ethics at the end of life brian hiestand md, mph assistant professor, dept. of emergency medicine...

Ethics at the end of lifeEthics at the end of life

Brian Hiestand MD, MPHBrian Hiestand MD, MPHAssistant Professor, Dept. of Assistant Professor, Dept. of

Emergency MedicineEmergency MedicineVice Chair, OSU Ethics CommitteeVice Chair, OSU Ethics Committee

Case PresentationCase Presentation

86 year old female from hospice with 86 year old female from hospice with history of NHL presents after choking on a history of NHL presents after choking on a grapegrape

Grape expelled in route, but patient still Grape expelled in route, but patient still tachycardic, although in no distresstachycardic, although in no distress

Family is present, including the daughter Family is present, including the daughter who is the medical POA, with the DNR-CC who is the medical POA, with the DNR-CC in handin hand

Case PresentationCase Presentation

What’s the legal thing to do?What’s the legal thing to do?What’s the ethical thing to do?What’s the ethical thing to do? Is there a difference?Is there a difference?Where does the family fit in?Where does the family fit in?

Baseline TermsBaseline Terms

Ethics – the application of values and Ethics – the application of values and moral rules to human behaviormoral rules to human behaviorFlexibleFlexibleCase basedCase based

Law –Law – Inflexible, adversarialInflexible, adversarialBased on unalterable directivesBased on unalterable directives


Both law and ethics evolve, incorporate Both law and ethics evolve, incorporate societal values, and form the basis for societal values, and form the basis for health care policyhealth care policy


Autonomy – the right of a competent Autonomy – the right of a competent person to direct their own careperson to direct their own careDoes not have to be rational, sensible, or Does not have to be rational, sensible, or

agreeableagreeableUS Supreme Court 1914, US Supreme Court 1914, Schloendorff v. Schloendorff v.

Society of New York HospitalSociety of New York Hospital““Every human being of adult years and sound Every human being of adult years and sound

mind has a right to determine what shall be mind has a right to determine what shall be done with his own body.”done with his own body.”


Power of attorney – in the setting where Power of attorney – in the setting where the patient is no longer competent, the the patient is no longer competent, the POA is empowered to make health care POA is empowered to make health care decisionsdecisions

While the patient has capacity, the POA While the patient has capacity, the POA has no right to make decisions for the has no right to make decisions for the patientpatient

Healthcare POA is different than financial Healthcare POA is different than financial POAPOA

Historical PerspectiveHistorical Perspective

Karen Ann Quinlan 1975 – anoxic brain Karen Ann Quinlan 1975 – anoxic brain injury leading to persistent vegetative stateinjury leading to persistent vegetative state

Initially vent dependant, the parents asked Initially vent dependant, the parents asked the physician to withdraw the vent, but he the physician to withdraw the vent, but he refusedrefused

In 1976, citing the Constitutional right of In 1976, citing the Constitutional right of privacy, the New Jersey Supreme Court privacy, the New Jersey Supreme Court appointed Mr. Quinlan the guardian and appointed Mr. Quinlan the guardian and ordered the withdrawal of ventilator careordered the withdrawal of ventilator care

Historical Cases - QuinlanHistorical Cases - Quinlan

Karen Quinlan survived the initial Karen Quinlan survived the initial withdrawal of the ventilator and was withdrawal of the ventilator and was transferred to a nursing home, where she transferred to a nursing home, where she later succumbed to pneumonialater succumbed to pneumonia

Karen’s right to privacy, when weighed Karen’s right to privacy, when weighed against the interests of the state, favored against the interests of the state, favored the Quinlan familythe Quinlan family

Historical Cases - CruzanHistorical Cases - Cruzan

Nancy Cruzan, 1983 – MVA, significant brain Nancy Cruzan, 1983 – MVA, significant brain injury, PEG tube placed. NOT vent dependantinjury, PEG tube placed. NOT vent dependant

Later that year, the parents requested the Later that year, the parents requested the removal of the PEG.removal of the PEG.

The Missouri Supreme Court refused to allow The Missouri Supreme Court refused to allow this, as there was a living will statute in Missouri, this, as there was a living will statute in Missouri, but Ms. Cruzan had not established one. but Ms. Cruzan had not established one. Available testimony from a previous roommate Available testimony from a previous roommate was deemed insufficient to allow withdrawal of was deemed insufficient to allow withdrawal of nutritionnutrition


The US Supreme Court upheld the ruling in The US Supreme Court upheld the ruling in 1990, stating that due process was not violated 1990, stating that due process was not violated by the requirement of either "clear and by the requirement of either "clear and convincing, inherently reliable evidence“ or a convincing, inherently reliable evidence“ or a living will when such a statute existsliving will when such a statute exists

A family member’s statement, in absence of A family member’s statement, in absence of clear and convincing evidence, is not “automatic clear and convincing evidence, is not “automatic assurance that the view of close family members assurance that the view of close family members would necessarily be the same as the patient's would necessarily be the same as the patient's would have been had she been confronted with would have been had she been confronted with the prospect of her situation while competent." the prospect of her situation while competent."


Later that year, further evidence of Later that year, further evidence of Cruzan’s wishes were discovered, and the Cruzan’s wishes were discovered, and the Missouri courts allowed the withdrawal of Missouri courts allowed the withdrawal of nutritionnutrition

Nancy Cruzan died two weeks laterNancy Cruzan died two weeks later

Historical Cases - SchiavoHistorical Cases - Schiavo

Terri Schindler-Schiavo, 1990 – cardiac Terri Schindler-Schiavo, 1990 – cardiac arrest with resultant anoxic injury. Not vent arrest with resultant anoxic injury. Not vent dependant.dependant.

1993 – Terri’s parents file suit to have 1993 – Terri’s parents file suit to have Michael removed as guardian. Case Michael removed as guardian. Case dismisseddismissed


1998 – Husband petitions for feeding tube 1998 – Husband petitions for feeding tube removalremoval

2000 – District court allows withdrawal2000 – District court allows withdrawal2001 – Appeals court allows withdrawal2001 – Appeals court allows withdrawalApril 2001 – Both Florida and US Supreme April 2001 – Both Florida and US Supreme

Courts refuse to intervene, tube is Courts refuse to intervene, tube is removed on April 24thremoved on April 24th


April 26, 2001 – another district judge April 26, 2001 – another district judge orders feeding to resumeorders feeding to resume

Oct 2002 – after a year of multiple Oct 2002 – after a year of multiple appeals, the parents’ lawyer alleges abuse appeals, the parents’ lawyer alleges abuse by the husband was responsible for her by the husband was responsible for her brain damage, based on a bone scan from brain damage, based on a bone scan from the early 90’s. This would later be refuted the early 90’s. This would later be refuted on autopsyon autopsy


2005 – US Congress intervenes to refer 2005 – US Congress intervenes to refer case to Federal Courts. Federal Court case to Federal Courts. Federal Court refuses to intervene, finding no refuses to intervene, finding no objectionable actions by the state courtsobjectionable actions by the state courts

Ms. Schiavo eventually dies of Ms. Schiavo eventually dies of dehydration.dehydration.

Key finding – in Florida, a written Living Key finding – in Florida, a written Living Will is not required to convey end of life Will is not required to convey end of life decisionsdecisions

Case Law SummaryCase Law Summary

The state does not have an interest in The state does not have an interest in keeping people alive against their advance keeping people alive against their advance directivesdirectives

Guardian / family can be sufficient Guardian / family can be sufficient evidence of desired wishes in the absence evidence of desired wishes in the absence of specific advance directivesof specific advance directives

State lawState law

In May of 1999, the state of Ohio enacted In May of 1999, the state of Ohio enacted a law implementing a standard DNR a law implementing a standard DNR provisionprovision

The goal was to provide commonality and The goal was to provide commonality and portability of a patient’s DNR status, portability of a patient’s DNR status, regardless of health care systemregardless of health care system

DNR-CCDNR-CC

Do not resuscitate – comfort careDo not resuscitate – comfort careBy state law, the only care permissible is By state law, the only care permissible is

that which provides comfortthat which provides comfortNarcotics, benzodiazepines, positioning, Narcotics, benzodiazepines, positioning,

suctioning, splinting, control of bleedingsuctioning, splinting, control of bleedingCannot: fluid bolus, any other life prolonging Cannot: fluid bolus, any other life prolonging

therapiestherapiesObviously: do not intubate, do not defibrillate, Obviously: do not intubate, do not defibrillate,

no CPRno CPR

DNR-CC arrestDNR-CC arrest

In general, full measures up to the point of In general, full measures up to the point of cardiac or pulmonary arrestcardiac or pulmonary arrest

Then, comfort measures only (?)Then, comfort measures only (?)Controversies are legionControversies are legion

Cardioversion of non-fatal dysrhythmiaCardioversion of non-fatal dysrhythmia Intubation in respiratory distressIntubation in respiratory distressBiPAP / CPAPBiPAP / CPAPWhat about going to the OR?What about going to the OR?

Living WillLiving Will

Takes effect when the patient enters a Takes effect when the patient enters a vegetative state or in case of medical vegetative state or in case of medical futilityfutility

Infrequently used for intended purposesInfrequently used for intended purposesCan represent a patient’s attitude towards Can represent a patient’s attitude towards

end of life issuesend of life issues

Medical FutilityMedical Futility

In some cases, CPR and other critical care In some cases, CPR and other critical care efforts have no reasonable chance of efforts have no reasonable chance of prolonging life or providing benefit to the prolonging life or providing benefit to the patient – i.e. they are futilepatient – i.e. they are futile


However, the definition of futility depends However, the definition of futility depends on the end goalon the end goalDischarge to home intactDischarge to home intactSurvival to ECF Survival to ECF Pain / symptom free lifePain / symptom free life


Physicians do not have to provide Physicians do not have to provide medically futile caremedically futile careA neurosurgeon does not offer surgery to A neurosurgeon does not offer surgery to

every brain tumor patientevery brain tumor patientNot every moribund patient should be offered Not every moribund patient should be offered

CPRCPRDiscuss with patient / familyDiscuss with patient / family

GoalsGoalsLimitations of therapyLimitations of therapyConsequences of therapyConsequences of therapy

ConflictsConflicts

DNR and the patientDNR and the patientThis is a complex and emotionally laden This is a complex and emotionally laden

issue, and many patients and physicians do issue, and many patients and physicians do not fully understand the State Designationsnot fully understand the State Designations

Families are generally less clear on what Families are generally less clear on what these designations entailthese designations entail

ConflictsConflicts

DNR and the patientDNR and the patientA patient with capacity can revoke the DNR at A patient with capacity can revoke the DNR at

any timeany timeOften, we are in a position to coerce the Often, we are in a position to coerce the

patientpatient ““Are you sure you don’t want us to help your Are you sure you don’t want us to help your

breathing by putting you on the breathing breathing by putting you on the breathing machine?”machine?”

vs.vs.““Do you want us to put you on life support?”Do you want us to put you on life support?”

ConflictsConflicts

DNR and the patientDNR and the patientRemember, if you change the patient’s code Remember, if you change the patient’s code

status after talking with the patient, document status after talking with the patient, document the conversation clearlythe conversation clearly

ConflictsConflicts

DNR orders and the familyDNR orders and the familyMake every attempt to reconcile the family’s Make every attempt to reconcile the family’s

perception, but remember that the DNR order perception, but remember that the DNR order represents the patient’s autonomous wishesrepresents the patient’s autonomous wishes

Compassionate persuasionCompassionate persuasionBurden of decision making often the issueBurden of decision making often the issue

In some situations, we can ask them to accept our In some situations, we can ask them to accept our making the decision and relieve that burdenmaking the decision and relieve that burden

ConflictsConflicts

DNR and the POADNR and the POAOften, the POA is the one that signed the Often, the POA is the one that signed the

DNR order with the physicianDNR order with the physician If so, ask what has changedIf so, ask what has changed If the patient has signed the DNR, and the If the patient has signed the DNR, and the

POA wants something different, then it gets POA wants something different, then it gets complicatedcomplicated

Try to get the POA to realize that they need to Try to get the POA to realize that they need to represent what the patient would have represent what the patient would have wanted, using the DNR to suggest what the wanted, using the DNR to suggest what the patient wantedpatient wanted

Back to the case…Back to the case…

Our patient with terminal NHL from Our patient with terminal NHL from hospice who choked on a grape is found hospice who choked on a grape is found to be in wide-complex ventricular to be in wide-complex ventricular tachycardia, still with a pulsetachycardia, still with a pulse

No respiratory distress or chest painNo respiratory distress or chest painSlightly hypotensive (90 systolic)Slightly hypotensive (90 systolic)What next?What next?

OptionsOptions

Shock?Shock?Chemical cardioversion?Chemical cardioversion?Vagal maneuvers?Vagal maneuvers?

What we didWhat we did

Nothing, reallyNothing, reallyWe gave her scheduled pain medicationsWe gave her scheduled pain medicationsWe admitted her to Hematology for We admitted her to Hematology for

comfort measurescomfort measuresHer shock was getting worse as she went Her shock was getting worse as she went

up to the floorup to the floor

RationaleRationale

Any therapy given would likely be life-Any therapy given would likely be life-prolongingprolonging

Shock – high risk of discomfortShock – high risk of discomfortDrugs – relatively low risk of discomfort (IV Drugs – relatively low risk of discomfort (IV

access was established en route)access was established en route)However…However…

RationaleRationale

Given that the patient was in hospice for terminal Given that the patient was in hospice for terminal NHL, there was little reason to provide life NHL, there was little reason to provide life prolonging therapy, as long as there was no prolonging therapy, as long as there was no accompanying discomfortaccompanying discomfort

Without the grape, ventricular tachycardia would Without the grape, ventricular tachycardia would have been an undiagnosed terminal eventhave been an undiagnosed terminal event

Even in the setting of accompanying discomfort Even in the setting of accompanying discomfort (say, rupturing AAA and peritonitis), treat the (say, rupturing AAA and peritonitis), treat the discomfortdiscomfort

Comfort care should be part of Comfort care should be part of everyevery patient’s patient’s regimenregimen

Further End of Life CareFurther End of Life Care

Withdrawal from ventilatorWithdrawal from ventilatorNo evidence for or against extubation vs. No evidence for or against extubation vs.

terminal weanterminal weanBoth analgesics and anxiolytics are helpfulBoth analgesics and anxiolytics are helpfulAnticholinergics, antipsychotics may be Anticholinergics, antipsychotics may be

adjunctive in the right situationadjunctive in the right situation

End of Life CareEnd of Life Care

To drip or not to drip…To drip or not to drip… If already on an analgesic drip, continueIf already on an analgesic drip, continueOtherwise, intermittent dosing will sufficeOtherwise, intermittent dosing will suffice

Adjust dosing for comfortAdjust dosing for comfortPrimary intention is to relieve sufferingPrimary intention is to relieve sufferingRespiratory depression is an acceptable Respiratory depression is an acceptable

side effect in these situationsside effect in these situationsUp-titrating to hasten death is not ethical Up-titrating to hasten death is not ethical

nor permittednor permitted

Organ DonationOrgan Donation

As medical technology improves, more As medical technology improves, more people are being considered for transplantpeople are being considered for transplant

This has lead to an increasing demand for This has lead to an increasing demand for donor organsdonor organs

History of Organ DonationHistory of Organ Donation

First cornea – 1905First cornea – 1905First living donor kidney – 1954First living donor kidney – 1954First post-mortem kidney- 1962First post-mortem kidney- 1962First liver – 1967First liver – 1967First heart - 1967First heart - 19671981 – First heart – lung1981 – First heart – lung1992 – first xenotransplantation, baboon 1992 – first xenotransplantation, baboon

liverliver

History of Brain DeathHistory of Brain Death

Prior to 1967, organs were harvested from Prior to 1967, organs were harvested from individuals that sustained cardiac deathindividuals that sustained cardiac death

The advent of mechanical ventilation had The advent of mechanical ventilation had produced an increasing number of patients produced an increasing number of patients that sustained cardiac function without that sustained cardiac function without neurologic or respiratory functionneurologic or respiratory function

History of Brain DeathHistory of Brain Death

In 1968, Harvard Medical School convened a In 1968, Harvard Medical School convened a committee to explore the issue of these patients committee to explore the issue of these patients with irreversible coma, coining the term ‘brain with irreversible coma, coining the term ‘brain death’death’

1981 – The President’s Commission for the 1981 – The President’s Commission for the Study of Ethical Problems in Medicine and Study of Ethical Problems in Medicine and Biomedical and Behavioral Research refined a Biomedical and Behavioral Research refined a "whole brain standard" which became the basis "whole brain standard" which became the basis for the Uniform Determination of Death Act. for the Uniform Determination of Death Act.

Definition of Brain DeathDefinition of Brain Death

Unresponsiveness, lack of receptivity, the Unresponsiveness, lack of receptivity, the absence of movement and breathing, the absence of movement and breathing, the absence of brainstem reflexes.absence of brainstem reflexes.

Rule out medical conditions that may Rule out medical conditions that may confound the clinical assessmentconfound the clinical assessmentSevere acid-base, electrolyte, or endocrineSevere acid-base, electrolyte, or endocrineHypothermiaHypothermiaAbsence of intoxicationAbsence of intoxication

Establishing Brain DeathEstablishing Brain Death

In the absence of brain stem function, In the absence of brain stem function, spinal reflexes can still create movementspinal reflexes can still create movementTrunk muscles may contract, giving the Trunk muscles may contract, giving the

appearance that the person is trying to riseappearance that the person is trying to riseArms may rise, facial twitching, head may turn Arms may rise, facial twitching, head may turn

side to sideside to side


Clinical examinationClinical examinationBrainstem reflexesBrainstem reflexes

Doll’s eyes, caloricsDoll’s eyes, calorics

Apnea testingApnea testingThe absence of respiratory drive with a PaCOThe absence of respiratory drive with a PaCO22 of of

60 mm or 20 mm above patient’s baseline60 mm or 20 mm above patient’s baseline


Confirmatory testing is optional in the US, Confirmatory testing is optional in the US, but required in Europe, Central and South but required in Europe, Central and South America, and AsiaAmerica, and AsiaCerebral angiography / MRACerebral angiography / MRAEEGEEGTranscranial Doppler ultrasoundTranscranial Doppler ultrasoundNuclear imagingNuclear imaging

Federal, State and local Federal, State and local authoritiesauthorities

By federal law, the family of every By federal law, the family of every potential donor must be informed of their potential donor must be informed of their option to donate organs or tissues or not option to donate organs or tissues or not to donateto donate

If you, or your consultants, declare If you, or your consultants, declare someone brain dead, you cannot withdraw someone brain dead, you cannot withdraw upon them until LOOP has had a chance upon them until LOOP has had a chance to talk with the familyto talk with the family

Organ donor registryOrgan donor registry

In 2000, Ohio enacted a law stating that In 2000, Ohio enacted a law stating that the individual’s preference, as obtained by the individual’s preference, as obtained by the BMV when the driver’s license is the BMV when the driver’s license is renewed, trumps the family preferencerenewed, trumps the family preference

As of July 2002, there is an online registry As of July 2002, there is an online registry accessible by LOOP with everyone who accessible by LOOP with everyone who has opted to be an organ donorhas opted to be an organ donor

Organ donor registryOrgan donor registry

ControversiesControversiesNon-English speakers Non-English speakers Minors – need witnesses for the consentMinors – need witnesses for the consent Informed consent provided by the BMVInformed consent provided by the BMVTo opt in, all you have to do is say yes at the To opt in, all you have to do is say yes at the

BMVBMVTo opt out, you have to download a form and To opt out, you have to download a form and

mail it inmail it in

Non-heart beating donorsNon-heart beating donors

In the fledgling years of organ retrieval, In the fledgling years of organ retrieval, kidneys were removed immediately after kidneys were removed immediately after their hearts stopped beatingtheir hearts stopped beating


With the advent of the concept of brain With the advent of the concept of brain death, asystolic donors fell out of favordeath, asystolic donors fell out of favor

As the definition of a viable transplant As the definition of a viable transplant candidate has expanded, the number of candidate has expanded, the number of people on the waiting list has far people on the waiting list has far surpassed the number of available organssurpassed the number of available organs


In 2002, there were 80,000 people waiting In 2002, there were 80,000 people waiting for organsfor organs24,000 transplants were performed from:24,000 transplants were performed from:

6,081 dead donors6,081 dead donors6,499 live donors6,499 live donors

The first year that living donors outnumbered The first year that living donors outnumbered dead donorsdead donors


Several transplant centers have been Several transplant centers have been harvesting organs, with family consent, harvesting organs, with family consent, from non-brain dead patientsfrom non-brain dead patients

Original controversy landed Cleveland Original controversy landed Cleveland Clinic on Clinic on 60 Minutes60 Minutes for the use of for the use of phentolamine as a pre-donor drugphentolamine as a pre-donor drug

Active killing vs comfort measuresActive killing vs comfort measures


Many countries, by law, assume that an Many countries, by law, assume that an individual consents to organ donation at individual consents to organ donation at death, unless the patient has death, unless the patient has documentation otherwisedocumentation otherwise


Weber Weber et alet al compared outcomes in 122 kidneys compared outcomes in 122 kidneys from asystolic donors matched against 122 from asystolic donors matched against 122 kidneys from donors with a heartbeat (study in kidneys from donors with a heartbeat (study in Switzerland)Switzerland)

There was a significantly higher incidence in There was a significantly higher incidence in delayed graft function in the asystolic group, but delayed graft function in the asystolic group, but there was no difference in long term function or there was no difference in long term function or mortalitymortality

NEJM 2002;347, 248-255.NEJM 2002;347, 248-255.


Protocol:Protocol:Step 1: The clinical team and the family Step 1: The clinical team and the family

decide to withdraw caredecide to withdraw careStep 2: LOOP is notified and the chart Step 2: LOOP is notified and the chart

reviewed, if the patient is a candidate the reviewed, if the patient is a candidate the family is approachedfamily is approached

BMV registry does not apply to NHBD!BMV registry does not apply to NHBD!Step 3: Family consents, and transplant Step 3: Family consents, and transplant

surgery team notifiedsurgery team notified


Step 4: Femoral catheters are placed by Step 4: Femoral catheters are placed by LOOP or the clinical team. 30,000 units of LOOP or the clinical team. 30,000 units of heparin are infused (similar to dose that heparin are infused (similar to dose that cardiac bypass patients receive)cardiac bypass patients receive)

Step 5: After family gathers and says Step 5: After family gathers and says goodbye, the patient is transferred on life goodbye, the patient is transferred on life support to the ORsupport to the OR

Step 6: Patient is prepped, draped, and Step 6: Patient is prepped, draped, and extubatedextubated


Step 7: If cardiac activity ceases within Step 7: If cardiac activity ceases within one hour of extubation, procurement one hour of extubation, procurement proceedsproceedsAsystole, ventricular fibrillation, or PEA must Asystole, ventricular fibrillation, or PEA must

persist for 5 minutespersist for 5 minutes If cardiac activity is maintained for one If cardiac activity is maintained for one

hour, the patient is returned to the floor hour, the patient is returned to the floor and family to continue with comfort and family to continue with comfort measuresmeasures


Potential conflicts with this are legionPotential conflicts with this are legionConflict of interest with the transplant centerConflict of interest with the transplant center

Is my loved one truly a candidate for withdrawal or Is my loved one truly a candidate for withdrawal or are you just short on kidneys?are you just short on kidneys?

Transplant surgeon and the declaration of deathTransplant surgeon and the declaration of death

Conflicts within the ICU staffConflicts within the ICU staffAre we truly doing no harm?Are we truly doing no harm?

Femoral catheterFemoral catheterHeparin bolusHeparin bolus


Conflict with the familyConflict with the familyCan they go to the OR?Can they go to the OR?

Conflict with the OPOConflict with the OPOUndue pressureUndue pressure Invasion of the physician-patient relationshipInvasion of the physician-patient relationshipTiming of LOOP’s involvementTiming of LOOP’s involvement

So far, we have not had difficultiesSo far, we have not had difficultiesStill an early programStill an early program

Final PointsFinal Points

End of life issues affect all aspects of End of life issues affect all aspects of medicine, not just ICU caremedicine, not just ICU care

Advance discussion when possible Advance discussion when possible regarding expectations, goals, risks of regarding expectations, goals, risks of therapiestherapiesWith few exceptions, the ER is a lousy place With few exceptions, the ER is a lousy place

to try to determine medical futility to try to determine medical futility de novode novoAdvance directives represent the patient’s Advance directives represent the patient’s

last chance to make their wishes known last chance to make their wishes known

ethics at the end of life brian hiestand md, mph assistant professor, dept. of emergency medicine...

Documents

financial poa slide

patient healthcare poa

financial poa healthcare

medical poa

health care policy slide

hand slide

baseline terms ethics

care autonomy