Ethical issues in resuscitation and intensive care medicine

Ethical issues in resuscitation and intensive care medicine

ETHICS requires input from clinicians if it is to work well. It involves: • analysis of the existing process • design of the new computerized process...

103KB Sizes 18 Downloads 108 Views

ETHICS

requires input from clinicians if it is to work well. It involves: • analysis of the existing process • design of the new computerized process • configuring the EPR to deliver the new process • testing the software and running clinical scenarios before ‘going live’ • if necessary, piloting the new clinical processes in a limited clinical area (e.g. a ward) with careful supervision and audit • formally reviewing the outcome of the pilot project and making changes as required • rolling out the new process and the EPR to other clinical areas.

Ethical issues in resuscitation and intensive care medicine

Anaesthetic considerations The data recording and reviewing requirements of anaesthesia and intensive care are similar to those of many other specialties. Assessment and investigation, recording of physiological data and drug and fluid administration, along with details of anaesthetic procedures, are not fundamentally different from the processes that are undertaken by clinicians in many other specialties. Modern EPRs can meet these requirements, though special anaesthetic screens may need to be designed when the EPR is being configured. Automatic downloading of physiological data from monitors has been technically possible for many years and is common in ICUs with central monitoring stations. Unfortunately the plethora of devices of varying vintages from different manufacturers that is in use in many operating theatres makes linking all these devices to an anaesthetic information management system (AIMS), or to an EPR, a technical nightmare, and potentially very expensive. It is probably for this reason, and because anaesthesia is now so safe (making the economic justification weak), that AIMS are not more widely available. However, anaesthetic data recording is now part of the implementation of the NCRS and significant developments are expected in the next few years. ‹

The latter part of the 20th century has witnessed profound changes in the way we manage critically ill patients. The emergence of designated critical care units staffed by trained individuals, alongside the development of technologically advanced organ support systems, has enabled access to life-sustaining therapies for many patients who would otherwise have died. While some of these patients will be restored to a normal functional existence, such interventions applied inappropriately can give rise to a population of patients who survive in a state of chronic persistent ill-health. Many of these patients will proceed to a slow death, which will not only have an emotional impact in terms of human suffering on the patient and their relatives but will also impose a financial drain on limited resources. The ethos of preserving life at all costs must be re-evaluated. Instead, the provision of quality end-of-life care should be a priority and an ethical obligation for all healthcare providers, not least of all the intensivist. We can start by devoting more time to teaching and training clinicians how to care for the dying and cope with the inherent ethical predicaments they may impose. In practising biomedical ethics it is prudent to analyse each situation in terms of a simple set of principles and definitions: • autonomy: an individual has the right to determine what can be done to their body • beneficence: do good • non-maleficence: do no harm • justice: healthcare resources should be allocated fairly to all.

Elizabeth S Wilson Nick Pace

Elizabeth S Wilson is a Consultant in Anaesthesia and Intensive Care at the Royal Infirmary of Edinburgh. She qualified from St Andrews and Glasgow University Medical Schools. She trained to post-fellowship level in cardiothoracic and general surgery before embarking on a career in anaesthesia and intensive care medicine. She was a specialist registrar in anaesthesia in Glasgow and held intensive care fellow posts in Glasgow and Perth, Western Australia. Her main intensive care interest is severe sepsis.

FURTHER READING Department of Health Information Technology homepage: http://www.dh.gov.uk/PolicyAndGuidance/InformationTechnology/fs/ en The Wanless Report: http://www.hm-treasury.gov.uk/Consultations_ and_Legislation/wanless/consult_wanless_final.cfm? Web sites change, so the references given here may become out of date. Internet search engine will provide suggestions for further reading. Particularly recommended is www.google.com

ANAESTHESIA AND INTENSIVE CARE MEDICINE 5:12

Nick Pace is Consultant Anaesthetist at the Western Infirmary, Glasgow. He qualified from Glasgow University and trained at the Western and Royal Infirmaries, Glasgow; University Hospital of South Wales; and Parkland Memorial Hospital, Dallas, Texas. He is a member of the British Transplant Society’s Ethics Committee and is completing a PhD in medical law.

414

© 2004 The Medicine Publishing Company Ltd

ETHICS

Autonomy

Advantages and disadvantages associated with advance directives

Patient autonomy has become a pivotal doctrine in Western society. Central to this principle is the right to self-determination (i.e. the ability to make healthcare decisions for oneself). This may take the form of allowing or withholding consent for a particular treatment or being able to terminate a course of treatment once it has begun. If the ability to participate in the decision-making process is lost, through illness or medication, then with appropriate preparation, an individual can make their opinions known in advance or nominate a proxy to act on their behalf. The concept of autonomy is closely associated with a number of other important issues including advance directives, do not resuscitate orders, and organ donation.

Advantages • Afford an individual some autonomy in treatment options after incapacitation • May strengthen relationships, by facilitating communication relating to death • Can act as a guide to assist others in making the most appropriate choices • May shorten the dying process by enabling limitation of lifesustaining treatments, and thus help relieve the burden on remaining loved ones

Advance directives First proposed by Kutner in 1969, advance statements, directives or ‘living will’ documents were initially envisaged for the use of patients with chronic debilitating illnesses, but are increasingly becoming applicable to the intensive care setting. (An example can be seen in: Mason J K, McCall Smith R A. Law and medical ethics. 4th ed. Butterworths, 1994, p. 439–40.) In their broadest context they allow a competent patient to express preferences towards medical treatment in the event of their becoming incapacitated, including when a patient is sedated in the ICU, or following brain injury. Advance statements can be generic, when they are intended for general use, or disease-specific, when they are directed at potential interventions liable to arise as a consequence of the patient’s condition. The term, advance directive, is normally reserved for instructions refusing some or all medical procedures; the most common example being the card carried by Jehovah’s Witnesses refusing the acceptance of blood or blood products. The USA has led the way in promoting advance statements. Although there is no specific legislation dealing with their legal authority, the law has a desire to support an individual’s right to self-determination once incompetent. In the UK, living wills are uncommon. The advantages and disadvantages associated with their use are given in Figure 1. The British Medical Association (BMA) endorsed their value in a statement in 1994 and in conjunction with the Royal Colleges and the Law Society, later published a code of practice providing guidance about their drafting and implementation.1 However, the legal standing of advance statements remains limited, mainly because their broad nonspecific nature can make their application difficult, particularly in the critical-care setting. For them to be legally binding, the individual must have envisaged the current situation in advance and made a clear refusal of the treatment in question at a time when they were competent. In all circumstances, a contemporaneous decision by a competent individual overrides previously expressed statements by that person. Differences in legislation within the UK, subsequent to devolution, are making the situation more complex. Although it does not mention advance directives specifically, the Adults with Incapacity (Scotland) Act, 2000, goes a step further in recognizing proxy authority. It provides for decisions to be made on behalf of adults who are incapable of managing their own affairs, owing to a mental disorder or an inability to communicate. It also permits a person to appoint a Welfare Attorney to act on their behalf, in the event of incapacity.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 5:12

Disadvantages • Uptake of advance directives has been small in most countries • Even when adopted, they have had little impact in changing treatment options. This may be due in part to a lack of awareness on the clinician’s part, but also a lack of their ready availability when life-sustaining measures are being made • The concept of commitment to patient self-determination may conflict with the clinician’s perception of what is best for the patient • Precise wording of the document is crucial (e.g. to refuse short-term dialysis during an episode of sepsis-induced acute renal failure is quite different from refusing lifelong haemodialysis) • There may be doubts about whether or not the current circumstances are the same as those contemplated by the patient when the advance directive was drafted 1

Do not resuscitate (DNR) orders Cardiopulmonary resuscitation (CPR) was established in the 1960s alongside the development of coronary care units, where healthy patients who sustained a recent severe cardiac insult could be cared for by highly trained staff with state-of-the-art electronic monitoring. In this environment, CPR was highly successful. However, when CPR became commonplace for all patients with a cardiac arrest, success rates fell. In some groups, such as those with overwhelming infection or concomitant failure of one or more major organ systems, success rates were so poor CPR could be considered futile. The practice of CPR also began with the assumption that most people who sustain a cardiopulmonary arrest would consent to resuscitative measures were they capable of doing so, which may not always be the case. Thus, it is essential to identify those patients for whom cardiopulmonary arrest represents a terminal event in their illness and in whom the delivery of CPR would be inappropriate. In the past, DNR orders have been a source of dissent and discord among doctors, nurses and others involved with the patient’s welfare. Many problems could have been avoided with adequate communication between relevant healthcare professionals and those close to the patient. In 1999, a joint statement on CPR was issued by the British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing.2 The importance of

415

© 2004 The Medicine Publishing Company Ltd

ETHICS

involving patients in decision making, when capable, the need to take into account advance directives and the value of involving the entire healthcare team were emphasized. Hopefully, we will adopt a more sensitive caring approach by discussing choices about resuscitation with our patients and their relatives before recording any decisions in their case records.

cure, ameliorate, improve or restore a quality of life that would be satisfactory to the patient’. The importance of medical futility is attributable to three factors: • the changing face of modern medical practice • the debate between patient autonomy and medical paternalism • cost implications. There is now a constant need to evaluate who should receive life-sustaining treatments and in what circumstances as well as when these treatments should be withdrawn. Disputes focusing on who should be responsible for these decisions have involved the law courts (Figure 2). The opinions of healthcare professionals about what is best for their patient may act as a source of conflict if they are at variance with their patient’s or the proxy’s wishes. The issue of finance in the determination of medical futility is also a problem and impacts on the principle of justice in medical ethics. In the current climate of limited financial resources is it justifiable to continue seemingly futile treatment at the expense of giving greater benefit to other patients? Continuing dialogue with the patient, or their proxy, is paramount to ensure appropriate decisions are reached regarding continuation, escalation, withholding or withdrawing of therapy. The underlying principle guiding any decision must be to protect the dignity, rights and comfort of the patient and, where possible, take into consideration the wishes of the patient or their proxy. A mutually acceptable arrangement is usually found, but the process is simplified if the patient has already made an advance directive. The BMA has issued guidelines to assist doctors in making these difficult decisions3 and the GMC has set out standards of practice that should be adopted.4 However, these have recently been challenged in court and need to be rewritten.

Brain death and organ donation Ethical issues include the diagnosis of brainstem death, the right of an individual to stipulate in advance of their death their desire to donate organs and controversies relating to ‘non-heart beating organ donation’. For centuries, traditional criteria for death have been based on cessation of circulatory and respiratory function. Even though these organs may remain viable and functioning, human life is not sustained in the absence of certain neurological functions. Consequently brain death is now recognized and can be defined as the loss of whole brain function, including the brainstem. Brainstem death is essential to current practices of organ procurement because it legitimizes organ retrieval in the presence of cardiorespiratory stability, and thereby avoids ischaemic injury to organs. Although families of patients declared brain dead are commonly asked to grant permission for organ donation, patients declared dead by cardiopulmonary criteria may also make suitable donors. These non-heart beating organ donors have formerly been a potential source of skin, bone, corneal and heart valve tissue. Recent protocols have expanded the potential role of these donors to allow procurement of additional solid organs, most notably kidneys and livers. They require life-sustaining treatments, such as mechanical ventilation, to be withdrawn under controlled conditions and death declared using cardiac criteria (i.e. a few minutes without a pulse). Alternatively, procurement may follow a failed resuscitation attempt in the Accident and Emergency Department. Then organs must be removed immediately or preserved in situ u by infusing cold preservative solutions. The BMA is pursuing the development of legislation to allow this technique to become more widespread and facilitate the greater use of non-heart beating donors. In considering these options, there must be strict adherence to ethical and technical detail. Indeed the procedure should not be contemplated until an institutional protocol is in place.

The acts and omissions doctrine and the principle of double effect Withholding or withdrawing treatment that hastens natural death is permissible. There appears to be a clear distinction between allowing a patient to die and killing them (i.e. there is a distinction between actively doing something and letting something happen). However, if analysed in terms of the intended outcome, there may be no difference. Therefore, the intention is all important. A physician’s withdrawal or withholding of life-sustaining medical treatment in accordance with a patient’s wishes falls under the remit of voluntary passive euthanasia. Physician-assisted suicide is very close to active euthanasia, the only difference being who delivers the lethal drug dose. Understandably many find these issues fraught with legal and moral difficulties. Certain treatments may have a beneficial and a harmful effect, such as comfort medications like opioids. Used in the appropriate setting these drugs can fulfil a crucial role in relieving symptoms even though they may compromise vital functions and hasten death. This is known as the ‘double effect’. By contrast, if the same medication is given with the sole intent of speeding up the dying process, then active euthanasia is in force.

Beneficence and non-maleficence The principles of beneficence and non-maleficence can be examined by reference to a number of interlinked concepts. Sanctity versus quality of life In the past, religion played a central role in influencing ethical decisions. This influence is diminishing, and instead of merely aiming to prolong life, judgement decisions about whether or not to instigate a treatment are often based on the anticipated quality of life.

Justice

Medical futility and ordinary versus extraordinary treatment Quality of life is closely linked with the concept of medical futility. In the context of the critically ill, dying patient, provision of care that cannot reverse their decline might well be described as futile. A more complete definition, proposed by Quinn, described a situation in which ‘treatment cannot within a reasonable probability

ANAESTHESIA AND INTENSIVE CARE MEDICINE 5:12

The cost of futile interventions is high in economic and emotional terms. In today’s economic climate appropriate rationing of funds with imposed limitations on treatment options are essential if healthcare resources are to be distributed fairly. Providing the financial means to maintain life-sustaining treatment in a seem-

416

© 2004 The Medicine Publishing Company Ltd

ETHICS

Landmark legal cases impacting on medical ethics Malette v Shulman (1990) 67 DLR (4th) 321. Canadian Courts Victim of a major road traffic accident, Mrs Malette’s condition was such that she required an emergency blood transfusion to save her life. Mrs Malette was a Jehovah’s Witness and carried a card indicating she would not wish to receive blood or blood products under any circumstances and was aware of the consequences. Dr Shulman knew of the existence of the card but overrode its terms in order to save her life. The court found in favour of Mrs Malette, stating ‘A doctor is not free to disregard a patient’s advance instructions any more than he would be free to disregard instructions given at the time of the emergency’. From this ruling the need for medical adherence was made absolutely clear, advocating that it is the patient who has the final say on whether to undergo a treatment, regardless of the doctor’s opinion.

Quinlan (1976) 355 A 2d 647, 70 NJ 10, US Supreme Court Karen Quinlan was in her twenties when she developed breathing difficulties after consuming alcohol and drugs. Her friends attempted to resuscitate her but on arrival at hospital she was found to have irreparable brain damage. Left in a persistent vegetative state she was kept alive on a mechanical ventilator. After 7 months her parents went to the courts to obtain an order to remove her from the ventilator. The court recognized the right of a competent person to refuse treatment or for a proxy to make treatment decisions on behalf of an incompetent person and authorized her removal from the ventilator. Karen Quinlan was able to breathe spontaneously and survived for a further 9 years. The Airedale NHS Trust and Quinlan decisions upheld the right to have life-sustaining treatments withheld or discontinued in patients in a persistent vegetative state. Decisions to discontinue lifesustaining treatments in these patients are fundamentally an application of medical futility.

Cruzan v Director, Missouri Department of Health (1990) 110 S Ct 2841. US Supreme Court Nancy Cruzan was left in a persistent vegetative state following severe injuries sustained in a car accident. The court demanded ‘clear and convincing’ evidence that she would have chosen not to survive in that condition before authorizing removal of treatment that could prolong her life. This included enteral nutrition. Later, additional evidence of her wishes was discovered, the feeding tube was removed and she died.

Glass 2004. European Court of Human Rights David Glass had severe brain injury from birth resulting in spastic quadriplegia, epilepsy and severe learning difficulties. Aged 13 years he was admitted to hospital with respiratory compromise necessitating mechanical ventilation. Against the wishes of his family a decision was made by doctors to withdraw ventilatory support and start an opioid infusion as it was felt he was dying. After some controversy, Mrs Glass was allowed to take her son home. He remains alive today. The ruling by the European Court of Human Rights stated that doctors who imposed treatment on a disabled child, in defiance of his mother’s objections, were in breach of his human rights. This ruling means that doctors who wish to withhold or withdraw treatment must first seek legal advice if consensus cannot be reached between themselves and the patient’s family.

Airedale NHS Trust v Bland [1993] 1 All ER 821. House of Lords Injured in the Hillsborough disaster, Anthony Bland survived for some years in a persistent vegetative state. His family and care team agreed that as his condition was irreversible it would be better if artificial feeding could be stopped in order that he might die. The House of Lords endorsed this decision, declaring it not to be unlawful for hydration and nutrition to be discontinued in this case.

2

ingly hopeless situation, at the expense of treating other patients who might receive greater benefit, could be considered a transgression. Even so, while clinician input into developing institutional policies governing scarce resources is to be encouraged, we must remain patient advocates and refrain from making treatment decisions based solely on financial reasons. ‹

KEY REFERENCES 1 British Medical Association (BMA). Advance statements about medical treatment. London: BMA, 1995. A full draft of the BMA’s code of practice relating to advance statements can be obtained from the BMA ethics website at: http://www.bma.org.uk/ap.nsf/Content/advertisements 2 British Medical Association (BMA). Decisions relating to cardiopulmonary resuscitation. London: BMA, 1999. 3 British Medical Association. Withholding and withdrawing lifeprolonging medical treatment. Guidance for decision making. London: BMA, 1999.

Acknowledgements The authors would like to thank Dr M Booth MB ChB, FRCA, MPhil, Consultant in Anaesthesia and Intensive Care Medicine at Glasgow Royal Infirmary, for helpful advice.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 5:12

4 General Medical Council (GMC). Withholding and withdrawing lifeprolonging treatments: Good practice in decision-making. London: GMC, 2002.

417

© 2004 The Medicine Publishing Company Ltd