1. Ethical Dilemmas in the ICU
Lauri Stephens RRT-NPS, RPFT
No man can be ignorant that he must die, nor be sure that he may not this very day.---Cicero

2. The U.S. & most “Western” societies are classed as death denying or defying
Fear of Death or Death Anxiety
Primary coping mechanism is avoidance
Death is rarely talked about
Now beginning to see increased focus training for health care professionals
Research & Surveys

3. Health Care Workers Are Different…
RCP’s regularly deal with death
“Others” may not understand
We frequently use humor to cope
Frequently move from “full court press” to withdrawal of care

4. The combination of the stress of providing care to critical patients & the absence of training in caring for the dying, make the ICU a challenging place to work.
Most Americans die in a hospital
Death in the ICU is common
Of all patients who die in a hospital, ½ are cared for in an ICU within 3 days of dying
1/3 spend at least 10 days in the ICU during their final hospitalization
90% of deaths in the ICU involve withdrawing or withholding at least one life supporting intervention. Most ICU deaths involve withholding or withdrawing multiple interventions

5. Quality of Death and Dying in two Medical ICU’s
Perceptions of Family and Clinicians
Cari R. Levy, MD; E. Wesley Ely, MD, MPH, FCCP; Kate Payne, RN, JD; Ruth A. Engelberg, PhD; Donald L. Patrick, PhD, MSPH; J. Randall Curtis, MD, MPH, FCCP
CHEST.  2005;127(5):  ©2005 American College of Chest Physicians
Evaluated attendings,
residents, ICU nurses and families response to death

6. How I chose this topic… Geared to MD’s Good range of topics
Recommend as department a resource

7. How I chose this topic… or way too much daytime TV
Numerous talk shows about the aftermath of withdrawing life support
Families grieving many years later, still not sure they made the right decision
Woman describing apnea trial and brain death declaration

8. In this patient situation…
Who do you think likely performed the apnea trial?
Who do you think withdrew support?
What image does this give our profession?
How does this impact our recruitment and retention?

9. What do I hope to accomplish by talking about ethics surrounding death?
Increasing education surrounding dealing with death & dying
Retaining & supporting students
Increased staff satisfaction and retention
Increased patient & family satisfaction (helping to provide a “good death”)

10. Increasing education surrounding dealing with death & dying…
Current RC classes where death education may occur
Psychology
Sociology
Speech/Communication
Ethics
Mechanical Ventilation?

11. Retaining & Supporting Students
Provide positive role model…
Allow time to debrief
Share experiences
Be aware that most young people have no direct experience with death or a dead body

12. Increasing Staff Satisfaction
Identify coping strategies
Staff support groups
Enlist Pastoral/Spiritual Care
Be involved in patient rounds & care conferences
Share family cards and letters with all staff
Palliative Care Consults
Allow staff rituals to mark the death of a patient or simply a moment to recover/debrief
Move away from “Angel of Death” mentality
Recognize that death is not a medical failure

13. Increasing Patient & Family Satisfaction
Families rate communication as equal or more important than clinical skills
We must be involved in Care Conferences, Physician Rounds and End of Life Care Discussions in order to avoid giving mixed messages
We are dealing with families experiencing grief
Less than 5% of patients are able to communicate their wishes regarding withholding or withdrawing life support at the time decisions are being made

14. Normal Grief Reactions
Feelings: shock, numbness, sadness, fear, anxiety
Physical Sensations: SOB, Chest Tightness, “Out of Body”
Cognitions: Disbelief, Preoccupied,
Hallucinations
Behaviors: Sleep Disturbances, Eating Difficulties, Absent Mindedness
5 Stages of Grief
Denial, Anger, Bargaining
Depression, Acceptance

15. Current Challenges in the ICU
Patient Centered Care
Education and shared knowledge
Involvement of family and friends
Collaboration and team management
Sensitivity to non-medical and spiritual dimensions of care
Respect for patient needs and preferences
Free flow and accessibility of information
Comfort Care- Advance Directives, Living Wills
Increase in Patients and Staff of Different Cultures
In 1998 racial & ethnic minority groups made up 28% of the US population
By 2020 over 44% of the pediatric population will be minorities
By 2030 approximately 40% of the total US population will consist of racial & ethnic minorities

16. Patient Centered Care Sharing my experiences… Halloween Code
“Bad” Code

17. Patient Centered Care
The creation of visitation policies that show respect to the family for their central role in the patient’s life is essential:
- Patients need support & contact with loved ones
(especially in the ICU & the crises of illness)
Family members need to be intimately aware of the patient’s situation (need to fulfill role within the family)
Demonstrating respect for the family generates a climate of mutual positive regard and trust for the health care team

18. 3 Ethical Justifications for Restricting ICU Visitation
When it is the patient’s preference
To protect the privacy of other patients
To protect or provide safety for hospital staff

19. Comfort Care
Families need to know their loved one will be respected as a person, not just viewed as a body
Withholding support versus withdrawal
Adequate sedation and pain management versus euthanasia

20. 1983 Report by the President’s Commission for the study of Ethical Problems in Medicine (Deciding to Forego Life-Sustaining Treatment)
No distinction between failing to initiate therapy & stopping therapy, that is, withholding versus withdrawing treatment, is not itself of moral importance because a justification that is adequate for not commencing a treatment is sufficient for ceasing it.
Actions that suggest administration of a pain medicine that may hasten a patient’s death are justified by the benefits expected to exceed the negative consequences as long as the sole purpose is not to poison or kill a patient

21. Comfort Care Guidelines
Care Plans or Standing Orders are recommended
Adequate sedation and pain medication, as evidenced by no grimacing or response to painful stimuli
Decrease to 21% and 0 PEEP
SIMV rate equal to patient rate or PS to maintain minute ventilation
Assess for air hunger, agitation or tachypnea and increase sedation as needed before proceeding with decreasing ventilation

22. Comfort Care Guidelines
Create a peaceful environment
Explain step by step
Plenty of chairs around bed + tissues
Patients face, mouth & hands clean & free
Make sure bed is locked

23. Cross Cultural Medicine
Patients and families in the ICU are vulnerable & should not be required to defend their belief systems
Culture encompasses beliefs & behaviors that are learned & shared by members of a group
Respecting a patient whose background is different than our own, requires that we accept cultural diversity and recognize that human dignity is more important than our differences

24. Tips for Cross Cultural Medicine
Consider Life Experience
Expressions of Pain
Cause of Illness
Role of Family
Attitudes regarding poor prognosis & information
Emotional expression will vary
Western medicine and alternative/native treatments are not viewed as mutually exclusive
In times of stress early learned beliefs may resurface

25. Cultural Cases
The Right Time to Die
Poor Prognosis
Releasing the Soul

26. Cultural Considerations
Four is considered an unlucky number in Chinese, Korean, and Japanese cultures because it sounds like the word "death"

28. Do not go gentle into that good night, Old age should burn and rave at close of day; Rage, rage against the dying of the light.
Though wise men at their end know dark is right, Because their words had forked no lightning they Do not go gentle into that good night.
Good men, the last wave by, crying how bright Their frail deeds might have danced in a green bay, Rage, rage against the dying of the light.
Wild men who caught and sang the sun in flight, And learn, too late, they grieved it on its way, Do not go gentle into that good night.
Grave men, near death, who see with blinding sight Blind eyes could blaze like meteors and be gay, Rage, rage against the dying of the light.
And you, my father, there on the sad height, Curse, bless me now with your fierce tears, I pray. Do not go gentle into that good night. Rage, rage against the dying of the light.
-Dylan Thomas