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

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

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

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

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):1775-1783.  ©2005 American College of Chest Physicians Evaluated attendings, residents, ICU nurses and families response to death

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

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

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?

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”)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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