Ethical Dilemmas in the ICUEthical Dilemmas in the ICU

Lauri Stephens RRT-NPS, RPFTLauri Stephens RRT-NPS, RPFT

No man can be ignorant that he must die, nor be No man can be ignorant that he must die, nor be sure that he may not this very day.---Cicerosure that he may not this very day.---Cicero

The U.S. & most “Western” societies The U.S. & most “Western” societies are classed as death denying or are classed as death denying or

defyingdefying

Fear of Death or Death AnxietyFear of Death or Death Anxiety Primary coping mechanism is avoidancePrimary coping mechanism is avoidance Death is rarely talked aboutDeath is rarely talked about Now beginning to see increased focus Now beginning to see increased focus

training for health care professionalstraining for health care professionals Research & SurveysResearch & Surveys

Health Care Workers Are Different…Health Care Workers Are Different…

RCP’s regularly deal RCP’s regularly deal with deathwith death

““Others” may not Others” may not understandunderstand

We frequently use We frequently use humor to copehumor to cope

Frequently move from Frequently move from “full court press” to “full court press” to withdrawal of carewithdrawal of care

The combination of the stress of providing care to The combination of the stress of providing care to critical patients & the absence of training in caring critical patients & the absence of training in caring for the dying, make the ICU a challenging place for the dying, make the ICU a challenging place

to work.to work. Most Americans die in a hospitalMost Americans die in a hospital Death in the ICU is commonDeath in the ICU is common Of all patients who die in a hospital, ½ are cared Of all patients who die in a hospital, ½ are cared

for in an ICU within 3 days of dyingfor in an ICU within 3 days of dying 1/3 spend at least 10 days in the ICU during their 1/3 spend at least 10 days in the ICU during their

final hospitalizationfinal hospitalization 90% of deaths in the ICU involve withdrawing or 90% of deaths in the ICU involve withdrawing or

withholding at least one life supporting withholding at least one life supporting intervention. Most ICU deaths involve withholding intervention. Most ICU deaths involve withholding or withdrawing multiple interventionsor withdrawing multiple interventions

Perceptions of Family and Perceptions of Family and CliniciansClinicians

Cari R. Levy, MD; E. Wesley Ely, MD, Cari R. Levy, MD; E. Wesley Ely, MD, MPH, FCCP; Kate Payne, RN, JD; MPH, FCCP; Kate Payne, RN, JD; Ruth A. Engelberg, PhD; Donald L. Ruth A. Engelberg, PhD; Donald L. Patrick, PhD, MSPH; J. Randall Patrick, PhD, MSPH; J. Randall

Curtis, MD, MPH, FCCPCurtis, MD, MPH, FCCP

CHEST.  2005;127(5):1775-CHEST.  2005;127(5):1775-1783.  ©2005 American College 1783.  ©2005 American College of Chest Physiciansof Chest Physicians

Quality of Death and Dying in two Quality of Death and Dying in two Medical ICU’sMedical ICU’s

Evaluated attendings,Evaluated attendings,

residents, ICU nurses and residents, ICU nurses and families response to deathfamilies response to death

How I chose this topic…How I chose this topic…

Geared to MD’sGeared to MD’s Good range of topicsGood range of topics Recommend as Recommend as

department a resourcedepartment a resource

How I chose this topic…How I chose this topic…or way too much daytime TVor way too much daytime TV

Numerous talk shows Numerous talk shows about the aftermath of about the aftermath of withdrawing life supportwithdrawing life support

Families grieving many Families grieving many years later, still not sure years later, still not sure they made the right they made the right decisiondecision

Woman describing apnea Woman describing apnea trial and brain death trial and brain death declarationdeclaration

In this patient situation…In this patient situation…

Who do you think likely Who do you think likely performed the apnea performed the apnea trial?trial?

Who do you think Who do you think withdrew support?withdrew support?

What image does this What image does this give our profession?give our profession?

How does this impact How does this impact our recruitment and our recruitment and retention?retention?

What do I hope to accomplish by talking What do I hope to accomplish by talking about ethics surrounding death?about ethics surrounding death?

Increasing education surrounding dealing Increasing education surrounding dealing with death & dyingwith death & dying

Retaining & supporting studentsRetaining & supporting students Increased staff satisfaction and retentionIncreased staff satisfaction and retention Increased patient & family satisfaction Increased patient & family satisfaction

(helping to provide a “good death”)(helping to provide a “good death”)

Increasing education surrounding Increasing education surrounding dealing with death & dying…dealing with death & dying…

Current RC classes where death education Current RC classes where death education may occurmay occur

PsychologyPsychology SociologySociology Speech/CommunicationSpeech/Communication EthicsEthics Mechanical Ventilation?Mechanical Ventilation?

Retaining & Supporting StudentsRetaining & Supporting Students

Provide positive role Provide positive role model…model…

Allow time to debriefAllow time to debrief Share experiencesShare experiences Be aware that most Be aware that most

young people have no young people have no direct experience with direct experience with death or a dead bodydeath or a dead body

Increasing Staff SatisfactionIncreasing Staff Satisfaction Identify coping strategiesIdentify coping strategies Staff support groupsStaff support groups Enlist Pastoral/Spiritual CareEnlist Pastoral/Spiritual Care Be involved in patient rounds & care Be involved in patient rounds & care

conferencesconferences Share family cards and letters with all Share family cards and letters with all

staffstaff Palliative Care ConsultsPalliative Care Consults Allow staff rituals to mark the death of Allow staff rituals to mark the death of

a patient or simply a moment to a patient or simply a moment to recover/debriefrecover/debrief

Move away from “Angel of Death” Move away from “Angel of Death” mentalitymentality

Recognize that death is not a medical Recognize that death is not a medical failurefailure

Increasing Patient & Family SatisfactionIncreasing Patient & Family Satisfaction

Families rate communication as equal or more Families rate communication as equal or more important than clinical skillsimportant than clinical skills

We must be involved in Care Conferences, We must be involved in Care Conferences, Physician Rounds and End of Life Care Physician Rounds and End of Life Care Discussions in order to avoid giving mixed Discussions in order to avoid giving mixed messagesmessages

We are dealing with families experiencing griefWe are dealing with families experiencing grief Less than 5% of patients are able to communicate Less than 5% of patients are able to communicate

their wishes regarding withholding or withdrawing their wishes regarding withholding or withdrawing life support at the time decisions are being madelife support at the time decisions are being made

Normal Grief ReactionsNormal Grief Reactions Feelings: shock, numbness, sadness, Feelings: shock, numbness, sadness,

fear, anxietyfear, anxiety Physical Sensations: SOB, Chest Physical Sensations: SOB, Chest

Tightness, “Out of Body”Tightness, “Out of Body” Cognitions: Disbelief, Preoccupied,Cognitions: Disbelief, Preoccupied, HallucinationsHallucinations Behaviors: Sleep Disturbances, Eating Behaviors: Sleep Disturbances, Eating

Difficulties, Absent MindednessDifficulties, Absent Mindedness

5 Stages of Grief5 Stages of GriefDenial, Anger, BargainingDenial, Anger, BargainingDepression, Acceptance Depression, Acceptance

Current Challenges in the ICUCurrent Challenges in the ICU Patient Centered CarePatient Centered Care

– Education and shared knowledge Education and shared knowledge – Involvement of family and friends Involvement of family and friends – Collaboration and team management Collaboration and team management – Sensitivity to non-medical and spiritual dimensions of care Sensitivity to non-medical and spiritual dimensions of care – Respect for patient needs and preferences Respect for patient needs and preferences – Free flow and accessibility of informationFree flow and accessibility of information

Comfort Care- Advance Directives, Living WillsComfort Care- Advance Directives, Living Wills Increase in Patients and Staff of Different CulturesIncrease in Patients and Staff of Different Cultures

– In 1998 racial & ethnic minority groups made up 28% of In 1998 racial & ethnic minority groups made up 28% of the US populationthe US population

– By 2020 over 44% of the pediatric population will be By 2020 over 44% of the pediatric population will be minoritiesminorities

– By 2030 approximately 40% of the total US population By 2030 approximately 40% of the total US population will consist of racial & ethnic minoritieswill consist of racial & ethnic minorities

Patient Centered CarePatient Centered Care

Sharing my experiences…Sharing my experiences… Halloween CodeHalloween Code ““Bad” CodeBad” Code

Patient Centered CarePatient Centered Care

The creation of visitation policies that show The creation of visitation policies that show respect to the family for their central role in the respect to the family for their central role in the patient’s life is essential:patient’s life is essential:- Patients need support & contact with loved ones- Patients need support & contact with loved ones

(especially in the ICU & the crises of illness)(especially in the ICU & the crises of illness)- Family members need to be intimately aware of the Family members need to be intimately aware of the

patient’s situation (need to fulfill role within the family)patient’s situation (need to fulfill role within the family)- Demonstrating respect for the family generates a Demonstrating respect for the family generates a

climate of mutual positive regard and trust for the health climate of mutual positive regard and trust for the health care teamcare team

3 Ethical Justifications for Restricting ICU 3 Ethical Justifications for Restricting ICU VisitationVisitation

When it is the patient’s When it is the patient’s preferencepreference

To protect the privacy To protect the privacy of other patientsof other patients

To protect or provide To protect or provide safety for hospital staffsafety for hospital staff

Comfort CareComfort Care

Families need to know their loved one will Families need to know their loved one will be respected as a person, not just viewed be respected as a person, not just viewed as a bodyas a body

Withholding support versus withdrawalWithholding support versus withdrawal Adequate sedation and pain management Adequate sedation and pain management

versus euthanasiaversus euthanasia

1983 Report by the President’s Commission for 1983 Report by the President’s Commission for the study of the study of Ethical Problems in Medicine Ethical Problems in Medicine

(Deciding to Forego Life-Sustaining Treatment)(Deciding to Forego Life-Sustaining Treatment)

No distinction between failing to initiate therapy & stopping No distinction between failing to initiate therapy & stopping therapy, that is, withholding versus withdrawing treatment, therapy, that is, withholding versus withdrawing treatment, is not itself of moral importance because a justification that is not itself of moral importance because a justification that is adequate for not commencing a treatment is sufficient for is adequate for not commencing a treatment is sufficient for ceasing it.ceasing it.

Actions that suggest administration of a pain medicine that Actions that suggest administration of a pain medicine that may hasten a patient’s death are justified by the benefits may hasten a patient’s death are justified by the benefits expected to exceed the negative consequences as long as expected to exceed the negative consequences as long as the sole purpose is not to poison or kill a patientthe sole purpose is not to poison or kill a patient

Comfort Care GuidelinesComfort Care Guidelines

Care Plans or Standing Orders are recommendedCare Plans or Standing Orders are recommended Adequate sedation and pain medication, as Adequate sedation and pain medication, as

evidenced by no grimacing or response to painful evidenced by no grimacing or response to painful stimulistimuli

Decrease to 21% and 0 PEEPDecrease to 21% and 0 PEEP SIMV rate equal to patient rate or PS to maintain SIMV rate equal to patient rate or PS to maintain

minute ventilationminute ventilation

Assess for air hunger, agitation or tachypnea and Assess for air hunger, agitation or tachypnea and increase sedation as needed before proceeding increase sedation as needed before proceeding with decreasing ventilationwith decreasing ventilation

Comfort Care GuidelinesComfort Care Guidelines

Create a peaceful environmentCreate a peaceful environment Explain step by stepExplain step by step Plenty of chairs around bed + tissuesPlenty of chairs around bed + tissues Patients face, mouth & hands clean & freePatients face, mouth & hands clean & free Make sure bed is lockedMake sure bed is locked

Cross Cultural MedicineCross Cultural Medicine

Patients and families in the ICU are vulnerable & Patients and families in the ICU are vulnerable & should not be required to defend their belief should not be required to defend their belief systemssystems

Culture encompasses beliefs & behaviors that are Culture encompasses beliefs & behaviors that are learned & shared by members of a grouplearned & shared by members of a group

Respecting a patient whose background is Respecting a patient whose background is different than our own, requires that we accept different than our own, requires that we accept cultural diversity and recognize that human dignity cultural diversity and recognize that human dignity is more important than our differencesis more important than our differences

Tips for Cross Cultural MedicineTips for Cross Cultural Medicine

Consider Life ExperienceConsider Life Experience Expressions of PainExpressions of Pain Cause of IllnessCause of Illness Role of FamilyRole of Family Attitudes regarding poor prognosis & informationAttitudes regarding poor prognosis & information Emotional expression will varyEmotional expression will vary Western medicine and alternative/native Western medicine and alternative/native

treatments are not viewed as mutually exclusivetreatments are not viewed as mutually exclusive In times of stress early learned beliefs may In times of stress early learned beliefs may

resurfaceresurface

Cultural CasesCultural Cases

The Right Time to DieThe Right Time to Die

Poor PrognosisPoor Prognosis

Releasing the SoulReleasing the Soul

Cultural ConsiderationsCultural Considerations

Four is considered an Four is considered an unlucky numberunlucky number in in ChineseChinese, , KoreanKorean, and , and JapaneseJapanese cultures cultures because it sounds like the word "death"because it sounds like the word "death"

Do not go gentle into that good night,Do not go gentle into that good night,Old age should burn and rave at close of day;Old age should burn and rave at close of day;Rage, rage against the dying of the light. Rage, rage against the dying of the light.

Though wise men at their end know dark is right,Though wise men at their end know dark is right,Because their words had forked no lightning theyBecause their words had forked no lightning theyDo not go gentle into that good night. Do not go gentle into that good night.

Good men, the last wave by, crying how brightGood men, the last wave by, crying how brightTheir frail deeds might have danced in a green bay,Their frail deeds might have danced in a green bay,Rage, rage against the dying of the light. Rage, rage against the dying of the light.

Wild men who caught and sang the sun in flight,Wild men who caught and sang the sun in flight,And learn, too late, they grieved it on its way,And learn, too late, they grieved it on its way,Do not go gentle into that good night. Do not go gentle into that good night.

Grave men, near death, who see with blinding sightGrave men, near death, who see with blinding sightBlind eyes could blaze like meteors and be gay,Blind eyes could blaze like meteors and be gay,Rage, rage against the dying of the light. Rage, rage against the dying of the light.

And you, my father, there on the sad height,And you, my father, there on the sad height,Curse, bless me now with your fierce tears, I pray.Curse, bless me now with your fierce tears, I pray.Do not go gentle into that good night.Do not go gentle into that good night.Rage, rage against the dying of the light. Rage, rage against the dying of the light.

-Dylan Thomas-Dylan Thomas