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End-of-life Care in the ICU: Practical and Ethical Issues Mazen Kherallah, MD, FCCP وَمَا تَدْرِي نَفْسٌ مَّاذَا تَكْسِبُ غَدًا وَمَا تَدْرِي نَفْسٌ بِأَيِّ

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Presentation on theme: "End-of-life Care in the ICU: Practical and Ethical Issues Mazen Kherallah, MD, FCCP وَمَا تَدْرِي نَفْسٌ مَّاذَا تَكْسِبُ غَدًا وَمَا تَدْرِي نَفْسٌ بِأَيِّ"— Presentation transcript:

1 End-of-life Care in the ICU: Practical and Ethical Issues Mazen Kherallah, MD, FCCP وَمَا تَدْرِي نَفْسٌ مَّاذَا تَكْسِبُ غَدًا وَمَا تَدْرِي نَفْسٌ بِأَيِّ أَرْضٍ تَمُوتُ إِنَّ اللَّهَ عَلِيمٌ خَبِيرٌ ( لقمان :34) وَمَا تَدْرِي نَفْسٌ مَّاذَا تَكْسِبُ غَدًا وَمَا تَدْرِي نَفْسٌ بِأَيِّ أَرْضٍ تَمُوتُ إِنَّ اللَّهَ عَلِيمٌ خَبِيرٌ ( لقمان :34)

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11 Case Scenario An 85-year-old man with New York Heart Association class IV heart failure, hypertension, and moderate Alzheimer’s disease is admitted to the hospital after a hip fracture. His postoperative course is complicated by pneumonia, delirium, and pressure ulcers on his heels and sacrum. Respiratory status is worsened with severe shortness of breath and hypoxemia requiring high flow O2. A decision for intubation and mechanical ventilation needs to be made

12 What would you do next: A.Intubate the patient and place on MV B.Do not intubate and Inform the family that prognosis is bad based on his previous condition C.Meet with the family and ask them what they want to do and proceed based on their wishes D.Meet the family and help in making decision: shared decision making

13 Palliative care within the experience of illness, bereavement, and risk. Risk-reducing Care Risk Diagnosis Death Bereavement CareSymptom Management/ Supportive Care Curative Hospice Palliative Care Life Closure (Planning for Death) Last Hours of Life Care (Dying) RiskIllnessBereavement Patient Family End of Life Care

14 One in Five Deaths in the U.S. Occur in the ICU Angus, Crit Care Med 2004; 32:638

15 Proportion of Deaths Preceded by CPR for Patients > 65 years old Ehlenbach, NEJM, 2009; 361:22

16 Variability in Withholding and Withdrawing Life Support in the US n = 6303 deaths, 131 ICU’s, 110 hospitals, 38 states Prendergast, Am J Resp Crit Care Med, 1998. 158:1163

17 OUTLINE Shared decision-making Tools for communicating with families Interdisciplinary communication Role of culture and ethnicity Withdrawing life support

18 What Do We Know About Shared Decision-making in the ICU? <5% of patients can participate in ICU decisions about withholding treatments – Communication is primarily with family Families rate communication as of equal or more importance than clinical skill Families under immense burdens – High level of anxiety and depression Prendergast, AJRCCM, 1997; Prochard, Crit Care Med, 2001

19 Shared Decision-making About End-of-life Care Clinician decision Family decision Carlet, Intensive Care Med 2004; 30:770 Treatments that are indicated Prognosis Level of certainty Patient/family: patient values & preferences

20 Family Preferences for Role in Decision-making n=1123 families of patients in 6 ICU’s Heyland, Intens Care Med, 2003; 29:75

21 Symptoms of PTSD Higher with Discordance in Decision-making Role p=0.005 p=0.10 p=0.06 Gries, Chest 2010; 137:280

22 Parentalism or Doctor Decides Autonomy or “Informed Choice” Shared Decision Making Default Starting Place Family preferencePrognosis and Certainty New Paradigm for “Right Approach” to Parentalism vs. Autonomy

23 Directive Provide some info Make decision Informative Provide info Make no recommendation Shared Decision Making Facilitative Elicit patient values Place in context Collaborative Elicit patient values Offer recommendation White, submitted, 2008 New Paradigm for “Right Approach” to Parentalism vs. Autonomy White, Arch Intern Med, 2007, 167:461

24 When Should We Involve Families in Decisions about Life Support? Not after the ICU team has decided it is time to withdraw life support Discussions with ICU team should occur on ICU admission – Review prognosis and potential outcomes – Bring family along with us as things change Discussion with other clinicians should occur prior to ICU admission

25 OUTLINE Shared decision-making Tools for communicating with families Interdisciplinary communication Role of culture and ethnicity Withdrawing life support

26 Case Scenario 69 year old with PMH of HTN, DM, and COPD Admitted with pneumonia and required to be intubated and placed on MV Condition is worsened with shock, renal failure requiring dialysis, DIC, severe ARDS and lactic acidosis (LA 8.9)

27 What would you do next: A.Continue current level of support, do not dialyze and no escalation of inotrops B.Discontinue all life support modalities and provide comfort care C.Escalate therapies, start hemodialysis, and do everything possible. D.Arrange for family conference and discuss the current condition, prognosis and expectation with the family and make a shared decision

28 Study of ICU Family Conferences Daily screen of all ICUs in 4 hospitals If conference planned, contact attending: – Is discussion of withholding or withdrawing life support likely? – Willing to have conference recorded? Consent/survey all participants 51 family conferences recorded (46%) McDonagh, Crit Care Med, 2004, 32:1484

29 Duration of Family Conferences and Proportion of Family Speech McDonagh, Crit Care Med, 2004, 32:1484 MeanSD Duration of conference32 min17-47 min Proportion family speech29%14-44%

30 Proportion Family Speech Correlates with Family Satisfaction McDonagh, Crit Care Med, 2004, 32:1484 % Family SpeechDuration r (p value) How would you rate the doctor’s communication 0.37 (0.01)-0.07 (NS) How well did this conference meet your needs? 0.31 (0.04)0.08 (NS) How much conflict, disagreements and negative feelings with MD -0.31 (0.04)0.28 (0.07)

31 Clinician Statements Associated with Increased Family Satisfaction Assure family that patient will not be abandoned prior to death Assure family that patient will be kept comfortable and not suffer prior to death Provide support for family around decisions to withdraw or continue life support Answer questions, clarify and follow up on family statements Acknowledge and address emotions Explore patient preferences Affirm non-abandonment Stapleton, Crit Care Med, 2006; 43:1679

32 VALUE: 5-step Approach to Improving Communication in ICU with Families V… Value family statements A… Acknowledge family emotions L… Listen to the family U… Understand patient as a person E…Elicit family questions Curtis, J Crit Care, 2002; 17:147

33 Missed Opportunities During ICU Family Conferences Listen and respond – Answer questions – Clarify and follow up on family statements Acknowledge and address emotions Address tenets of palliative care – Explore patient preferences – Explain surrogate decision-making – Affirm non-abandonment Curtis, Am J Resp Crit Care Med, 2005; 171:844

34 Lautrette, N Engl J Med 2007;356:469-78

35 Randomized Trial of Communication Strategy Lautrette, NEJM, 2007; 356:469 Randomized 126 patients if attending believed “patient would die in a few days” Proactive family conference using VALUE strategy 63 patients Usual practice at Center 63 patients Intervention Control

36 Family Member Outcomes: Clinically Significant Morbidity at 3 Months p<0.02 for all Lautrette, NEJM, 2007; 356:469

37 OUTLINE Shared decision-making Tools for communicating with families Interdisciplinary communication Role of culture and ethnicity Withdrawing life support

38 A meeting is scheduled, whom do want to be present? A.Yourself and patient’s wife B.Yourself, wife and closed relatives C.Yourself, wife, closed relatives and the primary physician D.Yourself, wife, closed relatives, primary physician and the nurse E.Yourself, wife, closed relatives, primary physician, the nurse and a religious person

39 Physician-Nurse Collaboration in the ICU Interdisciplinary collaboration associated with decreased – ICU mortality – ICU length of stay – ICU readmission rates – Physician and nurse conflict – Job stress for nurses

40 Doctor and Nurse Ratings of Interdisciplinary Communication p<0.001 for all Reader, Br J Anaesth, 2007; 98:347

41 Percent of Decisions with Physician-Nurse Collaboration in Decision-making Ferrand, Am J Resp Crit Care Med, 2003; 167:1210

42 Percent of Physicians Involving Nurses in Decisions about Withdrawal Yaguchi, Arch Intern Med, 2005; 165:1970

43 How do you assess the physician collaboration? (Nurses only) A.Poor B.Average C.Good D.Very good E.Excellent

44 How do you assess the nurses collaboration? (Physicians only) A.Poor B.Average C.Good D.Very good E.Excellent

45 OUTLINE Shared decision-making Tools for communicating with families Interdisciplinary communication Role of culture and ethnicity Withdrawing life support

46 Case Scenario 54 year old male with 30 years of smoking history who was recently diagnosed with metastatic lung cancer The wife request not to inform the patient with his diagnosis or prognosis

47 What would you do next? A.Tell the wife that it is his right to know the diagnosis and prognosis and inform the patient B.Respect the wife’s wish and tell the patient that he has pneumonia and treatment will be given to him C.Inform the wife to follow with other physician as you would not be able to carry on with her wish but do not inform the patient

48 In your opinion, should a patient be told of a cancer Dx? A.Yes B.No

49 In your opinion, should a patient decide about withdrawing life support treatment? A.Yes B.No

50 Cultural Differences: Survey of 800 Patients in LA Should a patient: Blackhall, JAMA, 1995; 274:820

51 OUTLINE Shared decision-making Tools for communicating with families Interdisciplinary communication Role of culture and ethnicity Withdrawing life support

52 A decision is made to withdraw LST, how would you do it? A.Do not escalate treatment, do no labs and continue with meds, fluids and feeding B.Do no labs, stop all medications except sedatives and analgesia and stop fluids and feeding C.Stop everything, sedate patient and extubate D.Stop everything, sedate patient and do terminal wean

53 Needs of the Patient Receiving adequate pain and symptom management. Avoiding inappropriate prolongation of dying Achieving a sense of control Relieving burden Strengthening relationships with loved ones.

54 Needs of Families

55 Components of the Withdrawal of Life Support Form Preparation – DNAR order; document discussion with family; discontinue prior orders Ventilator withdrawal protocol Analgesia and sedation – Infusion with broad range; no maximum dose; document reason for increase Principles of withdrawing life support Treece, Crit Care Med, 2004; 32:1141

56 Terminal Withdrawal of the Ventilator Full ventilatory support Remove supplemental O 2 and PEEP Reduce set rate or PS gradually Titrate sedation to ensure comfort Takes 5 minutes Titrate sedation to ensure comfort Takes 5 minutes Titrate sedation to ensure comfort Takes 5-20 min

57 Opioid Analgesics

58 Sedative Agents

59 Should Patients Be Extubated After Withdrawing Mechanical Ventilation? A.Yes B.No

60 Should Patients Be Extubated After Withdrawing Mechanical Ventilation? Little evidence to guide decisions Clinicians often have strong opinions Recent study suggests family ratings of care higher if patient extubated Case-based judgment based on – Family preferences – Level of support, amount of secretions, level of consciousness Glavan, Crit Care Med, 2008; 36:1138

61 Tips for Talking with Family About Withdrawal of Life Support When life support is withdrawn, stress – “Care” will not be withdrawn – Aggressive palliation will be used – avoid making firm predictions – about the patient’s clinical course – Time to death variable Offer option of family being present – Family presence associated with higher PTSD Describe process so they know what to expect Kross, AJRCCM, 2009; abstract

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63 Summary: Ethical and Practical Issues in End-of-life Care in the ICU Decision-making about end-of-life care common in the ICU and should start early Shared decision-making at the default – Need to adapt to individual patient and family Interdisciplinary communication essential Incorporate and honor cultural difference Withdrawal of life support is a clinical procedure

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