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City-Wide Palliative/Ethics Grand Rounds Next Session 11/19/07 Barry Smith SUNY Distinguished Professor Julian Park Professor The Future of Biomedical.

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Presentation on theme: "City-Wide Palliative/Ethics Grand Rounds Next Session 11/19/07 Barry Smith SUNY Distinguished Professor Julian Park Professor The Future of Biomedical."— Presentation transcript:

1 City-Wide Palliative/Ethics Grand Rounds Next Session 11/19/07 Barry Smith SUNY Distinguished Professor Julian Park Professor The Future of Biomedical Informatics

2 Jack P. Freer, MD UB Professor of Clinical MedicineProfessor of Clinical Medicine Palliative Medicine Course CoordinatorPalliative Medicine Course Coordinator Kaleida Health Ethics Committee ChairEthics Committee Chair Palliative Care Consultation (Gates)Palliative Care Consultation (Gates)

3 CME Disclosure No commercial supportNo commercial support No unapproved or off-label usesNo unapproved or off-label uses

4 Breathlessness Jack P. Freer, MD Professor of Clinical Medicine University at Buffalo

5 Learning Objectives Understand pathophysiology of dyspneaUnderstand pathophysiology of dyspnea Be familiar with basic modalities of treatmentBe familiar with basic modalities of treatment Be capable of sound ethical reasoning in intubation/ventilation decisionsBe capable of sound ethical reasoning in intubation/ventilation decisions Be able to guide coherent decisions based upon good medicine and good ethicsBe able to guide coherent decisions based upon good medicine and good ethics

6 Dyspnea PathophysiologyPathophysiology TreatmentTreatment Decision Making/Ethical IssuesDecision Making/Ethical Issues

7 Dyspnea: shortness of breath, breathlessness Rapid breathingRapid breathing Incomplete exhalationIncomplete exhalation Shallow breathingShallow breathing Increased work/effortIncreased work/effort Feeling of suffocationFeeling of suffocation Air hungerAir hunger Chest tightnessChest tightness Heavy breathingHeavy breathing

8 Dyspnea: shortness of breath, breathlessness Rapid breathing…Rapid breathing… Incomplete exhalation…Incomplete exhalation… Shallow breathing…Shallow breathing… Increased work/effort…Increased work/effort… Feeling of suffocation…Feeling of suffocation… Air hunger…Air hunger… Chest tightness…Chest tightness… Heavy breathing…Heavy breathing… COPD, pulm vasc dis Asthma, Asthma, Neuro-musc, Chest wall COPD, Interstitial, Asthma, N-m, Cw COPD, CHF COPD, CHF, Pregnancy AsthmaAsthma Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553

9 Dyspnea Cancer (dyspnea common)Cancer (dyspnea common) 1.Obvious cause (lung mets, effusion etc) 2.Co-morbid conditions (COPD/CHF) 3.No evidence of 1. or 2. (?cachexia) Non-malignant (COPD, CHF)Non-malignant (COPD, CHF)

10 Dyspnea in Cancer Cancer related causesCancer related causes Treatment related causesTreatment related causes General medical condition causesGeneral medical condition causes

11 Cancer Related Causes Airway obstruction by tumorAirway obstruction by tumor Lung parenchyma replacementLung parenchyma replacement Pleuro-pericardial effusionPleuro-pericardial effusion Lymphangitic carcinomatosisLymphangitic carcinomatosis SVC syndromeSVC syndrome AscitesAscites

12 Treatment Related Causes PneumonectomyPneumonectomy Radiation fibrosisRadiation fibrosis ChemotherapyChemotherapy –Cardiac toxicity –Pulmonary toxicity

13 General Medical Conditions (both related and unrelated to cancer) COPDCOPD CHFCHF AsthmaAsthma InfectionInfection AnemiaAnemia PneumothoraxPneumothorax Pulmonary embolusPulmonary embolus Pulmonary hypertension Psychosocial/Spiritual …

14 Mechanism of Dyspnea Mechanical Receptors LungLung Chest wallChest wall Upper airwayUpper airway

15 Mechanism of Dyspnea Sense of Respiratory Effort “Effort” major factor in breathlessness“Effort” major factor in breathlessness Simultaneous motor cortex signalsSimultaneous motor cortex signals –Efferent to respiratory muscles –Signal to sensory cortex

16 Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553

17 Mechanism of Dyspnea Sense of Respiratory Effort “Effort” major factor in breathlessness“Effort” major factor in breathlessness Simultaneous motor cortex signalsSimultaneous motor cortex signals –Efferent to respiratory muscles –Signal to sensory cortex –Mismatch enhances sense of effort –Probably similar signals from brainstem

18 Mechanism of Dyspnea Chemical Receptors HypercapniaHypercapnia HypoxiaHypoxia

19 Mechanism of Dyspnea Hypercapnia Early studies in normal subjects suggested CO 2 not a factorEarly studies in normal subjects suggested CO 2 not a factor Probably mediated by pHProbably mediated by pH

20 Mechanism of Dyspnea Hypoxia Some evidence of effectSome evidence of effect Still…Still… –Some patient hypoxic—not SOB –Some patients SOB—not hypoxic –Some hypoxic/SOB pts show little improvement with O 2 therapy

21 Treatment of Dyspnea Treat underlying causesTreat underlying causes OxygenOxygen Nebulized bronchodilatorsNebulized bronchodilators OpioidsOpioids BenzodiazepinesBenzodiazepines Nebulized opioids used by some but no solid evidence of efficacyNebulized opioids used by some but no solid evidence of efficacy Fans across faceFans across face

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23 Decision Making/Ethical Issues Opioids and hastening deathOpioids and hastening death Withdraw vs. WithholdWithdraw vs. Withhold DNIDNI

24 Resistance to Opioids for Dyspnea Hasten death; “kill patient”Hasten death; “kill patient” Response:Response: –Tolerance to respiratory depression –Slowing respirations may improve oxygenation

25 Resistance to Opioids for Dyspnea However, failing to intubate and ventilate a patient in severe respiratory failure will result in death (with or without opioids).However, failing to intubate and ventilate a patient in severe respiratory failure will result in death (with or without opioids). –Opioids may hasten that death –Double effect

26 Withhold LST vs. Withdraw Logical/clinical difference?Logical/clinical difference? –Therapeutic trials –Duty to start or stop independent of whether the treatment is already in place Legal difference? NOLegal difference? NO Religious differenceReligious difference Psychological differencePsychological difference

27 Withhold vs. Withdraw Ventilator Quality of life (prior to vent decision)Quality of life (prior to vent decision) ReversibilityReversibility

28 Withhold vs. Withdraw Ventilator Trial—withdraw later Acceptable quality of lifeAcceptable quality of life Reversible conditionReversible condition

29 Withhold vs. Withdraw Ventilator Trial—withdraw later Acceptable quality of lifeAcceptable quality of life Reversible conditionReversible condition Clear timetable, endpoints to gauge “success” of the trialClear timetable, endpoints to gauge “success” of the trial

30 Withhold vs. Withdraw Ventilator Trial—withdraw later Acceptable quality of lifeAcceptable quality of life Reversible conditionReversible condition Clear timetable, endpoints to gauge “success” of the trialClear timetable, endpoints to gauge “success” of the trial Legally appointed agent to act on behalf of the patientLegally appointed agent to act on behalf of the patient

31 Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) Poor quality of lifePoor quality of life Irreversible processIrreversible process

32 Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) Poor quality of lifePoor quality of life Irreversible processIrreversible process –Prior “reversible process,” tough wean

33 Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) Poor quality of lifePoor quality of life Irreversible processIrreversible process –Prior “reversible process,” tough wean Crystal clear informed consent: NO need for last minute “clarification.”Crystal clear informed consent: NO need for last minute “clarification.”

34 Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) Poor quality of lifePoor quality of life Irreversible processIrreversible process –Prior “reversible process,” tough wean Crystal clear informed consent: NO need for last minute “clarification.”Crystal clear informed consent: NO need for last minute “clarification.” Scrupulous symptom managementScrupulous symptom management

35 Withhold vs. Withdraw Ventilator Trial / Withdraw Good QoLGood QoL ReversibleReversible________________ Clear EndpointsClear Endpoints –Timeframe –Outcomes ProxyProxyWithhold Poor QoLPoor QoL IrreversibleIrreversible________________ Clear ConsentClear Consent –No last minute “clarifications” Symptom TreatmentSymptom Treatment

36 Dying Without Intubation Decision making: Broad planning based on goals of treatmentBroad planning based on goals of treatment Positive treatment directed toward ALL goalsPositive treatment directed toward ALL goals Reversibility/Quality of lifeReversibility/Quality of life Treat respiratory failure symptomaticallyTreat respiratory failure symptomatically –No intubation/ventilation

37 Dying Without Intubation Documentation Document rationale in detailDocument rationale in detail Document informed consent discussionDocument informed consent discussion Detailed symptomatic planDetailed symptomatic planCommunication Clear discussions with nurses, familyClear discussions with nurses, family Explain what to expectExplain what to expect Avoid focus on “not”Avoid focus on “not”

38 Dying Without Intubation What if the patient changes his mind?

39 Dying Without Intubation Failure to document the informed consent discussion can lead to last minute “clarification” about decision (and patient “changing mind” about intubation).

40 Dying Without Intubation Failure to provide adequate symptom relief can lead to suffering (and patient “changing mind” about intubation).

41 Respiratory Death without Intubation/Ventilation …can be the most appropriate and ethically defensible option.…can be the most appropriate and ethically defensible option. …can be part of a comprehensive palliative plan based on the patient’s goals of care.…can be part of a comprehensive palliative plan based on the patient’s goals of care. …can NOT be summarized in 3 letters.…can NOT be summarized in 3 letters.

42 Editorial


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