Lth|ca| Issues |n Intens|ve Care

Med|c|ne
uouglas 8. WhlLe, Mu, MAS
AssoclaLe rofessor
ulrecLor, rogram on LLhlcs and Crlucal Care Medlclne
ueparLmenL of Crlucal Care Medlclne
unlverslLy of lusburgh School of Medlclne

Iacu|ty D|sc|osures
no poLenual CCls relevanL Lo Lhls Lalk
key 1op|cs
SLandards of surrogaLe declslon maklng
Shared declslon maklng
ls Lhere an eLhlcal dlsuncuon beLween WP and Wu
llfe supporL?
rlnclple of double eecL
luullLy and conlcL resoluuon
Mr. au| |s a 72 year-o|d man w|th a h|story of CAD s]p CA8G,
adm|ued w|th pneumon|a. ne deve|ops seps|s, MSCI and |s
adm|ued to the ICU where he |s |ntubated, venn|ated and g|ven
pressors |n add|non to annb|oncs. Aher 3 days |n the ICU, Mr.
au| |s c||n|ca||y unchanged except for worsen|ng rena| funcnon,
h|s AACnL 3 score pred|cts 70 morta||ty rate. In meenng w|th
the fam||y, they ask you, "Who dec|des whether we keep
go|ng?"
A. 1he famlly- based on Lhelr values and preferences.
8. 1he famlly and physlclan- based on Lhe pauenL's values
C. 1he physlclan- accordlng Lo Lhe pauenL's besL lnLeresLs.
u. 1he courLs
L. 1he hosplLal eLhlcs commluee



Surrogate Dec|s|on Mak|ng
8eauchamp & Chlldress. rlnclples of 8lomedlcal
LLhlcs. 1994
Autonomy |n ICU anents
AuLonomy: derlved from Creek !"#$% (self") and
'$($% (rule")
ersonal rule of Lhe self LhaL ls free from conLrolllng
lnLerferences by oLhers."
CenLral Lo Amerlcan bloeLhlcs
1he foundauon of Lhe auenL Self ueLermlnauon AcL
auenLs are Lhe besL arblLers of whlch medlcal
opuons promoLe Lhelr self-lnLeresL.
8eauchamp & Chlldress. rlnclples of 8lomedlcal
LLhlcs. 1994
Surrogate Dec|s|on-mak|ng
lncapaclLaLed pauenL's wlshes are spoken Lhrough a surrogaLe:

Stated w|shes: LreaLmenL preferences prevlously expressed by
Lhe pauenL.
Subsntuted [udgment standard: surrogaLe dons Lhe menLal
manLle of Lhe pauenL."
WhaL would Lhe pauenL say lf he could speak for hlmself?"
8est |nterest standard: surrogaLe decldes on Lhe LreaLmenL
course wlLh Lhe hlghesL beneL for Lhe pauenL wlLhouL clear
knowledge of whaL Lhe pauenL would wanL.
Amerlcan courLs have repeaLedly amrmed LhaL surrogaLes can llmlL llfe susLalnlng LreaLmenLs.



CrlL Care Med, 2004, 32:1781
A1S, SCCM, LkS, LSICM Consensus
Conference

"We advocaLe a shared approach Lo end of llfe
declslon maklng, wlLh responslblllLy for Lhe declslon
shared beLween Lhe careglver Leam and Lhe pauenL's
surrogaLe."
Sherldan SL. Am ! rev Med 2004,26:36-66
Shared Dec|s|on-mak|ng
1wo-way lnformauon sharlng and uM beLween Lhe
surrogaLe and physlclan.
hys|c|an |nput: lnformauon abouL Lhe dlsease sLaLes,
currenL LreaLmenLs and prognosls.
Surrogate |nput: lnformauon abouL pauenL's values and
LreaLmenL preferences.
Io|nt de||beranon and dec|s|on: physlclan and surrogaLe
muLually agree upon a plan.

Case of Mr. au|
Pemodlalysls ls lnluaLed and Mr. aul conunues Lo do
poorly. Pe now has A8uS, remalns hypoLenslve and ls
compleLely unresponslve. Clven hls worsenlng ln Lhe
face of aggresslve LreaLmenL, Lhe famlly decldes Lo
wlLhdraw hemodlalysls. 1he lu consulLanL says lL would
have been accepLable noL Lo begln dlalysls, buL once
lnluaLed lL ls uneLhlcal Lo sLop lL- lL's llke kllllng Lhe
pauenL."
Is it ethically acceptable to withdraw dialysis?
A. Yes
B. No
W|thdraw|ng and W|thho|d|ng 1reatment
W|thho|d|ng: never sLarung a LreaLmenL
W|thdraw|ng: sLopplng a LreaLmenL
noL an eLhlcally meanlngful dlsuncuon when boLh reecL
pauenL's values Lo be allowed Lo dle.
Lega| erspecnve on Iorego|ng 1reatment
lL ls legally and eLhlcally permlsslble Lo wlLhhold or
wlLhdraw any medlcal lnLervenuon, lncludlng
nuLrluon and hydrauon.
U.S. Supreme Court 1990, Cruzan decision
Chang|ng Nature of Death |n the ICU
0
10
20
30
40
50
60
70
1987-8 (n=224) 1992-3 (n=200)
P
e
r
c
e
n
t

o
f

d
e
a
t
h
s


Full support
Withhold LST
Withdraw LST
rendergast & Luce, AIkCCM, 1997, 1SS:1S
p<0.001
What |f you cou|d w|thho|d but not
w|thdraw treatment?
1he unknown pauenL wlLh resplraLory fallure ln Lhe
L8, who laLer ls found Lo have an advance dlrecuve
sLaung 'unl'.
1he pauenL who would accepL a ume llmlLed Lrlal of
Mv, buL noL prolonged Mv.
Case of Mr. au|
1wo days laLer, he develops hyperkalemla and acldosls
as hls renal funcuon deLerloraLes furLher.

When you dlscuss hls worsenlng prognosls wlLh Lhe
famlly, Lhey say he would noL wanL furLher llfe
supporL and LogeLher you agree Lo wlLhdraw llfe
supporL.
Case of Mr. au|
Mechanlcal venulauon and Pu are dlsconunued. 3 hours laLer Mr.
aul ls sull allve. Pls famlly asks lf Lhere ls anyLhlng you can do Lo
move Lhlngs along. Pls wlfe says, lL's [usL agonlzlng for hlm."
?ou observe LhaL Mr. aul appears comforLable and has no
ob[ecuve slgns of paln or dlsLress.
Is it ethically acceptable to increase the opioid dose?
A. Yes
B. No



1he rlnclple of uouble LecL
Doub|e Lect
lL ls permlsslble Lo admlnlsLer LreaLmenLs lf Lhe
lnLended eecL ls Lo LreaL sympLoms, even lf hasLened
deaLh ls a foreseeable buL unlnLended consequence.
AdmlnlsLerlng hlgh-dose oplolds Lo LreaL paln ln a
Lermlnally lll pauenL ls accepLable even lf Lhe
medlcauon hasLens Lhe pauenL's deaLh
1he lnLenL ls rellef of suerlng
1he foreseen buL unlnLended consequence ls hasLened deaLh
1he lnLended eecL (paln rellef) ls noL achleved Lhrough Lhe
bad eecL (causlng deaLh).
Case of Mr. au|
Mechanlcal venulauon and Pu are dlsconunued. 3 hours
laLer Mr. aul ls sull allve. Pls famlly asks lf Lhere ls
anyLhlng you can do Lo move Lhlngs along. Pls wlfe says,
lL's [usL agonlzlng for hlm."
?ou observe LhaL Mr. aul appears comforLable and has no
ob[ecuve slgns of paln or dlsLress.
Is it ethically acceptable to administer
KCl?
Luthanas|a & hys|c|an Ass|sted Su|c|de
LuLhanasla- Lhe lnLenuonal kllllng of a pauenL.
-lllegal ln uS

hyslclan AsslsLed Sulclde: physlclan prescrlbes
medlcauon Lo pauenL knowlng LhaL Lhe pauenL
lnLends Lo use lL Lo commlL sulclde.
-Legal ln Cregon and WashlngLon, lllegal everywhere
else ln uS.
Case of Mr. au|
1wo days laLer, he develops hyperkalemla and acldosls as hls
renal funcuon deLerloraLes furLher.

?ou belleve LhaL Mr. aul's chance of survlvlng Lo dlscharge ls
<3. When you dlscuss Lhls wlLh Lhe famlly, Lhey say he
would wanL everyLhlng posslble Lo glve hlm a chance" and
ask abouL sLarung hemodlalysls for renal fallure.
Is hemodialysis futile in this setting?
A. Yes
B. No


luullLy
Lo 8. 8esolvlng LLhlcal ullemmas 2000, 72-79
1he Concept of Iun||ty
Laun: )"*+,%- leaky
CLu: )"*+.: leaky, falllng ln Lhe deslred end Lhrough lnLrlnslc
defecL.
Creek myLhology: Lhe daughLers of uanaus were condemned
ln Pades Lo ll a large pond by Lransporung waLer ln leaky
buckeLs.

luule medlcal lnLervenuons serve no meanlngful purpose, no
mauer how oen Lhey are repeaLed.
Lo 8. 8esolvlng LLhlcal ullemmas. 2000, 72-79
1he Str|ct Concept of Iun||ty
Iusnhcanon for Un||atera| Dec|s|ons
uenluon: Lhe lnLervenuon wlll noL accompllsh lLs lnLended goal.
1he lnLervenuon has no paLhophyslologlc rauonale. (Lreaung
Ml wlLh anufungal Lherapy)
D|scarded concepts of fun||ty
uanntanve- chance of success
Pow small ls small enough? (1)
Pow much prognosuc uncerLalnLy ls Lhere?
ua||tanve- quallLy of llfe poor
no worLhwhlle goals can be achleved
Accordlng Lo whom?
8eneLs noL worLh Lhe cosL
Who decldes?
CrlL Care Med 1997,23:887-891
SCCM Consensus Statement on Iun||ty
uenluon: A fuule lnLervenuon ls one LhaL wlll noL
accompllsh Lhe lnLended goal.

luule LreaLmenLs are rare.
luullLy generally noL a useful concepL for pollcles Lo
llmlL LreaLmenL
CrlL Care Med 1997,23:887-891
Categor|zanon of 1ypes of 1reatments
luule 1reaLmenL: Wlll noL achleve Lhe lnLended
ouLcome

oLenually lnadvlsable 1reaLmenL
ls exLremely unllkely Lo achleve Lhe lnLended
ouLcome
ls poLenually beneclal buL exLremely expenslve
ls of uncerLaln or conLroverslal beneL
1he AMA Due rocess Approach 1o keso|ve
D|sagreements about "Inappropr|ate"1reatment
1. lamlly should be glven lnformauon abouL Lhe lnadvlsablllLy"
deLermlnauon process
2. lamlly glven nouce and lnvlLed Lo paruclpaLe ln Lhe consulLauon
process
3. LLhlcs commluee should musL provlde a wrluen reporL of lLs ndlngs Lo
Lhe famlly
4. lf dlspuLe cannoL be resolved, Lhen hosplLal musL auempL Lo arrange
Lransfer Lo anoLher hosplLal.