city-wide palliative/ethics grand rounds next session 11/19/07 barry smith suny distinguished...

City-Wide Palliative/Ethics City-Wide Palliative/Ethics

Grand RoundsGrand Rounds

Next Session 11/19/07Next Session 11/19/07

Barry Smith Barry Smith SUNY Distinguished Professor SUNY Distinguished Professor

Julian Park ProfessorJulian Park Professor

The Future of Biomedical InformaticsThe Future of Biomedical Informatics

Jack P. Freer, MDJack P. Freer, MD

UBUB• Professor of Clinical MedicineProfessor of Clinical Medicine• Palliative Medicine Course CoordinatorPalliative Medicine Course Coordinator

Kaleida HealthKaleida Health• Ethics Committee ChairEthics Committee Chair• Palliative Care Consultation (Gates)Palliative Care Consultation (Gates)

CME DisclosureCME Disclosure

• No commercial supportNo commercial support

• No unapproved or off-label usesNo unapproved or off-label uses

BreathlessnessBreathlessness

Jack P. Freer, MDJack P. Freer, MDProfessor of Clinical MedicineProfessor of Clinical Medicine

University at BuffaloUniversity at Buffalo

Learning ObjectivesLearning Objectives

• Understand pathophysiology of Understand pathophysiology of dyspnea dyspnea

• Be familiar with basic modalities of Be familiar with basic modalities of treatment treatment

• Be capable of sound ethical reasoning Be capable of sound ethical reasoning in intubation/ventilation decisionsin intubation/ventilation decisions

• Be able to guide coherent decisions Be able to guide coherent decisions based upon good medicine and good based upon good medicine and good ethicsethics

DyspneaDyspnea

• PathophysiologyPathophysiology

• TreatmentTreatment

• Decision Making/Ethical IssuesDecision Making/Ethical Issues

Dyspnea: Dyspnea: shortness of breath, breathlessnessshortness of breath, breathlessness

• Rapid breathingRapid breathing• Incomplete exhalationIncomplete exhalation• Shallow breathingShallow breathing• Increased work/effortIncreased work/effort• Feeling of suffocationFeeling of suffocation• Air hungerAir hunger• Chest tightnessChest tightness• Heavy breathingHeavy breathing

Dyspnea: Dyspnea: shortness of breath, breathlessnessshortness of breath, breathlessness

• Rapid breathing…Rapid breathing…• Incomplete exhalation…Incomplete exhalation…• Shallow breathing…Shallow breathing…• Increased work/effort…Increased work/effort…• Feeling of suffocation…Feeling of suffocation…• Air hunger…Air hunger…• Chest tightness…Chest tightness…• Heavy breathing…Heavy breathing…

COPD, pulm vasc disCOPD, pulm vasc dis

Asthma,Asthma,

Asthma, Neuro-musc, Chest wallAsthma, Neuro-musc, Chest wall

COPD, Interstitial, Asthma, N-m, CwCOPD, Interstitial, Asthma, N-m, Cw

COPD, CHFCOPD, CHF

COPD, CHF, PregnancyCOPD, CHF, Pregnancy

AsthmaAsthma

AsthmaAsthma

Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553

DyspneaDyspnea

• Cancer (dyspnea common)Cancer (dyspnea common)1.1. Obvious cause (lung mets, effusion etc)Obvious cause (lung mets, effusion etc)

2.2. Co-morbid conditions (COPD/CHF)Co-morbid conditions (COPD/CHF)

3.3. No evidence of 1. or 2. (?cachexia)No evidence of 1. or 2. (?cachexia)

• Non-malignant (COPD, CHF)Non-malignant (COPD, CHF)

Dyspnea in CancerDyspnea in Cancer

• Cancer related causesCancer related causes• Treatment related causesTreatment related causes• General medical condition causesGeneral medical condition causes

Cancer Related CausesCancer Related Causes

• Airway obstruction by tumorAirway obstruction by tumor• Lung parenchyma replacementLung parenchyma replacement• Pleuro-pericardial effusionPleuro-pericardial effusion• Lymphangitic carcinomatosisLymphangitic carcinomatosis• SVC syndromeSVC syndrome• AscitesAscites

Treatment Related CausesTreatment Related Causes

• PneumonectomyPneumonectomy• Radiation fibrosisRadiation fibrosis• ChemotherapyChemotherapy

– Cardiac toxicityCardiac toxicity– Pulmonary toxicityPulmonary toxicity

General Medical ConditionsGeneral Medical Conditions(both related and unrelated to cancer)(both related and unrelated to cancer)

• COPDCOPD• CHFCHF• AsthmaAsthma• InfectionInfection• AnemiaAnemia

• PneumothoraxPneumothorax• Pulmonary embolusPulmonary embolus

Pulmonary hypertension• Psychosocial/Spiritual• …

Mechanism of DyspneaMechanism of Dyspnea

Mechanical ReceptorsMechanical Receptors• LungLung• Chest wallChest wall• Upper airwayUpper airway


Sense of Respiratory EffortSense of Respiratory Effort

• ““Effort” major factor in breathlessnessEffort” major factor in breathlessness• Simultaneous motor cortex signals Simultaneous motor cortex signals

– Efferent to respiratory musclesEfferent to respiratory muscles– Signal to sensory cortexSignal to sensory cortex

Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553


Sense of Respiratory EffortSense of Respiratory Effort

• ““Effort” major factor in breathlessnessEffort” major factor in breathlessness• Simultaneous motor cortex signals Simultaneous motor cortex signals

– Efferent to respiratory musclesEfferent to respiratory muscles– Signal to sensory cortexSignal to sensory cortex– Mismatch enhances sense of effortMismatch enhances sense of effort– Probably similar signals from brainstemProbably similar signals from brainstem


Chemical ReceptorsChemical Receptors

• HypercapniaHypercapnia• HypoxiaHypoxia


HypercapniaHypercapnia

• Early studies in normal subjects Early studies in normal subjects suggested COsuggested CO22 not a factor not a factor

• Probably mediated by pHProbably mediated by pH


HypoxiaHypoxia

• Some evidence of effectSome evidence of effect• Still…Still…

– Some patient hypoxic—not SOBSome patient hypoxic—not SOB– Some patients SOB—not hypoxic Some patients SOB—not hypoxic – Some hypoxic/SOB pts show little Some hypoxic/SOB pts show little

improvement with Oimprovement with O22 therapy therapy

Treatment of DyspneaTreatment of Dyspnea

• Treat underlying causesTreat underlying causes• OxygenOxygen• Nebulized bronchodilatorsNebulized bronchodilators• OpioidsOpioids• BenzodiazepinesBenzodiazepines• Nebulized opioids used by some but no Nebulized opioids used by some but no

solid evidence of efficacysolid evidence of efficacy• Fans across faceFans across face

Decision Making/Ethical IssuesDecision Making/Ethical Issues

• Opioids and hastening deathOpioids and hastening death• Withdraw vs. Withhold Withdraw vs. Withhold • DNIDNI

Resistance to Opioids for DyspneaResistance to Opioids for Dyspnea

• Hasten death; “kill patient” Hasten death; “kill patient”

• Response:Response:– Tolerance to respiratory depressionTolerance to respiratory depression– Slowing respirations may improve oxygenationSlowing respirations may improve oxygenation

Resistance to Opioids for DyspneaResistance to Opioids for Dyspnea

• However, failing to intubate and ventilate a However, failing to intubate and ventilate a patient in severe respiratory failure will patient in severe respiratory failure will result in death (with or without opioids). result in death (with or without opioids).

– Opioids may hasten that deathOpioids may hasten that death– Double effectDouble effect

Withhold LST vs. WithdrawWithhold LST vs. Withdraw

• Logical/clinical difference?Logical/clinical difference?– Therapeutic trialsTherapeutic trials– Duty to start or stop independent of whether the Duty to start or stop independent of whether the

treatment is already in placetreatment is already in place

• Legal difference? NOLegal difference? NO• Religious differenceReligious difference• Psychological differencePsychological difference

Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator

• Quality of life Quality of life (prior to vent decision)(prior to vent decision)

• ReversibilityReversibility


Trial—withdraw laterTrial—withdraw later

• Acceptable quality of life Acceptable quality of life • Reversible conditionReversible condition



• Acceptable quality of lifeAcceptable quality of life• Reversible conditionReversible condition• Clear timetable, endpoints to gauge Clear timetable, endpoints to gauge

“success” of the trial“success” of the trial



• Acceptable quality of life Acceptable quality of life • Reversible conditionReversible condition• Clear timetable, endpoints to gauge Clear timetable, endpoints to gauge

“success” of the trial“success” of the trial• Legally appointed agent to act on behalf of Legally appointed agent to act on behalf of

the patientthe patient


Die without intubation/ventilation (“DNI”)Die without intubation/ventilation (“DNI”)

• Poor quality of life Poor quality of life • Irreversible processIrreversible process



• Poor quality of lifePoor quality of life• Irreversible processIrreversible process

– Prior “reversible process,” tough weanPrior “reversible process,” tough wean




– Prior “reversible process,” tough weanPrior “reversible process,” tough wean• Crystal clear informed consent: Crystal clear informed consent: NONO need need

for last minute “clarification.”for last minute “clarification.”




– Prior “reversible process,” tough weanPrior “reversible process,” tough wean• Crystal clear informed consent: Crystal clear informed consent: NONO need need

for last minute “clarification.”for last minute “clarification.”• Scrupulous symptom managementScrupulous symptom management


Trial / WithdrawTrial / Withdraw• Good QoLGood QoL• ReversibleReversible

________________________________• Clear EndpointsClear Endpoints

– TimeframeTimeframe– OutcomesOutcomes

• Proxy Proxy

WithholdWithhold• Poor QoLPoor QoL• IrreversibleIrreversible

________________________________• Clear Consent Clear Consent

– No last minute No last minute “clarifications”“clarifications”

• Symptom TreatmentSymptom Treatment

Dying Without IntubationDying Without Intubation

Decision making:Decision making: • Broad planning based on goals of treatmentBroad planning based on goals of treatment• Positive treatment directed toward ALL goalsPositive treatment directed toward ALL goals• Reversibility/Quality of lifeReversibility/Quality of life• Treat respiratory failure symptomaticallyTreat respiratory failure symptomatically

– No intubation/ventilationNo intubation/ventilation


DocumentationDocumentation • Document rationale in detailDocument rationale in detail• Document informed consent discussionDocument informed consent discussion• Detailed symptomatic planDetailed symptomatic plan

CommunicationCommunication• Clear discussions with nurses, familyClear discussions with nurses, family• Explain what to expectExplain what to expect• Avoid focus on “Avoid focus on “notnot””


What if the patient changes his mind?What if the patient changes his mind?


Failure to document the informed Failure to document the informed consent discussion can lead to consent discussion can lead to last minute “clarification” about last minute “clarification” about decision (and patient “changing decision (and patient “changing mind” about intubation).mind” about intubation).


Failure to provide adequate Failure to provide adequate symptom relief can lead to symptom relief can lead to suffering (and patient “changing suffering (and patient “changing mind” about intubation).mind” about intubation).

Respiratory Death Respiratory Death without Intubation/Ventilationwithout Intubation/Ventilation

• ……can be the most appropriate and ethically can be the most appropriate and ethically defensible option.defensible option.

• ……can be part of a comprehensive palliative can be part of a comprehensive palliative plan based on the patient’s goals of care.plan based on the patient’s goals of care.

• ……can NOT be summarized in 3 letters.can NOT be summarized in 3 letters.

EditorialEditorial

city-wide palliative/ethics grand rounds next session 11/19/07 barry smith suny distinguished...

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