Objectives. Sometimes We Get Ahead of Ourselves 3/6/2015
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1 Withholding and Withdrawing No Longer Beneficial Medical Interventions: Historical, Ethical and Practical Issues Marcia Levetown, MD FAAHPM HealthCare Communication Assocs Houston, TX Objectives Be able to explain why the issue of withholding or withdrawing (w/w) medical intervention became relevant to care Recognize patient scenarios for whom w/w is relevant Be able to address issues of w/w with clarity and compassion Know how to prevent distressing symptoms during the practice of w/w Discuss the issues of tissue and organ donation in the face of w/w Sometimes We Get Ahead of Ourselves 1950: Ventilators come out of the OR and into the ICU, polio epidemic. First in US in 1955, Dartmouth Apply medical intervention without data in effort to preserve life. PVS cases arise. Supreme Court involvement DNR policies first appear in 1976 Then ANH controversies Dialysis, pacemakers, ICDs, LVADs, balloon pumps 1
2 Conceptual Framework Assessment of Benefit Clearly Beneficial Marginal/ Uncertain Benefit Clearly Nonbeneficial Benefit vs Burden What are the hoped for outcomes? What is the likelihood? What are the risks and their likelihood? What are the alternatives? Consider: Dialysis in PVS AICD in MOSF Practitioner Roles Acknowledge uncertainty Recognize there is no right answer Strive to understand patient and family perspectives and make recommendations on this basis Remember the family lives with the decisions forever 2
3 Consider All Potential Interventions in Light of the Whole Patient It is morally and legally permissible to base treatment decisions on: Patient priorities and preferences Impact on QOL, patient defined dignity Prognosis In Texas, this includes ANH, ABX, etc. What Words Do You Use to Discuss Withholding or e Withdrawing with Your Patients and Families? Words, Feelings, Consequences What is a life-sustaining treatment? How might this phrase influence decision-making, grief and guilt? How can one determine if it is a no longer beneficial treatment? Role of time limited trials What other treatments/ interventions can be described this way? 3
4 Step-wise Process for Timelimited Trials Define a therapeutic goal Gain a firm and clearly stated commitment to that goal by all the parties Try intervention for an agreed-upon period of time, set up meeting to review outcome Observe effects of treatment closely Encourage family to observe closely Time-limited Trials Including family in this way helps them come to terms with the impending death of their loved one. Should the goal not be met by the end of the therapeutic trial, the trial is then concluded and the treatment stopped. Excerpted from Frederich M. Artificial hydration and nutrition in the terminally ill. American Academy of Hospice & Palliative Medicine Bulletin, Fall Mrs. M Multi-infarct dementia, but able to read, do puzzles, visit with family, hold a conversation Aspirating, hospitalization x 3 in last 5 months for aspiration pneumonia. Now has J tube following episode of vomiting and distention with G tube Rapid weight loss, colectomy 12/14 for colon CA, IIIA Longstanding history of dry mouth, facility prefers her to be NPO 4
5 Mrs. M What would you discuss with Mrs. M and her family? QOL priorities Likely course of events Interventions and their outcomes, potential time limited trials Recommendations regarding treatments that will not likely be beneficial How to maintain comfort 21 Year old Man with DMD and Cardiomyopathy Destination LVAD? Is Withholding Different than Withdrawing? 5
6 62 Year old Man with CHF, Pacemaker, AICD, Inotropes Assess patient goals Indications, evidence for current treatments? Benefits and burdens Symptoms to anticipate if stopped? Preventing/ controlling symptoms Sedation ALS Patient on Home Ventilator, Able to Communicate Assess patient s goals, values Expected course of illness, potential thresholds regarding QOL Assistive devices available, cost, coverage Family willingness, potential locations of care If vent forgone, what personnel are needed and where are they available? If institutionalized, what are relevant policies and capacities? Is a move required? Minimally Conscious Patient After Anoxia Is patient terminal? Is that relevant to the ability to stop or not start interventions? How are brain dead, PVS and MCS different and the same? Does patient have known values? What are likely terminal events? What should be discussed regarding forgoing or withholding interventions? What does the law support? 6
7 65 yo with ESRD, Diabetic Neuropathy, Chronic Pain Wants to stop dialysis after 5 years of treatment Questions to ask Depression Inadequate pain treatment Financial or family concerns If stopped, time course to death? Possible mechanisms of death? Role of Kayexalate? Symptom control? Role of opioids? Patient with AIDS, Inanition, Recurrent Infection Are antibiotics comfort measures? Are antibiotics ordinary treatments? Does ordinary/ extraordinary matter? How would you approach the topic? Is there ever a reason to discontinue HAART? What are the Data on CPR? 7
8 Why Think About Tissue or Organ Donation? Is it ever relevant to a hospice patient? Comments and Questions 8
Objectives. Sometimes We Get Ahead of Ourselves 5/22/2015
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