Dying patients in the intensive care unit: forgoing treatment, maintaining care.

End-of-life care of patients in the intensive care unit (ICU) often requires dramatic shifts in attitudes and interventions, from traditional intensive rescue care to intensive palliative care. The care of patients dying in ICUs raises both clinical and ethical difficulties. Because fewer ICU patients are able to make decisions about withdrawing treatment, careful attention must be paid to previously expressed preferences and surrogate input. Cultural and spiritual values of patients and families may differ markedly from those of clinicians. Although prognostic models are increasingly able to predict mortality rates for groups of ICU patients, their usefulness in guiding specific decisions to forego treatment has not been established. When a decision to forego treatment is made, the focus should be on specifying the patient's goals of care and assessing all treatments in light of these goals; interventions that do not contribute to the patient's goals should be discontinued. Symptoms accompanying withdrawal of life support can almost always be controlled with appropriate palliative measures. After ICU interventions are foregone, patient comfort must be the paramount objective. Whether in the ICU or elsewhere, hospitals have an ethical obligation to provide settings that offer dignified, compassionate, and skilled care.

The role of guidelines in the practice of physician-assisted suicide. University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel.

Oregon has legalized and implemented physician-assisted suicide, while observers argue about the moral import of attempting to formulate guidelines; the utility any set of guidelines can have for physician practice, health care providers, patients, or families; and whether guidelines can really protect against harm or abuse. What were once theoretical questions have taken on new urgency. The debate over the value and power of guidelines includes the following questions: What has been the experience of efforts to implement physician-assisted suicide using consensus guidelines? What goals are guidelines intended to serve? Who should formulate guidelines? What features should be reflected in any proposed guidelines to make them practical and to permit achievement of their goals? Are there any fundamental obstacles to the creation or implementation of guidelines? Is dying a process that is amenable to direction under guidelines, be they issued by physicians, departments of health, blue ribbon panels, or other regulatory bodies? This paper explores these questions as physician-assisted suicide becomes legal.

Should assisted suicide be only physician assisted? University of Pennsylvania Center for Bioethics Assisted Suicide Consensus Panel.

Discussions in the media, courts, legislatures, and professional societies generally assume assistance with suicide to be a physician's task; in these venues it is commonly referred to as "physician-assisted suicide." This paper defines both the necessity and the limits of the physician's role in assisted suicide by asking the question: Should assisted suicide be only physician assisted? Although physician involvement is necessary, we argue that it is not sufficient to ensure that patients requesting assisted suicide receive the best care. Assisted suicide requires physician involvement, but physicians' limited competence in performing the full range of tasks, the competencies of other professions, and the possibility that other professions could expand their authority in this area suggest that physician-assisted suicide is a far too narrow construct of the task. The willingness of other professionals--including nurses, social workers, and clergy--to participate and even take the lead in assisting suicides is critical to meet society's interest that assisted suicide should be humane, effective, and confined to appropriate cases. As long as legislation and guidelines focus exclusively on the physician's role, our laws and regulations will fall short of meeting societal expectations.

The sequence of withdrawing life-sustaining treatment from patients.

PURPOSE: To describe the observed sequence of withdrawal of eight different forms of life-sustaining treatment and to determine whether aspects of those treatments determine the order of withdrawal. SUBJECTS AND METHODS: We observed 211 consecutive patients dying in four midwestern US hospitals from whom at least one of eight specific life-sustaining treatments was or could have been withdrawn. We used a parametric statistical technique to explain the order of withdrawal based on selected characteristics of the forms of life support, including cost, scarcity, and discomfort. RESULTS: The eight forms of life support were withdrawn in a distinct sequence. From earliest to latest, the order was blood products, hemodialysis, vasopressors, mechanical ventilation, total parenteral nutrition, antibiotics, intravenous fluids, and tube feedings (P <0.0001). The sequence was almost identical to that observed in a previous study based on hypothetical scenarios. Forms of life support that were perceived as more artificial, scarce, or expensive were withdrawn earlier. CONCLUSION: The preference for withdrawing some forms of life-sustaining treatments more than others is associated with intrinsic characteristics of these treatments. Once the decision has been made to forgo life-sustaining treatment, the process remains complex and appears to target many different goals simultaneously.

A multi-institutional study of care given to patients dying in hospitals. Ethical and practice implications.

BACKGROUND: Relatively little attention has been paid to how physicians care for dying patients once an initial decision to forgo life-sustaining treatment is made. OBJECTIVES: To describe characteristics of patients forgoing treatment, determine the range and sequential process of forgoing treatment, and suggest ethical and practice implications. METHODS: Charts of 75 consecutive patients dying at each of 4 hospitals were reviewed for this case series. Two hundred ninety-one (98%) of 297 charts were available for review; 274 patients died in acute care beds and are included in this study. Data collected included patients' diagnoses, mental statuses, lengths of stay, timing of the first decision to forgo treatment, and range and sequence of interventions forgone. MAIN OUTCOME MEASURES: Proportion forgoing life-sustaining treatment, number of interventions forgone and decision times per patient, and ranked order of treatment withdrawal. RESULTS: Two hundred twenty-nine (84%) of 274 patients who died had some intervention forgone before death. Only 35% of patients forgoing life-sustaining treatment were able to participate in decision making. On average, 3.8 interventions were forgone per patient. Resuscitation and/or intubation were generally the first measures withheld; once a patient required ventilatory support, withdrawing ventilatory support was a late decision. CONCLUSIONS: The majority of patients dying at these institutions did so after decisions to limit treatment, but few patients were able to participate in these decisions. Forgoing life-sustaining treatment generally occurred in a sequential manner over several days; the rationale for this stepwise retreat is not, however, clinically or ethically obvious.

The clinical management of dying patients receiving mechanical ventilation. A survey of physician practice.

OBJECTIVE: Despite mechanical ventilation's widespread use, there is scant literature to guide the management of patients receiving mechanical ventilatory assistance who are foregoing life-sustaining treatment. This survey was conducted to characterize physician treatment of such patients. DESIGN: Surveys were mailed to 513 randomly selected critical care physicians and returned by 308 (60 percent); 273 respondents were involved in ventilator management; all others were excluded. PARTICIPANTS: Forty percent of respondents were internists, 28 percent were surgeons, 16 percent were pediatricians, and 11 percent were anesthesiologists; 85 percent of physicians were board eligible/certified in a critical care subspecialty. RESULTS: Fifteen percent of respondents almost never withdrew ventilators from dying patients foregoing life-sustaining treatment; 37 percent did so less than half the time. Twenty-six percent of physicians believed there was a moral difference between withholding and withdrawing ventilators. Of physicians who withdrew ventilators, 33 percent preferred terminal weaning, 13 percent preferred extubation, and the remainder used both methods. Reasons for preferring extubation included the directness of the action (72 percent), family perceptions (34 percent), and patient comfort (34 percent). Reasons for preferring terminal weaning included patient comfort (65 percent), family perceptions (63 percent), and the belief that terminal weaning was less active (49 percent). Morphine and benzodiazepines were used frequently by 74 percent (morphine) and 53 percent (benzodiazepines) of physicians when withdrawing ventilators; 6 percent used paralytics at least occasionally. CONCLUSIONS: There is significant variation in the care of dying patients receiving mechanical ventilatory assistance, with 15 percent of respondents almost never withdrawing ventilators from such patients. Two very different methods of ventilator withdrawal each have advocates, yet rationales of patient comfort and family perceptions are matters of individual experience, absent published studies. The occasional use of paralytics during ventilator withdrawal raises concern about current practice.

Beyond futility to an ethic of care.

The medical futility debate is usually framed as a conflict between physician and patient (or surrogate) over the right to decide whether a particular life-saving treatment is futile and should not be attempted. Arguments on behalf of physician-determined futility emphasize the limits of physicians' obligations; arguments on behalf of patient-determined futility reflect concerns over the potential erosion of recent gains in patient autonomy against medical paternalism. Underlying the arguments of those pressing for "value-free" definitions of medical futility and unlimited obligations of physicians to patients may be fears of covert rationing and patient abandonment. Often overlooked in this debate, both at the bedside and in public commentary, is the ethical duty of the physician to redirect efforts from life-saving treatments toward the conscientious pursuit of treatments that maximize comfort and dignity for the patient and the grieving family. To supplement the limited terms of the futility debate with an ethic of care, physicians should lead in advocating greater awareness of the ethics of care in doctor-nurse interactions, institutional facilities, insurance policies, and public education.

Survival of adult bone marrow transplant patients receiving mechanical ventilation: a case for restricted use.

A retrospective study of all adults receiving BMT over a 13 year period at a large transplant center was performed to determine overall survival and prognostic indicators of poor outcome among patients receiving mechanical ventilation (MV). Of 653 adult BMT patients, 191 (29%) received MV after transplant. Of these 191, 161 (84%) died on the ventilator or within hours of extubation; 18 (10%) survived 1 week after extubation and 6 (3%) survived 6 months. Survival was not predicted by type of graft, use of total body irradiation (TBI) or reason for intubation. The patient's age and the timing of intubation were predictive of survival. Of patients > or = 40 years, 98% died within a week of extubation and all died within 30 days. Similarly, of those intubated within 90 days of transplant, 94% died within a week of extubation and all died by day 100. These results suggest that MV is rarely effective in achieving long-term survival in adult BMT recipients, especially older patients and those early in their transplant course. An argument, based on cost/benefit considerations and medical futility, can be developed to withhold MV in certain patient subsets apart from a clinical research trial.

Ethical issues in the allocation and reimbursement of bone marrow transplantation.

At its best, today's conference might be an attempt to limit the premature dissemination of poorly studied, toxic, expensive therapies to desperate patients by accepting limitations to BMT, especially outside of a well-designed experimental study; and, at the same time, an acknowledgment that, in certain circumstances, the patient's best interests are served by receiving experimental therapy (never mind the interests of society) and that our current patchwork system of reimbursement is inherently unfair in its inconsistency. If we can agree on this, there is some small hope that we can reach a fair consensus regarding cases like Mrs. Washburn's. If experimental therapy is distinguished from standard therapy not only in terms of efficacy, but in terms of method and intent, it becomes apparent that experimental therapy is not a monolithic entity, and has a large and sometimes predictable range of probabilities of benefiting the individual patient. Consideration ought to be given to bypassing the experimental vs. standard debate altogether, working toward consensus regarding reimbursement decisions using alternative methods for assessing efficacy and allocating medical care.

Process of forgoing life-sustaining treatment in a university hospital: an empirical study.

OBJECTIVES: The difficult decision to forgo (withhold or withdraw) life-sustaining treatment has received extensive commentary. Little attention has been paid to how physicians do, and should, care for dying patients once this decision is made. This study describes the characteristics of patients who forgo treatment, determines the range and sequential process of forgoing treatment, and suggests ethical and public policy implications. DESIGN: The charts of all patients who died at the University of Minnesota Hospital during a 2-month period were reviewed. The patient information that was collected included age and sex, diagnoses, mental status, location in the hospital length of hospital stay, method of payment, the timing of the first decision to forgo treatment, and the range and sequence of interventions forgone. SETTING: All ICUs and general wards in a 586-bed tertiary care university hospital. PATIENTS: All patients who died at the University of Minnesota Hospital during May and June 1989. MAIN RESULTS: A total of 52 (74%) of 70 patients who died had some intervention withheld or withdrawn before death. Those patients in whom treatment was forgone were more likely to have an underlying malignancy or impaired mental status and longer hospital stays. Thirty-two (62%) of 52 patients who declined some treatment were in an ICU; 26 (50%) of 52 patients required mechanical ventilation. On average, 5.4 separate interventions were forgone per patient. Resuscitation and/or endotracheal intubation were generally the first measures withheld; once a patient required a ventilator, withdrawing the ventilator was a late decision. Precise methods of ventilatory and vasopressor withdrawal varied considerably among patients. CONCLUSIONS: Forgoing life-sustaining treatment is not a single decision but it often occurs in a sequential manner over several days. A strict analysis of the benefits and burdens of various interventions may be inadequate in deciding what interventions are appropriate in the care of the dying patient.

Aphasia in senile dementia of the Alzheimer type.

We assessed language function, using a brief clinical Aphasia Battery and psychometric measures, in 150 subjects with senile dementia of the Alzheimer type (SDAT) and 83 elderly controls. Aphasia occurred only in demented subjects, and its prevalence increased with severity of dementia. Aphasia in mildly demented subjects was associated with both an earlier age of onset and more rapid progression of SDAT than in similarly demented nonaphasics. Language dysfunction in SDAT subjects was characterized by early decline in measures of comprehension and written expression, whereas other components, including oral naming, were less profoundly affected. Performance on the verbal psychometric measures, the Sentence Repetition and the Token tests, correlated strongly with Aphasia Battery scores and declined only minimally in nonaphasics, despite increasing dementia. We conclude that aphasia is a common feature of SDAT subjects and identifies a subgroup with more rapid progression of dementia. Furthermore, it represents language-specific dysfunction beyond the global cognitive impairment of SDAT.