Elderly patient with significant comorbidity• Profound septic shock and MSOF and no

improvement in 48 hours of maximum therapy• Outlook bleak...discussion with family...patient

would not want treatment that will not get her better....would not want CPR etc

• Agreement to DNAR and no escalation with clear plan to withdraw the following day if no MAJOR improvement (definition given)...family content with plan and communicated to extended family

•Change of consultant the next day•New consultant gets verbal hand-over of

decision making process and outcome•New consultant not happy to withdraw•Family upset and angry with change in

plan•Patient treated aggressively for further

48 hours before withdrawal and death

Scenario 2

Your thoughts?