1. Sick Patients, Grieving Families, and a Selection of Issues in Ethics
Allen Roberts, MD
Professor of Clinical Medicine
Georgetown University Hospital

2. “On that day, men will gather in great mead halls and sing of the day when physicians, like giants, walked the earth.”
- Richard Selzer Notes on the Art of Surgery

4. A day in the life of the intensivist…
Rounds
Codes
Family meetings
Admissions
Procedures
Academic conferences

5. The ICU Team Physicians Nurses Respiratory therapists
Nutrition specialists
Clinical pharmacologists Available: Pastoral Care Palliative Care International Services

6. The week of February 25…
175 ICU patient visits, ventilator adjustments, miscellaneous interventions and procedures. Most will survive, but…
37 year old man with rapidly progressive pneumonia, respiratory failure, septic shock, died.
48 year old man with severe streptococcal infection of the major muscle groups of both legs. Septic shock, respiratory failure; emergent surgery to remove non-viable tissue. Will survive, but with extensive rehab.
29 year old man with influenza A, complicated by pneumonia, respiratory and kidney failure, died.
Three patients with liver failure of various causes. All died while awaiting a transplant.

7. The cords of death encompassed me; the torrents of destruction assailed me…
Psalm 18:4

8. ICU Glossary: basics Intubation and mechanical ventilation Pressors
Renal-replacement therapy: dialysis, continuous vs intermittent
Prognosis, severity of illness, APACHE
“Full Code” vs “DNR”
“Comfort measures” Withdrawal of Care

10. Pastoral Care and Clinical Medicine: Intersections
Family meetings: Diagnosis Prognosis What’s changed now that the patient is in the ICU Realistic goals of care Family & social support Faith tradition
Preparation for death
Family care following death

11. Ministry in the Unit: Meeting with the Family
Early-on after ICU admission
Purpose: - inform the family and establish goals of care diagnosis, prognosis, statistics v gestalt - establish who is the spokesperson - identify family dynamics encourage unity - establish a follow-up meeting

12. Meeting the Family
Most meetings go smoothly - include residents, nurses & medical students
Mentality: - family is in tsunami-mode - spectrum: concerned <–> distraught <–> openly hostile
Gage need for “Security”
Focus on problems at hand
Sit close to the door

13. Ethical Issues in the ICU
Most ethics issues center around the beginning or the end of life
Ethical dilemmas at the end of life are the necessary consequence of advanced, life saving and life-sustaining medical care.

14. End-of Life Scenarios
The natural end-point of a terminal disease - malignancy - liver failure - neuromuscular disease
Extreme old age chronological vs physiological age
Complication of long-term care
Severe, acute illness which advances relentlessly despite aggressive, multi-modality measures - age non-specific

15. Medical-Pastoral Questions
Keep everything going and wait for recovery?
Wait for God to intervene with a miracle?
Allow natural death/shift to providing comfort?
What would the patient want?
What does the family want?
What’s ‘the right thing?’
How to make a decision that everyone can live with ….?
When is continuing care futile?

16. A Selection of Ethical Issues
The Georgetown mantra: beneficence, non-maleficence, autonomy, and justice
The evolution of patient (family ) autonomy
What’s technically possible vs what’s the right thing to do (or not do)
Concept of futility vs ‘no benefit’

17. Principles of End-of-Life Counseling in the ICU
Confidence in the diagnosis and prognosis
Provide for comfort and consolation
Provide for pastoral care, if desired
That which ends the patient’s life is the underlying disease process, NOT the withdrawal of biological life-sustaining measures
Medical decisions made by MDs in close dialogue with family
“Let’s make decisions we can look back on 10 years form now and know we did right.”

18. Withdrawing Care Morphine concept of the “double-effect”
Dose to relieve evidence of distress (not dosed to end life)
Shut off all pressors
Remove the ventilator
Allow the family proximity, if desired

19. Georgetown Ethics Initiatives
Identify clinical data points which suggest that survival in the ICU is unlikely
If these criteria are met, establish a “Goals of Care” meeting with family early, with Pastoral Care and Palliative Care presence
Establish who will serve as the surrogate decision maker for the patient
Time limits on interventions of questionable benefit
Ethics Community monitoring of all ICU “comfort-measure” deaths

20. Contemporary Ethics Issues
Patient/family autonomy vs physician’s right of conscience - lessons learned from the abortion debate - Christian Medical/Dental Association lobby
Physician-assisted suicide - legal in Oregon, Montana, Nevada - getting press time in professional journals
Transplantation ethics - technical success way ahead of ethics dialogue - the vetting process for living donors
The perfect storm….

21. Other things to think about…
“Spirituality” in medicine
Sharing Jesus with our patients
Praying with patients
Christian medical professionalism
Medical errors and complications - full disclosure