"Unilateral Withdrawal: An 11th Commandment?"

Unilateral Withdrawal: An 11th Commandment?

Unilateral Withdrawal: An 11th Commandment?

Section of Critical Care MedicineSection of Infectious Diseases

University of Manitoba, Winnipeg, Canada

Anand Kumar, MD

The Primary Obligation of a Physician:

•Life

•Truth

Case #1

• 88 year old woman with history of moderate dementia due to Alzheimer’s disease requiring chronic care support

• Unexpected cardiac arrest with prolonged downtime initially requiring pressors and ventilation…

• After 3 days, neurologic exam suggests high probability of best outcome is vegetative state

• Termination of support recommended• Sister (only relative) objects to support withdrawal on

religious grounds (no reliable evidence of patient’s previously stated wishes)…Evangelical Christian with belief in “miracle” based on prayer

Case #2

• 39 year old woman presents with AML with marrow ablation (WBC 0.1) and bilateral invasive pulmonary aspergillosis

• No effective treatment option for malignancy or infection (attempted therapy failed)

• Patient aware of imminent death but still requests maximal ICU support to delay death as long as possible (despite any possible pain)

• Sequentially develops respiratory failure, shock, severe ARDS requiring increasing pressors and PEEP

Case #3• 86 year old Jewish male who suffered a fall 4

years previously • At that time, presented to ER with a large

epidural hematoma and GCS 4…• Left parietal/frontal/temporal lobectomy at

family insistence (advised against by neuroSx) left as expected severely impaired; “minimally conscious state” requiring tracheostomy and total dependence without communication at chronic hospital facility

Case #3-continued• 4 years later, develops pneumonia and

admitted to acute care hospital for antibiotic therapy; significant bedsores present

• Fails to respond to antimicrobial therapy developing septic encephalopathy, respiratory failure and shock

• Family requests admission to ICU• Based on poor medical prognosis and non-

awareness of environment, ICU care initially declined

• Under insistence of family, attending ICU physician agrees to short-term ICU admission to assess for reversibility

Case #3-continued• At the end of a week there is no substantial

improvement…it appears that patient cannot improve to point of leaving ICU but can be sustained with continued ventilator and intermittent pressor/inotropic support

• Also requiring continued active medical management for electrolyte imbalances and renal failure (which may best be managed with chronic dialysis which is not available for chronic hospital patients outside of the acute hospital setting)

Case #3-continued• Support is continued for several weeks without

improvement with intermittent discussions with family (son has been appointed guardian) regarding inappropriateness of continued support

• Ethics consult of little use…recommends continued attempts to communicate with family

• In the interim, the patient begins to develop sepsis associated with worsening bedsores

• After 3 weeks a senior attending starts service…within a week additional tests are performed which indicate severe pulmonary hypertension (incompatible with prolonged life) and chronic borderline cardiogenic shock

• Additional discussions with family ensue..

Case #3-continued• The patient has never directly expressed his wishes

and has never ceded decision making to his children• The family believe, supported by their rabbi, that any

therapy that could potentially preserve biological life for even a minute (irregardless of probability of benefit or cost) is mandated from a religious point of view

• The family further believes that termination of therapy (e.g. pressors or ventilator support) or even failure to implement any therapy that could potentially delay biological death (e.g. dialysis, heart-lung transplant or ECMO/ cardiopulmonary bypass) is tantamount to murder

• no common ground can be found

Case #3-continued• Since it is clear after 5 weeks in ICU that a)

the patient has never and will never achieve an awareness of the environment and b) will never survive the ICU stay, the attending physician determines that the burden of therapy outweighs the benefit.

• A 2nd independent ICU physician is consulted who concurs with the current attending (and also with 2 other attending staff who have cared for the patient)

Case #3-continued• After reviewing the situation with the family

again, the attending physician informs the family that the patient will be removed from ventilator support (with palliation as required) in 96 hours…the family is advised of administrative and legal options that they may take

• An ex-parte order is obtained blocking this action; in the meantime, all efforts to preserve the patient’s life is ordered (without restriction)

• a court date for the litigating the case is set…..

Case #3-continued• The court date for this litigation is December

2009….approximately 1 year after the initial events described.

• 3 months after this court order, 3 of 6 ICU physicians of the hospital resign or otherwise refuse to continue care of the patient feeling that they are inflicting severe harm without any hope of benefit i.e. torture

• Within another month, the remaining 3 physicians tender or decide to tender their own resignations or refusal to participate in the care of the patient for the same reason

Reasons to limit support

• Societal/Global: appropriate use of limited resources overall

• Logistical/Practical: average ICU admission is days-week; blocking an ICU bed for 1 year stops about 50-100 patients from accessing this resource

The real reason to limit/terminate support

• ICU support by it’s nature is at a minimum uncomfortable and at a maximum quite painful

• Used to save a life, it can be justified• Used to delay an inevitable death without any

hope of improvement, it is tantamount to torture• Such support can only result in pain for patient

and severe distress for health care workers forced against their will to engage in torture

The courts should stay out of it!

• Why?

The courts should stay out of it!Why?• Don’t know what they are doing when it comes to

medical issues and exceedingly uncomfortable with end of life cases– dynamic situations that do not lend themselves to simple

judicial orders

• Good at dispute resolution but very, very bad for rapid dispute resolution – see 1 year time to planned litigation in our case

• Should never enter an order they are unwilling or unable to enforce…breeds contempt for judicial process – see history of end of life conflicts that have reached court

Non-initiation = withdrawal• If the law is black and white…medicine is infinite

shades of grey• The law has tended to consider non-initiation and

withdrawal as separate issues; nonsensical from a medical point of view

• Often, there is uncertainty due to lack of information at presentation

• May not be able to reliably determine at the outset whether a condition is survivable or not...but we can within a few days

• If we do not concede equivalence, then physicians response will be to fail to initiate rather than risk inability to terminate support for questionable cases

• People will die unnecessarily

Unilateral Non-initiation/Withdrawal

• Decision making should involve all parties• 99.9% of cases can be resolved with some time and

effort• Rare cases, often involving religious views, cannot be

resolved• Unilateral action/inaction (ie without family approval)

is ethical in these situations• There is a reason that medical therapies are

restricted to physicians• Appropriate framework should be that any party

required to initiate therapy can block implementation/continuation of support

Can a family/patient mandate specific care?

• Even at their optimum, supportive therapies such as ventilation and vasopressors are only effective when coupled with more definitive therapies…

• Much like being told to provide a parachute but hold the ripcord…

• are courts prepared to order chemotherapy or surgical intervention when necessary?

• Otherwise… court-mandated pain and suffering (for both patient and health care team)

Can a family/patient mandate specific care?

• It is always possible to delay biological death

• Decompressive craniectomies to avoid coning and brain death for those who would accept vegetative state?

• Continued support for patients with families who do not accept brain death?

• ECMO/cardiopulmonary bypass for all families who demand it?

Solution• Process Based non-judicial disposition

(by legislation)

• Texas solution• Ontario approach• Legislative adoption of Manitoba

College Statement on Withholding/Withdrawing of Life Support; don’t hold your breath

The Edge of Life

• Laws of physics break down at the beginning of time

• Similarly, the laws of man break down at the edge of life

Unspoken Truths at the Edge of Life

• Death (right here, right now) is optional– Almost all ICU deaths are due to termination of support…

otherwise we could put everyone on cardiopulmonary bypass

• Brain death is preventable– We just don’t tell people about hemicraniectomies because

we think it’s unreasonable

• The futility debate has been argued and won– What is brain death except permanent, irreversible

unconsciousness? And how is that different (from a patient perspective) than a vegetative state?

Unspoken Truths at the Edge of Life• The current ethical paradigm of obtaining

patient/family consent for all major actions is a conceit of Western culture. Many Eastern cultures do not allow consent to withdrawal/with-holding of medical support for reasons of “honor” or “face”. Can accept a decision by physician but cannot affirmatively embrace decision

• The idea that one can truly obtain an informed consent in a critical care situation is similarly a legal fiction. It is impossible to get across the enormity in terms of intrusiveness and discomfort of things that must be done to support dying patients (closest analogy…telling someone how profoundly the birth of a first child will affect their lives…you can tell them but…)

Unspoken Truths at the Edge of Life• When a physician tells a family that wants

“everything” done, that “everything” has been done…the physician usually means “everything” that the physician believes is reasonable under the circumstances (don’t ask, don’t tell policy of therapy)

• When a family who cannot accede to termination of support on religious grounds is told that a proposed therapy has an outside chance of working but may kill the patient, what’s really occurring is that the physician (knowing there is no real chance of response) is proposing to execute the patient under the guise of therapy in order to provide the family with a religious fig leaf.

Unspoken Truths at the Edge of Life

• An unethical court order for continued support is easily circumvented

• Much of medical therapy is based on judgment and timing

• Faced with an support order a physician thinks is unethical and harmful to the patient, it is easy to (consciously or unconsciously) delay critical therapy or fail to implement therapy where a judgment call is needed

• Few, if any, physicians will torment a dying patient on the order of the court; if forced to do so, they can, will and do allow death to occur through passive inaction

An 11th Commandment?

• “Thou may not die”