end-of-life choices: cpr & dnr when patient & family conflict over decision: ethical...

Liza Manalo, MDWithholding or Withdrawing Life Sustaining Treatment

End-of-Life Choices: CPR & DNR

WHEN PATIENT & FAMILY CONFLICT

OVER DECISION:

Ethical Considerations for the Competent Patient

LIZA C. MANALO, MD, MSc.PALLIATIVE CARE


SALIENT POINTS

40 year old female, married, nulligravid

Diagnosis: AdenoCA Left Ovary, Stage IVS/P Explore lap, Left Oophorecystectomy Left Infracolic omentectomyBilateral Lymph node dissection

S/P Explore lap, Tube Jejunostomy, due to PGO

due to adhesionsType 2 DMAcute Kidney Injury, 20 to hypoperfusion


SALIENT POINTS:

Medical treatment options, including chemotherapy, as well as palliative and hospice care, and the prognosis of the disease were fully explained to the family.

The patient knew about the cancer diagnosis, but the actual stage and prognosis were not disclosed to her, per family’s request.

Patient is amenable to chemotherapy, pain management, artificial nutrition and hydration, blood transfusion, and IV medications, but not to CPR, intubation, and mechanical ventilation. However, advance directives were not formally discussed and signed by the patient.

The patient’s natural family (parents and siblings) knew of the patient’s wishes, but left the decision-making to the husband.

When the patient went into respiratory distress due to hospital acquired pneumonia, T/C sepsis, and had a CP arrest, the husband agreed and signed the consent for CPR, intubation, mechnical ventilation and ICU admission.


ETHICAL PRINCIPLE:TRUTH-TELLING (DISCLOSURE)

In general, necessary items to disclose include:

a) the patient’s current medical status including the likely course if no treatment is provided.

b) the contemplated procedure or medication

c) alternative available procedures or medication

d) anticipated risks and benefits of both

e) a statement offering an opportunity to ask further questions

f) a professional opinion about the alternatives

g) in case of research, his right to withdraw any time


ETHICAL PRINCIPLE:RESPECT FOR AUTONOMY or SELF-DETERMINATION

Right to informed consent - to receive all necessary

information concerning diagnosis and treatment in

order to be able to give consent based on his/her

value system.

“Informed consent” - the willing and uncoerced

acceptance of a medical intervention by a patient

after adequate disclosure by the health professional

of the nature of the intervention, its expected risks,

and benefits, and alternatives available, before that

treatment is administered.

Liza Manalo, MD

Competent patients have the right to make

decisions about their own treatment, the

right to accept or refuse medical care.

“Competence” - the ability to communicate

choices, understand information about a

treatment decision, and appreciate the

situation, and its consequences

Appelbaum PS, Grisso T. (1988)

Withholding or Withdrawing Life Sustaining Treatment

ETHICAL PRINCIPLE:RESPECT FOR AUTONOMY or SELF-DETERMINATION

Liza Manalo, MD

Resolving Conflict Between the Principles of Autonomy and the Sanctity of Life can be Difficult

What does one do when a competent adult

patient decides on a course of action that

may shorten his or her life, as in the case of

a Jehovah's witness who refuses a

potentially life-saving blood transfusion? The Jehovah's witness does not want to die but is prepared

to do so because of a religious conviction.

In North America, this competent patient's autonomy and

right to refuse medical intervention would be respected.

Jonsen AR, Siegler M, Winslade WJ (1986)


Withholding, Withdrawing

Life-Sustaining Treatment

RICHARD J. ACKERMANN, M.D.Am Fam Physician. 2000 Oct 1;62(7):1555-1560.

Adapted with permission from Education for Physicians on End-of-Life

Care Trainer's Guide, Module 11, withholding, withdrawing therapy. In:

Emanuel LL, von Gunten C J, Ferris FD. Education for physicians on end-

of-life care/Institute for Ethics at the American Medical Association.

Chicago, IL: EPEC Project, The Robert Wood Johnson Foundation, 1999.


There are many factors involved in decisions to limit life-sustaining therapy.

From the medical point of view, the 1st

requirement is that there is at least acceptance and at best consensus agreement among all the members of the medical team, to limit therapy when hope for recovery is outweighed by burden of the treatment.

Prognosis in critical illness is often uncertain. Physicians and families may disagree about how to value a small chance of improvement or to weigh the continuing burdens of treatment.

WITHDRAWING & WITHHOLDING

LIFE-SUSTAINING TREATMENT


The patient’s wishes for continuation or discontinuation of treatment are of paramount importance.

ADVANCE DIRECTIVES - A competent, adult patient may, in advance, formulate and provide a valid consent to the withholding or withdrawal of life-support systems in the event that injury or illness renders that individual incompetent to make such a decision.

A patient may also appoint a surrogate decision maker in accordance with the law (durable power of attorney for health care).

WITHDRAWING & WITHHOLDING

LIFE-SUSTAINING TREATMENT

Liza Manalo, MD

Surrogate consent

If the patient has expressed preferences in the past, the surrogate must use knowledge of these in making the consent.

If patient’s own preferences are unclear, surrogate must consider the patient’s “best interest” using some more objective, socially accepted values, such as relief of suffering and preservation or restoration of function.

For minors, this is usually given by parents or guardians.

Liza Manalo, MD

What does the medical team do when a competent patient has previously refused treatment, but the surrogate decision-maker consents to heroic/aggressive measures when the patient is no longer able to decide for herself?

It is essential not to abandon the patient’s family members, but to work closely with them in determining why they are making decisions that do not appear to be promoting the patient’s best interest.

This exploration, combined with ongoing education by all the members of the health care team, is ethically desirable, in order to make the surrogate decision-maker realize that both he and the medical team have the duty to respect and uphold the patient’s right to self-determination in health care.


There is no ethical distinction between

withdrawing and withholding life-sustaining

treatment.

Medical treatment should only be withdrawn or

withheld on clinical grounds. Every such

decision should be made upon its own merits

and must not be made on the basis of either

cost or medical convenience.

ETHICAL GUIDELINES FOR

LIMITATION OF LIFE-SUSTAINING

TREATMENT


Limitation of treatment should be regarded as a formal procedure subject to the same preparation, thought, care, and consent as for any other aspect of care.

When patients are admitted, there needs to be a clear plan for their management, including definitions of the limits of any invasive interventions.

The physician, patient, and/or family jointly define the goals of treatment.

ETHICAL GUIDELINES FOR

LIMITATION OF LIFE-SUSTAINING

TREATMENT


MEDICAL TREATMENT:Founded on beneficence and compassion for the patient

Discontinuing medical procedures

that may be burdensome,

dangerous, or disproportionate

to expected outcome

"the refusal of 'over-zealous'

treatment"

Taking away the

proportionate means of

preserving life, such as

ordinary feeding, hydration,

and normal medical care

BLESSED JOHN PAUL II :

Clarify the substantive moral difference between


If the good outweighs the harm, then it can be reasonably affirmed that the means is morally ordinary (“proportionate”).

If the harm outweighs the good, then disproportion probably exists and means is probably morally extraordinary.

Foregoing Extraordinary Means of Sustaining Life


On one hand, we have to consider the physical, psychological, economic and other harm which a given modality of treatment is expected to cause, first of all, to a patient, but also to his or her relatives and friends as well as to society.

Whether a treatment is ordinary or extraordinary depends upon the balance between 2 sets of factors:


On the other hand, we have to take into account the degree of probability, if any, first of all, that the patient will be cured or will be able, for a significant period of time, to live on under humanizing conditions.

Whether a treatment is ordinary or extraordinary depends upon the balance between 2 sets of factors:


Extraordinary means usually refer to highly

specialized, physically difficult, psychologically

draining or very expensive measures used in order

to delay the imminent death and prolong the life of

the dying patient.

These extraordinary means no longer correspond to

the real situation of the patient, either because they

are by now disproportionate to any expected results

or because they impose an excessive burden on the

patient and his family.



Here one does not will to cause death; one's inability to impede it is merely accepted.

The decisions should be made by the patient if he is competent and able or, if not, by those legally entitled to act for the patient, whose reasonable will and legitimate interests must always be respected.

- Catechism of the Catholic Church, 2278


Liza Manalo, MD

Cardiopulmonary resuscitation

CPR is a combination of breathing for the victim-to supply oxygen-and compressing the chest wall, which squeezes the heart and pushes blood out to vital organs. In this way, oxygen is delivered to the brain and to the arteries of the heart itself.

After a cardiac arrest, unless breathing and circulation are established within four to six minutes, brain death and permanent death start to occur. The chance of survival diminishes 7-10% for every minute without

defibrillation and CPR.

At 8-10 minutes post-episode, a victim has virtually no chance of survival.

CPR cannot preserve life indefinitely, but it can keep a person alive until more effective medical intervention is available to restore normal heart function.

Liza Manalo, MD

Cardiopulmonary Resuscitation in Hospitalized Patients: When is it

Futile?

Performing CPR on hospitalized patients is usually ineffective, with only 6 to 17 percent of patients surviving to discharge; many survivors die during the next few months or have a poor quality of life.

Patients with malignancy, sepsis, pneumonia or renal failure have even lower survival rates.

More than 90 percent of all hospital deaths now occur without performing CPR.

Von Gunten CF. (1991) Am Fam Physician.

Liza Manalo, MD

CPR vs. DNR Discussions

The convention of discussing CPR initially as “starting the heart” or “putting on a breathing machine” implies a false sense of reversibility, or suggests that those heart and lung functions are isolated problems.

In patients with advanced illness, circulation and breathing stop because of the relentless progression of disease.

Liza Manalo, MD

CPR vs. DNR Discussions

Performing CPR should not be described as “doing everything.”

This implies that not performing CPR is “doing nothing.”

Everyone wants to do whatever is possible to maintain health and well being.

In patients with advanced progressive illness where the prognosis is limited, however, performing CPR often does not help achieve the patient's goals.

Liza Manalo, MD

Do Not Resuscitate

“DNR does not mean no care; it means a

different kind of care that can best be

achieved through end-of-life protocols

and education.”

Fields, 2007, Journal of Neuroscience Nursing


Care for the Terminally-ill

Even if death is thought imminent, the ordinary care owed to a sick person cannot be legitimately interrupted.

The use of painkillers to alleviate the sufferings of the dying, even at the risk of shortening their days, can be morally in conformity with human dignity if death is not willed as either an end or a means, but only foreseen and tolerated as inevitable

Palliative care is a special form of disinterested charity. As such it should be encouraged.

- Catechism of the Catholic Church, 2279


What is Palliative Care?

It is a patient and family-centered care to persons with life-threatening or debilitating illness that focuses upon effective management of pain and other distressing symptoms, while incorporating psychosocial and spiritual care according to patient/family needs, values, beliefs, and culture(s).

Goal: to prevent and relieve suffering and to support the best possible quality of life for patients and their families, regardless of the stage of the disease and the need for other therapies.

NCCN Practice Guidelines in Oncology-v.2.2011


Resuscitation (CPR)

Elective intubation,

mechanical ventilation

Surgery

Dialysis, Hemofiltration

Blood transfusions, blood

products

Diagnostic tests

Artificial nutrition,

(parenteral or enteral) or

hydration (IVF)

Antibiotics

Vasopressors

Future hospital, ICU

admissions

…aimed at maintaining organ function that

only prolong death may be withdrawn or

withheld

ANY LIFE-SUSTAINING THERAPY…


Are physicians legally required to provide all life-sustaining measures possible?

No. To the contrary, patients have a right to

refuse any medical treatment, even life-

sustaining treatments such as mechanical

ventilation, or even artificial hydration and

nutrition.

-Emanuel LL, von Gunten C J, Ferris. (1999).

Education for Physicians on End-of-Life Care Trainer's Guide.


Is withdrawal or withholding of treatment equivalent to euthanasia?

No. There is a strong general consensus that

withdrawal or withholding of treatment is a decision

that allows the disease to progress on its natural

course.

It is not a decision to seek death and end life.

Euthanasia actively seeks to end the patient's life.

-Emanuel LL, von Gunten C J, Ferris. (1999).



Can large doses of opioids to relieve pain, breathlessness, or other symptoms constitute euthanasia?

No. For patients who have been using opioids for pain,

it is very difficult to give such high doses that death is

caused or even hastened in the absence of a disease

process that is leading to imminent death.

Patients tend to sleep off the effect if they receive too

much medication.

However, in the rare circumstance when opioids might

contribute to death, provided the intent was genuinely to

treat the symptoms, then opioid use is not euthanasia.-Emanuel LL, von Gunten C J, Ferris. (1999).


Liza Manalo, MD

No. Palliative or terminal sedation of those imminently

dying is the monitored use of medications intended to

induce a state of decreased or absent awareness

(unconsciousness).

The intention is to relieve intolerable or otherwise

intractable suffering; the procedure is to use a

sedating drug for symptom control; the successful

outcome is the alleviation of distress.

In euthanasia, the intention is to kill the patient; the procedure

is to administer a lethal drug; the successful outcome is

immediate death


Is palliative or terminal sedation equivalent to euthanasia?


Can a dying patient who wants to die at home be discharged?

Yes. Sometimes, following sudden realization of a rapid

decline, a patient may decide that he/she wants to go

home to die. This is consistent with respect for patient’s

autonomy.

In these changing circumstances, time can be short and

clinicians need to be flexible for this to be possible.

Proper discharge care planning, together with the

palliative home care team, facilitates safe discharge and

access to continuing care support for such patients.

- Watson et al, Oxford Handbook of Palliative Care, 2009


HOPEHope lies not only in an expectation of cure or even of the

remission of present distress. For dying patients, the hope of cure will always be shown to be ultimately false, and even the hope of relief too often turns to ashes.

When my time comes, I will seek hope in the knowledge that insofar as possible I will not be allowed to suffer or be subjected to needless attempts to maintain life; I will seek it in the certainty that I will not be abandoned to die alone; I am seeking it now, in the way I try to live my life, so that those who value what I am will have profited by my time on earth and be left with comforting recollections of what we have meant to one another.

- Nuland, Sherwin B (1994). How We Die: Reflections on Life’s Final Chapter


HOPEThere are those who will find hope in faith and their belief in an

afterlife; some will look forward to the moment a milestone is reached or a deed is accomplished; there are even some whose hope is centered on maintaining the kind of control that will permit them the means to decide the moment of their death…

Whatever form it may take, each of us must find hope in his or her own way.

- Nuland, Sherwin B (994). How We Die: Reflections on Life’s Final Chapter


The problem with doctors

Doctors are no more immune to a fear of death

than the rest of us, it seems—especially when they

see death not as a natural and inevitable outcome

of disease, but as a personal defeat or failure.

“It’s frightening for a lot of physicians to deal with

dying patients.”

“Physicians find lots of ways to get away from

these patients quickly.”

http://www.advancedbc.org/files/ABC Chapter 201 Final

Gifts.pdf


Competent Care for the Dying

In the real world in which physicians care for dying

patients, withdrawing treatment and aggressively

treating pain are acts that respect patients’

autonomous decisions not to be battered by

medical technology and to be relieved of their

suffering.

- Foley, Kathleen M. (1997). NEJM

Liza Manalo, MD

SUMMARY

Competent patients have the right to make

decisions about their own treatment, the right to

accept or refuse medical care.

When further intervention to prolong the life of a

patient becomes futile, physicians have an

obligation to shift the intent of care toward comfort

and closure.


Liza Manalo, MD

Withholding or withdrawing life-sustaining

therapies is ethical and medically appropriate in

these circumstances.

Before reviewing specific treatment preferences, it

is useful to ask patients about their understanding

of the illness and to discuss their values and

general goals of care.


SUMMARY

Liza Manalo, MD

Terminally-ill patients with decision-making capacity

can opt to forego any extraordinary medical

intervention aimed at maintaining organ function that

only prolong death.

If the patient is unable to make his/her own medical

decisions and has expressed preferences in the past,

the surrogate must use knowledge of these in making

end-of-life decisions on behalf of the patient.

Even if death is thought imminent, the ordinary care

owed to a sick person cannot be legitimately

interrupted.


SUMMARY


“It's only when we truly know and understand that we have a limited time on earth and that we have no way of knowing when our time is

up, we will then begin to live each day to the fullest, as if it was the only one we had.”

- Elisabeth Kubler Ross

“We have to ask ourselves whether medicine is to remain a humanitarian and respected profession, or a new but depersonalized

science in the service of prolonging life rather than diminishing human suffering.”

end-of-life choices: cpr & dnr when patient & family conflict over decision: ethical...

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