Medical Futility in the ICU

Transcription

1 Medical Futility in the ICU Michael W. Rabow, MD Director, Symptom Management Service Helen Diller Family Comprehensive Cancer Center Professor of Clinical Medicine UCSF June 3, 2010

2

3 ...not for the good it will do, but that nothing may be left undone on the margin of the impossible. T.S. Eliot

4 Outline I. Background on Futility II. The Challenges of Futility III. Practical Recommendations

5 I. Ethics, History & the Law Patient s s right to decide about withdrawing/withholding treatment Surrogate s s right to decide if necessary Physician s s professional, legal, ethical right to withhold/withdraw futile treatment Luce JM, White DB. Crit Care Clin Jan;25(1): American Medical Association Code of Ethics, June 1994

6 Ethics of Futility Oldest principles (fiduciary relationship) Beneficence Non-maleficence Newer principles Autonomy Justice

7 History of Patient Autonomy 1976: Quinlan decision (right to die,refuse LSMT) 1990: Cruzan decision reaffirms 1990: Patient Self-Determination Act 1990: 50% of ICU deaths involve wd/wh (Smedira) 1997: 77% (Prendergast) 1997: AMA, SCCM, ATS, ACCP ethical and legal propriety of limiting unwanted treatment, necessity of pall care

8 History of Futility 430s BC: Hippocrates refusal to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless 1976: CPR policies out of the closet Fried. N Engl J Med Aug 12;295(7): s: Futility to justify unilateral decisions 1987: Blackhall: CPR not universal Blackhall LJ. N Engl J Med Nov 12;317(20): : Futility defined as none in the last 100 Schneiderman LJ et al. Ann Intern Med Jun 15;112(12):

9 Futility as Practiced Commonly used 34% MDs continue treatment against patient/surrogate wishes 83% withhold, 82% withdraw unilaterally interventions judged to be futile Asch DA et al. Am J Respir Crit Care Med Feb;151(2 Pt 1):

10 Definitions of Futility Physiologic futility Quantitative futility Qualitative futility

11 II. The Challenges of Futility Achieving consensus Determining & Following patient preferences Estimating prognosis Evaluating benefit Physician fears Balancing individuals & society: resource allocation

12

13 Achieving Consensus Cannot agree on the definition In the eye of the beholder, subjective/personal: a) is unlikely to be of any benefit to a particular patient in a particular medical situation b) will not achieve the patient s intended goals Helft. N Engl J Med. 2000;343:

14 Determining & Following Patient Preference AD may not be present AD may not be specific enough Surrogates may be unrealistic No improved mortality Increased cost KH Berge et al. Mayo Clin Proc. 2005;80:

15 Patient Preferences cont. AD may not influence care Support Trial Danis M, et al. Crit Care Med Nov;24(11): But may be that is changing Silveira MJ, et al. N Engl J Med Apr 1;362(13): Detering KM, et al. BMJ 2010;340:c1345.

16 Estimating Prognosis We re poor at prognosticating RNs and MDs don t agree on futility Docs and RNs not agree in 63% of dying Cannot predict QOL RNs more pessimistic, more correct Frick S et al. Crit Care Med Feb;31(2): APACHE less effective at individual level Zimmerman JE et al. Crit Care Med Aug;26(8):

17 Evaluating Benefit May be unexpected 47% hospital survival for >70yo >30 day in ICU Montuclard L et al. Crit Care Med Oct;28(10): Cannot figure out others quality of life Experiences change patient s preferences eg CPR

18 Experience Changes Preferences Assessment of CPR by Survivors 55% 3% 42% Ambivalent Want CPR Again Not Want CPR Again

19 Physician Fears of Litigation Generally, courts don t want to be involved Only 11 states have laws requiring treatment with no time limit to allow transfer Almost always support physician decisions Especially Ex Post (duty, breach, direct causation, damages) Ex Ante sometimes injunctions are ordered to allow transfer

20 Individual and Society: Resource Allocation Public policy should not be determined at the bedside However, when will rationing of health care enter the debate? Teres D. Civilian triage in the intensive care unit: the ritual of the last bed. Crit Care Med Apr;21(4):

21 III. Practical Recommendations 1. Don t t talk about futility 2. Give it time 3. Focus on the relationship 4. Offer excellent communication 5. Rely on policies 6. Call in help 7. Support each other

22 1. Don t t Talk about Futility We don t agree on what it is We don t agree on how to evaluate the benefit of interventions We can misuse the futility argument 33% used the argument of Quantitative Futility but estimated the chance of survival to be 0-75% 18% used the argument of Qualitative Futility, but only 1/3 discussed QOL Curtis, JAMA, 1995 American Medical Association Code of Ethics, June 1994

23 Focus on goals of care specific achievable benefits and burdens Siegel MD. Clin Chest Med Mar;30(1):

24 2. Give it Time Talk AND listen more Allows for conflict resolution 57% of patients and surrogates agreed immediately to a physician's recommendation to limit intensive care 90% agreed within 5 days Prendergast TJ. New Horiz Feb;5(1): Therapeutic trials

25 3. Focus on the Relationship Fiduciary Physician commits himself to the patient's best interests but retains a role in defining those interests. TJ Prendergast Assent rather than consent

26 Enhanced Models of the Patient- Physician Relationship Type of Automony Goals Plan None (Parentalism) MD MD Simple (Consumerism) Patient Patient Enhanced (Professionalism) Patient MD Types of Patient-Physician Relationships Paternalistic Deliberative (includes shared decision-making)

27 All medical care flows through the relationship between physician and patient, and the spoken word is the most important tool in medicine. Eric Cassell

28 4. Offer Excellent Communication Communication not Criteria or Committees Burns J and Truog R. Chest, 2007; 132(6): Communication as a skill Effective communication about end-of-life care requires training, practice, and supervision, as well as planning and preparation Curtis JR. Crit Care Clin Jul;20(3):363-80, viii. Communication improves outcomes Family meeting and EOLC as opportunities for improved care Curtis JR et al. Crit Care Med. 2001;29(2, suppl):n26-n33. Prendergast TJ, Puntillo KA. JAMA Dec 4;288(21):

29 Family Communication Needs (1) A clinician willing to talk (2) Timely and clear information Information needs are paramount Prognostic information > decision-making Control over timing Steinhauser, J Pain Sx Mgmt. 2001;22:727 Butow, Support Care Cancer, 2002 (3) A clinician able to listen

30

31 Listening Outcomes Seattle ICU study 51 family meetings Average length 32 minutes (7-74minute range) 29% vs 71% Increased proportion of family speech associated with Increased satisfaction Less reported conflict McDonagh, Crit Care Med, 2004

32 Evidence for Family Meeting Bereavement brochure and communication guidelines (VALUE) Valuing what the family members said Acknowledging their emotions Listening Understanding the patient as a person through asking questions Eliciting questions from the family members. 30 vs 20 min meetings: 14 vs 5 min family talk Decreased caregiver depression, anxiety and PTSD at 2 months Lautrette, NEJM, 2007

33 5. Rely on Policies if Necessary Community-based consensus standards Hospital futility policies Due process: negotiation, shared decisionmaking, ethics committee Transfer to another MD (if institutional review supports proxy) or another institution (if supports MD) If no transfer possible, no intervention Luce JM. Am J Respir Crit Care Med Dec;156(6): AMA Code of Ethics, 1994

34 6. Get Help: Ethics Committees & Palliative Care Services Help is usually Communication Proven benefits to Ethics Committee No difference in mortality Decreased ICU/hospital LOS among dying Schneiderman LJ et al. JAMA Sep 3;290(9): Proven benefits to Palliative Care Consultation No difference in mortality Pain & Non-pain symptoms Patient/family satisfaction ICU length of stay & Cost Jordhay et al Lancet 2000; Higginson et al, JPSM, 2003; Finlay et al, Ann Oncol 2002; Higginson et al, JPSM 2002, Zimmerrman, JAMA 2008

35 7. Support Each Other Crisis of conscience: Adults 47% of MDs and RNs 70% of house officers Solomon MZ et al. Am J Public Health Jan;83(1): Crises of conscience: Peds 54% of house officers 48% of critical care nurses 38% of critical care attending physicians Solomon MZ et al. Pediatrics : Spend the time to achieve consensus, or at least offer support and mutual respect