Transcript Ethics at the end of life - Scioto County Medical Society

Ethics at the end of life
Brian Hiestand MD, MPH
Assistant Professor, Dept. of
Emergency Medicine
Vice Chair, OSU Ethics Committee
Case Presentation
86 year old female from hospice with
history of NHL presents after choking on a
grape
 Grape expelled in route, but patient still
tachycardic, although in no distress
 Family is present, including the daughter
who is the medical POA, with the DNR-CC
in hand

Case Presentation
What’s the legal thing to do?
 What’s the ethical thing to do?
 Is there a difference?
 Where does the family fit in?

Baseline Terms

Ethics – the application of values and
moral rules to human behavior
Flexible
 Case based


Law –
Inflexible, adversarial
 Based on unalterable directives

Baseline Terms

Both law and ethics evolve, incorporate
societal values, and form the basis for
health care policy
Baseline Terms

Autonomy – the right of a competent
person to direct their own care


Does not have to be rational, sensible, or
agreeable
US Supreme Court 1914, Schloendorff v.
Society of New York Hospital
“Every human being of adult years and sound
mind has a right to determine what shall be
done with his own body.”
Baseline Terms
Power of attorney – in the setting where
the patient is no longer competent, the
POA is empowered to make health care
decisions
 While the patient has capacity, the POA
has no right to make decisions for the
patient
 Healthcare POA is different than financial
POA

Historical Perspective
Karen Ann Quinlan 1975 – anoxic brain
injury leading to persistent vegetative state
 Initially vent dependant, the parents asked
the physician to withdraw the vent, but he
refused
 In 1976, citing the Constitutional right of
privacy, the New Jersey Supreme Court
appointed Mr. Quinlan the guardian and
ordered the withdrawal of ventilator care

Historical Cases - Quinlan
Karen Quinlan survived the initial
withdrawal of the ventilator and was
transferred to a nursing home, where she
later succumbed to pneumonia
 Karen’s right to privacy, when weighed
against the interests of the state, favored
the Quinlan family

Historical Cases - Cruzan



Nancy Cruzan, 1983 – MVA, significant brain
injury, PEG tube placed. NOT vent dependant
Later that year, the parents requested the
removal of the PEG.
The Missouri Supreme Court refused to allow
this, as there was a living will statute in Missouri,
but Ms. Cruzan had not established one.
Available testimony from a previous roommate
was deemed insufficient to allow withdrawal of
nutrition
Historical Cases - Cruzan


The US Supreme Court upheld the ruling in
1990, stating that due process was not violated
by the requirement of either "clear and
convincing, inherently reliable evidence“ or a
living will when such a statute exists
A family member’s statement, in absence of
clear and convincing evidence, is not “automatic
assurance that the view of close family members
would necessarily be the same as the patient's
would have been had she been confronted with
the prospect of her situation while competent."
Historical Cases - Cruzan
Later that year, further evidence of
Cruzan’s wishes were discovered, and the
Missouri courts allowed the withdrawal of
nutrition
 Nancy Cruzan died two weeks later

Historical Cases - Schiavo
Terri Schindler-Schiavo, 1990 – cardiac
arrest with resultant anoxic injury. Not vent
dependant.
 1993 – Terri’s parents file suit to have
Michael removed as guardian. Case
dismissed

Historical Cases - Schiavo
1998 – Husband petitions for feeding tube
removal
 2000 – District court allows withdrawal
 2001 – Appeals court allows withdrawal
 April 2001 – Both Florida and US Supreme
Courts refuse to intervene, tube is
removed on April 24th

Historical Cases - Schiavo
April 26, 2001 – another district judge
orders feeding to resume
 Oct 2002 – after a year of multiple
appeals, the parents’ lawyer alleges abuse
by the husband was responsible for her
brain damage, based on a bone scan from
the early 90’s. This would later be refuted
on autopsy

Historical Cases - Schiavo
2005 – US Congress intervenes to refer
case to Federal Courts. Federal Court
refuses to intervene, finding no
objectionable actions by the state courts
 Ms. Schiavo eventually dies of
dehydration.
 Key finding – in Florida, a written Living
Will is not required to convey end of life
decisions

Case Law Summary
The state does not have an interest in
keeping people alive against their advance
directives
 Guardian / family can be sufficient
evidence of desired wishes in the absence
of specific advance directives

State law
In May of 1999, the state of Ohio enacted
a law implementing a standard DNR
provision
 The goal was to provide commonality and
portability of a patient’s DNR status,
regardless of health care system

DNR-CC
Do not resuscitate – comfort care
 By state law, the only care permissible is
that which provides comfort

Narcotics, benzodiazepines, positioning,
suctioning, splinting, control of bleeding
 Cannot: fluid bolus, any other life prolonging
therapies
 Obviously: do not intubate, do not defibrillate,
no CPR

DNR-CC arrest
In general, full measures up to the point of
cardiac or pulmonary arrest
 Then, comfort measures only (?)
 Controversies are legion

Cardioversion of non-fatal dysrhythmia
 Intubation in respiratory distress
 BiPAP / CPAP
 What about going to the OR?

Living Will
Takes effect when the patient enters a
vegetative state or in case of medical
futility
 Infrequently used for intended purposes
 Can represent a patient’s attitude towards
end of life issues

Medical Futility

In some cases, CPR and other critical care
efforts have no reasonable chance of
prolonging life or providing benefit to the
patient – i.e. they are futile
Medical Futility

However, the definition of futility depends
on the end goal
Discharge to home intact
 Survival to ECF
 Pain / symptom free life

Medical Futility

Physicians do not have to provide
medically futile care
A neurosurgeon does not offer surgery to
every brain tumor patient
 Not every moribund patient should be offered
CPR
 Discuss with patient / family

 Goals
 Limitations
of therapy
 Consequences of therapy
Conflicts

DNR and the patient
This is a complex and emotionally laden
issue, and many patients and physicians do
not fully understand the State Designations
 Families are generally less clear on what
these designations entail

Conflicts

DNR and the patient
A patient with capacity can revoke the DNR at
any time
 Often, we are in a position to coerce the
patient
 “Are you sure you don’t want us to help your
breathing by putting you on the breathing
machine?”
vs.
“Do you want us to put you on life support?”

Conflicts

DNR and the patient

Remember, if you change the patient’s code
status after talking with the patient, document
the conversation clearly
Conflicts

DNR orders and the family
Make every attempt to reconcile the family’s
perception, but remember that the DNR order
represents the patient’s autonomous wishes
 Compassionate persuasion
 Burden of decision making often the issue

 In
some situations, we can ask them to accept our
making the decision and relieve that burden
Conflicts

DNR and the POA
Often, the POA is the one that signed the
DNR order with the physician
 If so, ask what has changed
 If the patient has signed the DNR, and the
POA wants something different, then it gets
complicated
 Try to get the POA to realize that they need to
represent what the patient would have
wanted, using the DNR to suggest what the
patient wanted

Back to the case…
Our patient with terminal NHL from
hospice who choked on a grape is found
to be in wide-complex ventricular
tachycardia, still with a pulse
 No respiratory distress or chest pain
 Slightly hypotensive (90 systolic)
 What next?

Options
Shock?
 Chemical cardioversion?
 Vagal maneuvers?

What we did
Nothing, really
 We gave her scheduled pain medications
 We admitted her to Hematology for
comfort measures
 Her shock was getting worse as she went
up to the floor

Rationale
Any therapy given would likely be lifeprolonging
 Shock – high risk of discomfort
 Drugs – relatively low risk of discomfort (IV
access was established en route)
 However…

Rationale




Given that the patient was in hospice for terminal
NHL, there was little reason to provide life
prolonging therapy, as long as there was no
accompanying discomfort
Without the grape, ventricular tachycardia would
have been an undiagnosed terminal event
Even in the setting of accompanying discomfort
(say, rupturing AAA and peritonitis), treat the
discomfort
Comfort care should be part of every patient’s
regimen
Further End of Life Care
Withdrawal from ventilator
 No evidence for or against extubation vs.
terminal wean
 Both analgesics and anxiolytics are helpful
 Anticholinergics, antipsychotics may be
adjunctive in the right situation

End of Life Care

To drip or not to drip…
If already on an analgesic drip, continue
 Otherwise, intermittent dosing will suffice

Adjust dosing for comfort
 Primary intention is to relieve suffering
 Respiratory depression is an acceptable
side effect in these situations
 Up-titrating to hasten death is not ethical
nor permitted

Organ Donation
As medical technology improves, more
people are being considered for transplant
 This has lead to an increasing demand for
donor organs

History of Organ Donation
First cornea – 1905
 First living donor kidney – 1954
 First post-mortem kidney- 1962
 First liver – 1967
 First heart - 1967
 1981 – First heart – lung
 1992 – first xenotransplantation, baboon
liver

History of Brain Death
Prior to 1967, organs were harvested from
individuals that sustained cardiac death
 The advent of mechanical ventilation had
produced an increasing number of patients
that sustained cardiac function without
neurologic or respiratory function

History of Brain Death


In 1968, Harvard Medical School convened a
committee to explore the issue of these patients
with irreversible coma, coining the term ‘brain
death’
1981 – The President’s Commission for the
Study of Ethical Problems in Medicine and
Biomedical and Behavioral Research refined a
"whole brain standard" which became the basis
for the Uniform Determination of Death Act.
Definition of Brain Death
Unresponsiveness, lack of receptivity, the
absence of movement and breathing, the
absence of brainstem reflexes.
 Rule out medical conditions that may
confound the clinical assessment

Severe acid-base, electrolyte, or endocrine
 Hypothermia
 Absence of intoxication

Establishing Brain Death

In the absence of brain stem function,
spinal reflexes can still create movement
Trunk muscles may contract, giving the
appearance that the person is trying to rise
 Arms may rise, facial twitching, head may turn
side to side

Establishing Brain Death

Clinical examination

Brainstem reflexes
 Doll’s

eyes, calorics
Apnea testing
 The
absence of respiratory drive with a PaCO2 of
60 mm or 20 mm above patient’s baseline
Establishing Brain Death

Confirmatory testing is optional in the US,
but required in Europe, Central and South
America, and Asia
Cerebral angiography / MRA
 EEG
 Transcranial Doppler ultrasound
 Nuclear imaging

Federal, State and local
authorities
By federal law, the family of every potential
donor must be informed of their option to
donate organs or tissues or not to donate
 If you, or your consultants, declare
someone brain dead, you cannot withdraw
upon them until LOOP has had a chance
to talk with the family

Organ donor registry
In 2000, Ohio enacted a law stating that
the individual’s preference, as obtained by
the BMV when the driver’s license is
renewed, trumps the family preference
 As of July 2002, there is an online registry
accessible by LOOP with everyone who
has opted to be an organ donor

Organ donor registry

Controversies
Non-English speakers
 Minors – need witnesses for the consent
 Informed consent provided by the BMV
 To opt in, all you have to do is say yes at the
BMV
 To opt out, you have to download a form and
mail it in

Non-heart beating donors

In the fledgling years of organ retrieval,
kidneys were removed immediately after
their hearts stopped beating
Non-heart beating donors
With the advent of the concept of brain
death, asystolic donors fell out of favor
 As the definition of a viable transplant
candidate has expanded, the number of
people on the waiting list has far
surpassed the number of available organs

Non-heart beating donors

In 2002, there were 80,000 people waiting
for organs

24,000 transplants were performed from:
 6,081
dead donors
 6,499 live donors

The first year that living donors outnumbered
dead donors
Non-heart beating donors
Several transplant centers have been
harvesting organs, with family consent,
from non-brain dead patients
 Original controversy landed Cleveland
Clinic on 60 Minutes for the use of
phentolamine as a pre-donor drug
 Active killing vs comfort measures

Non-heart beating donors

Many countries, by law, assume that an
individual consents to organ donation at
death, unless the patient has
documentation otherwise
Non-heart beating donors


Weber et al compared outcomes in 122 kidneys
from asystolic donors matched against 122
kidneys from donors with a heartbeat (study in
Switzerland)
There was a significantly higher incidence in
delayed graft function in the asystolic group, but
there was no difference in long term function or
mortality
NEJM 2002;347, 248-255.
Non-heart beating donors

Protocol:
Step 1: The clinical team and the family
decide to withdraw care
 Step 2: LOOP is notified and the chart
reviewed, if the patient is a candidate the
family is approached
 BMV registry does not apply to NHBD!
 Step 3: Family consents, and transplant
surgery team notified

Non-heart beating donors
Step 4: Femoral catheters are placed by
LOOP or the clinical team. 30,000 units of
heparin are infused (similar to dose that
cardiac bypass patients receive)
 Step 5: After family gathers and says
goodbye, the patient is transferred on life
support to the OR
 Step 6: Patient is prepped, draped, and
extubated

Non-heart beating donors

Step 7: If cardiac activity ceases within
one hour of extubation, procurement
proceeds


Asystole, ventricular fibrillation, or PEA must
persist for 5 minutes
If cardiac activity is maintained for one
hour, the patient is returned to the floor
and family to continue with comfort
measures
Non-heart beating donors

Potential conflicts with this are legion

Conflict of interest with the transplant center
 Is
my loved one truly a candidate for withdrawal or
are you just short on kidneys?
 Transplant surgeon and the declaration of death
Conflicts within the ICU staff
 Are we truly doing no harm?

 Femoral
catheter
 Heparin bolus
Non-heart beating donors

Conflict with the family


Can they go to the OR?
Conflict with the OPO
Undue pressure
 Invasion of the physician-patient relationship
 Timing of LOOP’s involvement

So far, we have not had difficulties
 Still an early program

Final Points
End of life issues affect all aspects of
medicine, not just ICU care
 Advance discussion when possible
regarding expectations, goals, risks of
therapies



With few exceptions, the ER is a lousy place
to try to determine medical futility de novo
Advance directives represent the patient’s
last chance to make their wishes known