who should make resus decisions?
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Who should make resus decisions?. Dr Regina Mc Quillan Palliative Medicine Consultant. Guardian newspaper. Goals of Care. To cure sometimes, to relieve often, to comfort always. An intervention may. Cure Rehabilitate Prolong life Stabilize condition Palliate Fail. Ethical Behaviour. - PowerPoint PPT PresentationTRANSCRIPT
Who should make resus decisions?
Dr Regina Mc Quillan
Palliative Medicine Consultant
Guardian newspaper
Goals of Care
To cure sometimes, to relieve often, to
comfort always
An intervention may
Cure Rehabilitate Prolong life Stabilize condition Palliate Fail
Ethical Behaviour
‘Good is to be done and evil avoided’
Act in the patient’s best interests (Medical Council 4.1)
Primum non nocere
Beneficence
Non-maleficence
Consider which treatment option would provide the best clinical outcome for the patient (Medical Council 34.6)
Twentieth century
Antibiotics Surgery and anaesthetic advances Cancer treatment Diabetes management etc, etc
Create an expectation that health can be maintained and death deferred, but at some point, treatment not helpful
Challenges in treatment decisions Drive to do all to prolong life
The technological imperative
Sanctity of life
Appropriate recognition of impossibility of prolonging life, and preventing death
Rights and responsibilities to withhold or withdraw treatment
Do Not Attempt Resuscitation Order
A form of advance directive or advance care plan
DNAR
Urgent need to institute treatment At a time when patient is unable to consent
If there is no DNAR, presumption in favour of ACPR
Medical Council- End of Life Care
22.2 There is no obligation to start or continue a treatment, or artificial nutrition or hydration, that is futile or disproportionately burdensome
22.4 You should take care to communicate effectively and sensitively with patients and their families so that they can have a clear understanding of what can and cannot be achieved
Futility
Futility is goal specific
Physiological futility is when the proposed intervention cannot physiologically achieve the desired effect. Most objective definition
Quantitative futility is when the proposed intervention is highly unlikely to achieve the desired effect.
Qualitative futility is when the proposed intervention, if successful, will probably produce such a poor outcome that it is best not to attempt it
Sokol, DK. BMJ 2009; 338:b2222
Futile treatment as ritual
Rituals are used to make sense of life events
CPR may be futile, but when it fails, clearly defines for the family and staff the moment of death
Mohammed and Peter, Nursing Ethics, 2009,16(3) 292-302
Attempted cardiopulmonary resuscitation
Less than 2% success rate Success rate lower with increasing age,
co-morbidities, unwitnessed arrests, out of hospital
When to make decision?
Health care transitions New diagnosis of fatal illness Deterioration in chronic illness eg
-multiple admissions with eg COPD, CCF
-MND needing RIG or NIV
-nursing home admission
-dementia with feeding problems
-cancer progression
Who makes the decision?
Patient choice to refuse treatment even if life- prolonging
If ACPR is not futile, consider patient involvement If ACPR is futile, should not be offered If patient requests ACPR which is considered futile,
explore understanding of ACPR; the patient’s wishes should be respected where possible. Doctors are not required to give treatment against their wishes.
DHRMF 2010
Who makes the decision?
No one has the right to make a health care decision for an adult.
Decision-making is the responsibility of the doctor in charge, and must be in the best interests of the patient, in consultation with the multidisciplinary team and the patient’s family network
Consultation with the family, sensitive and clear
Family
Family
Whose is the family?
Family
Whose is the family? Their role is to represent what the patient’s
wish may be Must consider the patient’s best interest
Team conflict
Team conflict
If you keep on doing what you are doing, you will keep on getting what you’ve got
Team conflict
If you keep on doing what you are doing, you will keep on getting what you’ve got
Everybody acts in the patient’s interest
Team conflict
If you keep on doing what you are doing, you will keep on getting what you’ve got
Everybody acts in the patient’s interest How to effect change
Communicating the decision
To the patient, if appropriate To the family, for information, not decision In healthcare record In transfer documentation
Who makes resus decisions?
The patient can refuse The patient can’t insist on futile treatment If there is doubt about the value, the doctor
makes the decision, in the best interests of the patient, following consultation with the patient, family and MDT.
Additional reading
Medical Futility: its Meaning and Ethical Implications. Schneiderman, Jecker, Jonsen. Annals of Internal Medicine. 1990:112:949-954
Debate: Extraordinary means and the sanctity of life. Journal of Medical Ethics. 1981: 74-82
Guide to Professional Conduct and Ethics for Registered Medical Practitioners 2009