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Ethical issues in resuscitation and intensive care medicine
ETHICS
Ethical issues in resuscitation and intensive care medicine
Learning objectives After reading this article, you should be able to: C understand the concepts of decision-making capacity, advanced directives and Lasting Power of Attorney, as they apply to intensive care patients C use four principles of biomedical ethics to guide your decision making in intensive care medicine and understand the limitations of these principles C describe an approach to rationing intensive care resources C appreciate the ethical dilemmas posed by the use of extracorporeal membrane oxygenation
Lucy Modra Andrew Hilton
Abstract Intensive care medicine is richly endowed with ethical dilemmas, including decision making on behalf of incompetent patients, withdrawal of treatment decisions and rationing of limited resources. Intensive care physicians need to be attuned to these ethical aspects of their practice. Beauchamp and Childress’ four principles of medical ethics provide a useful approach to ethical problems. However, the principles provide a framework rather than an ‘answer’. The advent of ECMO-CPR illustrates some common ethical dilemmas in intensive care medicine.
weighting is considerably diminished in the unconscious ICU patient, particularly in an emergency setting where the premorbid wishes of the patient are unknown.
Decision making in the ICU One of the unique ethical challenges of intensive care is that most ICU patients are unable to make decisions regarding their own care. Their autonomy, or ability to self-govern, is diminished by factors such as illness, sedation and communication impairments. Decisions made on behalf of an ICU patient are likely to impact significantly on the rest of their life. Thus, ICU patients are a vulnerable population, as defined by their inability to protect their own interests.
Keywords Advanced directives; autonomy; capacity; elderly; end of life care; futility; Lasting Power of Attorney; rationing Royal College of Anaesthetists CPD Matrix: 1F05; 1F01; 1E03; 2C06
Ethical problems are prominent in intensive care medicine because the stakes are high and the gains uncertain. The intensive care unit (ICU) can provide potentially life-saving treatments to critically ill patients, some of whom will not survive. Intensive care treatments can be painful, undignified or distressing to patients and stressful for families. Crucially, most ICU patients are unable to participate in the decision making regarding their own care. The intensive care physician therefore needs an approach to determining ethically acceptable treatments for individual patients, whilst fairly allocating expensive and limited critical care resources between all potential patients. Biomedical ethics and the law provide useful, but distinct, frameworks to guide the intensive care physician in these matters. In this article we outline important ethical issues in intensive care medicine, primarily using the principlist approach of Beauchamp and Childress (Box 1).1 Their framework of four ethical principles can be used to identify relevant ethical considerations within a scenario. In most ethically challenging clinical situations there is a tension between two or more of these principles. The principlist framework is not prescriptive: it does not offer a weighting to any of the principles. For a given clinical situation, each principle should be specified, then ranked and balanced accordingly. For example, autonomy has enjoyed a privileged position amongst the principles. However, its
Competence and capacity Diminished autonomy is described in terms of competence or capacity to make decisions. Strictly speaking, competence is a legal determination and decision-making capacity a medical determination. However, the two terms are often used interchangeably.2 Both terms refer to a person’s ability to understand information relevant to a particular decision, weigh options and communicate their choice. Competence is decision or task specific. For example, a person may not be competent to accept or refuse risky but potentially life-saving surgery, whilst still being competent to request an extra blanket. A competent adult may make autonomous choices that appear to go against their best interests, including the refusal of medical treatment. The Mental Capacity Act (2005 e England and Wales) states, ‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision.’3 However, a patient’s level of decision-making capacity should be proportionate to the gravity of the decision at hand.4 A patient who refuses
Ethical principles C
Lucy Modra FACEM MBBS(Hons) BMedSci GradDipArts(Phil) is an Intensive Care Registrar at Austin Hospital, Melbourne, Australia. Conflicts of interest: none declared.
C C C
Andrew Hilton MBBS FCICM FANZCA is a Senior Intensivist at Austin Hospital, Melbourne, Australia. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Autonomy: self-governance; respecting and supporting autonomous decisions Beneficence: promoting benefit Non-maleficence: avoiding harm Justice: fairly distributing benefits, risks and costs
Box 1
1
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Modra L, Hilton A, Ethical issues in resuscitation and intensive care medicine, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2015.10.006
ETHICS
patient’s personal and cultural values even if they are not legallyappointed surrogates.7 Clinicians should be wary of their own biases when making best interests determinations. For example, perceived quality of life changes with age and younger adults may fail to appreciate an elderly person’s enjoyment in life.8
potentially life-saving surgery should be able to demonstrate that they understand the potential implications of this decision, including their own death. In contrast, one would require little evidence that a patient requesting an extra blanket understood the implications of their request. Competence is a dynamic state, just like critical illness. Patients who were not competent to make decisions early in their ICU admission may regain competence as their condition improves. Appropriate use of sedation breaks and tools such as a tracheostomy speaking valve may be used to ascertain patient preferences in some situations.
Withdrawal of care, futility and end-of-life care Patients and their families hope that ICU treatment will allow them to return to a level of physical, mental and social functioning that is at least minimally acceptable to them. When these goals cannot be met, it is appropriate to consider withdrawing treatment and allowing the patient to die. Withdrawing treatment is a difficult decision because prognostication is uncertain and the patient usually cannot be consulted. Legally, doctors are not obliged to provide or persist with futile treatment. ‘Futile’ is an empty term unless used with reference to an explicit goal. For example, mechanical ventilation may not be futile with respect to a physiological goal of maintaining a normal carbon dioxide level. However, it may be futile in the face of a patient-oriented goal of recovering independent function. ‘Futile’ treatments are sometimes ‘futile’ with respect to immediately prolonging life; more often they are ‘futile’ with respect to returning the patient to a quality of life acceptable to them.9 Most ICU deaths now occur following withdrawal of treatment, rather than a catastrophic deterioration. Communicating with a patient’s family about withdrawal of treatment often requires repeated sensitive discussions over several days or longer. Intensive care physicians should be highly competent at providing end of life care, including symptom management and support for the patient’s family. Individual intensivists vary substantially in their approach to end of life decision making.10 This can manifest in the way treatment options are presented or whether end of life care options are presented at all. This is ethically problematic as the physician’s values are not morally relevant considerations in the treatment decision. Wilkinson and Truog suggest potential solutions to this problem including a collaborative or ‘team’ approach to decision making, and the use of advanced care planning.10
Proxy decision making and advanced directives When a patient cannot participate in decision making, the intensive care physician can promote their autonomy by seeking evidence of what the patient would choose in their current situation. The Mental Capacity Act (2005 e England and Wales) allows competent adults to pre-emptively record their healthcare wishes by appointing a Lasting Power of Attorney (LPA) or recording an Advanced Directive.3,a This is an important development as many people lose decision-making capacity before their death, but have clear wishes about their future healthcare and resuscitation. LPAs and Advanced Directives should only be used when the patient is not competent to make decisions regarding their care. A legally valid advanced refusal of life-saving treatment must be made in writing, signed and witnessed, and specifically state that the person understands that refusing such treatment will likely result in their death.3 A key problem with advanced directives is that it may be unclear whether the directive applies to the patient’s current situation. For this reason, advanced directives that specify acceptable goals of treatment may be more useful than advanced directives that refuse or request specific therapies.5 Organ donor registration is one important type of advanced directive. There is controversy over how this type of advanced directive operates, with many clinicians still seeking the assent of the registered organ donor’s family before proceeding to donation.6 In December 2015 Wales introduces an ‘opt-out’ donor registry, in which everyone is presumed to consent to organ donation unless they have registered an objection. This ‘consent by omission’ may be seen to carry less weight than written advanced directives.
Resource allocation Intensive care consumes a significant proportion of the healthcare budget. Rationing refers to the allocation of necessarily limited resources between potential patients. Intensive care physicians are frequently involved in bedside rationing decisions; for example, fairly allocating ICU beds between potential patients, or even allocating their own time and attention between patients.11 There is a tension between promoting beneficence for individual patients and promoting justice, or the fair division of healthcare resources between patients. A utilitarian approach to rationing attempts to maximize the overall health benefits achieved from the point of view of all potential patients. In situations of scarcity the clinician must estimate patients’ relative need for, and relative potential to derive enduring benefit from, ICU care. Such estimation is inexact and the clinician’s own biases or values may colour their decision making.
Best wishes determinations In the absence of evidence of the patient’s likely wishes, the clinician determines treatment based on the patient’s best interests. This paternalistic model of decision making prioritizes beneficence and non-maleficence ahead of patient autonomy. Despite its frequent pejorative use, paternalism is not a normative term. Paternalism can be an acceptable model of decision making, especially in emergency situations. In determining the patients’ best interests, the clinician is obliged to consider the views of the family, carers or loved ones.3 The family can effectively advocate for their relative, and also represent the
a
In Scotland, the Adults with Incapacity (Scotland) Act 2000 applies.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
2
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Modra L, Hilton A, Ethical issues in resuscitation and intensive care medicine, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2015.10.006
ETHICS
Summary
Ethical implications of extra-corporeal membrane oxygenation (ECMO) C
C
The four principles of biomedical ethics described by Beauchamp and Childress provide a useful approach to the complex ethical problems that arise in intensive care medicine. The clinician’s challenge lies in specifying the content of these principles as they pertain to a particular dilemma, and adjudicating between these considerations. The increasing ethical complexity of intensive care medicine is well illustrated by considering the ethics of undertaking extra-corporeal membrane oxygenation (ECMO) (Box 2). A
ECMO is an emerging technology with increasing caseload worldwide The ethical dilemmas posed by this new technology are similar to those associated with more established technology such as renal replacement therapy. They are: The ethics of undertaking highly invasive, expensive organ support in the face of uncertain prognosis When to offer ECMO and when to withdraw ECMO support How old is ‘too old’ for ECMO?
C
C
C
REFERENCES 1 Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th edn. Oxford: Oxford University Press, 2009. 2 British Medical Association. Advance decisions and proxy decision-making in medical treatment and research: guidance from the BMA’s Medical Ethics Department. London. 2007, http:// bma.org.uk/practical-support-at-work/ethics/mental-capacity (accessed 9 Aug 2015). 3 The Mental Capacity Act 2005 (England and Wales) http://www. legislation.gov.uk/ukpga/2005/9/section/1 (accessed 9 Aug 2015). 4 Buchanan A. Mental capacity, legal competence and consent to treatment. J R Soc Med 2004; 97: 415. 5 Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised control trial. BMJ 2010; 340: c1345. 6 Modra LJ, Hilton AK. Ethical issues in organ transplantation. Anaesth Intensive Care Med 2015; 16: 321e3. 7 Curtis JR, Vincent J-L. Ethics and end-of-life care for adults in the intensive care unit. Lancet 2010; 375: 1349. 8 Boumendil A, Somme D, Garrouste-Orgeas M, Guidet B. Should elderly patients be admitted to the intensive care unit? Intensive Care Med 2007; 33: 1252e62. 9 Gavrin JR. Ethical considerations at the end of life in the intensive care unit. Crit Care Med 2007; 35(suppl 2): S87. 10 Wilkinson DJC, Truog RD. The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive Care Med 2013; 39: 1128e32. 11 Truog RD, Brock DW, Cook DJ, et al. Rationing in the intensive care unit. Crit Care Med 2006; 34: 959. 12 Luce JM, White DB. A history of ethics and law in the intensive care unit. Crit Care Clin 2009; 25: 231. 13 Abrams DC, Prager K, Blinderman CD, Burkart KM, Brodie D. Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults. Chest 2014; 145: 876e82. 14 Crow S, Fischer A, Schears R. Extracorporeal life support: utilization, cost, controversy and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth 2009; 13: 183e91.
ECMO can be implemented in the event of cardiac arrest (E-CPR). The decision to implement E-CPR is difficult, as it must be made quickly based on limited clinical information Some are concerned E-CPR could become the default ‘standard of care’, with significant resource implications13 Undertaking randomised controlled trials of ECMO is ethically fraught as it is unclear if true clinical equipoise exists.14 In the case of E-CPR, patients randomised to standard advanced life support would have an extremely high mortality.
Box 2
Ideally, all patients who have a genuine need for ICU care are accommodated, although this leads to a dilution of resources between more patients-itself a form of rationing. Some patients are inevitably excluded from the ICU because their immediate needs are judged to be relatively less than other potential patients at the time. Communicating this decision to the patient and their family is extremely difficult. Luce and White emphasize that it is deceptive to claim that a patient has nothing to gain from ICU admission (‘not sick enough’ or ‘too sick’) when in fact they have been denied ICU admission due to a shortage of beds.12 However, openly disclosing rationing decisions to patients and families may lead to significant anger or distress, particularly if the patient dies after being denied access to the ICU. Given the increasing demand for intensive care beds, it is important to ensure that people who do not want ICU admission have the opportunity to formally record their wishes prior to critical illness. Advanced care planning encompasses a facilitated discussion between a patient and their family about end of life care, with the opportunity to appoint a surrogate or make an advanced directive. This important intervention not only improves patient and family satisfaction with end of life care, but also decreases the patient’s likelihood of dying in ICU.5
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
3
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Modra L, Hilton A, Ethical issues in resuscitation and intensive care medicine, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2015.10.006
Ethical issues in resuscitation and intensive care medicine
Learning objectives After reading this article, you should be able to: C understand the concepts of decision-making capacity, advanced directives and Lasting Power of Attorney, as they apply to intensive care patients C use four principles of biomedical ethics to guide your decision making in intensive care medicine and understand the limitations of these principles C describe an approach to rationing intensive care resources C appreciate the ethical dilemmas posed by the use of extracorporeal membrane oxygenation
Lucy Modra Andrew Hilton
Abstract Intensive care medicine is richly endowed with ethical dilemmas, including decision making on behalf of incompetent patients, withdrawal of treatment decisions and rationing of limited resources. Intensive care physicians need to be attuned to these ethical aspects of their practice. Beauchamp and Childress’ four principles of medical ethics provide a useful approach to ethical problems. However, the principles provide a framework rather than an ‘answer’. The advent of ECMO-CPR illustrates some common ethical dilemmas in intensive care medicine.
weighting is considerably diminished in the unconscious ICU patient, particularly in an emergency setting where the premorbid wishes of the patient are unknown.
Decision making in the ICU One of the unique ethical challenges of intensive care is that most ICU patients are unable to make decisions regarding their own care. Their autonomy, or ability to self-govern, is diminished by factors such as illness, sedation and communication impairments. Decisions made on behalf of an ICU patient are likely to impact significantly on the rest of their life. Thus, ICU patients are a vulnerable population, as defined by their inability to protect their own interests.
Keywords Advanced directives; autonomy; capacity; elderly; end of life care; futility; Lasting Power of Attorney; rationing Royal College of Anaesthetists CPD Matrix: 1F05; 1F01; 1E03; 2C06
Ethical problems are prominent in intensive care medicine because the stakes are high and the gains uncertain. The intensive care unit (ICU) can provide potentially life-saving treatments to critically ill patients, some of whom will not survive. Intensive care treatments can be painful, undignified or distressing to patients and stressful for families. Crucially, most ICU patients are unable to participate in the decision making regarding their own care. The intensive care physician therefore needs an approach to determining ethically acceptable treatments for individual patients, whilst fairly allocating expensive and limited critical care resources between all potential patients. Biomedical ethics and the law provide useful, but distinct, frameworks to guide the intensive care physician in these matters. In this article we outline important ethical issues in intensive care medicine, primarily using the principlist approach of Beauchamp and Childress (Box 1).1 Their framework of four ethical principles can be used to identify relevant ethical considerations within a scenario. In most ethically challenging clinical situations there is a tension between two or more of these principles. The principlist framework is not prescriptive: it does not offer a weighting to any of the principles. For a given clinical situation, each principle should be specified, then ranked and balanced accordingly. For example, autonomy has enjoyed a privileged position amongst the principles. However, its
Competence and capacity Diminished autonomy is described in terms of competence or capacity to make decisions. Strictly speaking, competence is a legal determination and decision-making capacity a medical determination. However, the two terms are often used interchangeably.2 Both terms refer to a person’s ability to understand information relevant to a particular decision, weigh options and communicate their choice. Competence is decision or task specific. For example, a person may not be competent to accept or refuse risky but potentially life-saving surgery, whilst still being competent to request an extra blanket. A competent adult may make autonomous choices that appear to go against their best interests, including the refusal of medical treatment. The Mental Capacity Act (2005 e England and Wales) states, ‘A person is not to be treated as unable to make a decision merely because he makes an unwise decision.’3 However, a patient’s level of decision-making capacity should be proportionate to the gravity of the decision at hand.4 A patient who refuses
Ethical principles C
Lucy Modra FACEM MBBS(Hons) BMedSci GradDipArts(Phil) is an Intensive Care Registrar at Austin Hospital, Melbourne, Australia. Conflicts of interest: none declared.
C C C
Andrew Hilton MBBS FCICM FANZCA is a Senior Intensivist at Austin Hospital, Melbourne, Australia. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
Autonomy: self-governance; respecting and supporting autonomous decisions Beneficence: promoting benefit Non-maleficence: avoiding harm Justice: fairly distributing benefits, risks and costs
Box 1
1
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Modra L, Hilton A, Ethical issues in resuscitation and intensive care medicine, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2015.10.006
ETHICS
patient’s personal and cultural values even if they are not legallyappointed surrogates.7 Clinicians should be wary of their own biases when making best interests determinations. For example, perceived quality of life changes with age and younger adults may fail to appreciate an elderly person’s enjoyment in life.8
potentially life-saving surgery should be able to demonstrate that they understand the potential implications of this decision, including their own death. In contrast, one would require little evidence that a patient requesting an extra blanket understood the implications of their request. Competence is a dynamic state, just like critical illness. Patients who were not competent to make decisions early in their ICU admission may regain competence as their condition improves. Appropriate use of sedation breaks and tools such as a tracheostomy speaking valve may be used to ascertain patient preferences in some situations.
Withdrawal of care, futility and end-of-life care Patients and their families hope that ICU treatment will allow them to return to a level of physical, mental and social functioning that is at least minimally acceptable to them. When these goals cannot be met, it is appropriate to consider withdrawing treatment and allowing the patient to die. Withdrawing treatment is a difficult decision because prognostication is uncertain and the patient usually cannot be consulted. Legally, doctors are not obliged to provide or persist with futile treatment. ‘Futile’ is an empty term unless used with reference to an explicit goal. For example, mechanical ventilation may not be futile with respect to a physiological goal of maintaining a normal carbon dioxide level. However, it may be futile in the face of a patient-oriented goal of recovering independent function. ‘Futile’ treatments are sometimes ‘futile’ with respect to immediately prolonging life; more often they are ‘futile’ with respect to returning the patient to a quality of life acceptable to them.9 Most ICU deaths now occur following withdrawal of treatment, rather than a catastrophic deterioration. Communicating with a patient’s family about withdrawal of treatment often requires repeated sensitive discussions over several days or longer. Intensive care physicians should be highly competent at providing end of life care, including symptom management and support for the patient’s family. Individual intensivists vary substantially in their approach to end of life decision making.10 This can manifest in the way treatment options are presented or whether end of life care options are presented at all. This is ethically problematic as the physician’s values are not morally relevant considerations in the treatment decision. Wilkinson and Truog suggest potential solutions to this problem including a collaborative or ‘team’ approach to decision making, and the use of advanced care planning.10
Proxy decision making and advanced directives When a patient cannot participate in decision making, the intensive care physician can promote their autonomy by seeking evidence of what the patient would choose in their current situation. The Mental Capacity Act (2005 e England and Wales) allows competent adults to pre-emptively record their healthcare wishes by appointing a Lasting Power of Attorney (LPA) or recording an Advanced Directive.3,a This is an important development as many people lose decision-making capacity before their death, but have clear wishes about their future healthcare and resuscitation. LPAs and Advanced Directives should only be used when the patient is not competent to make decisions regarding their care. A legally valid advanced refusal of life-saving treatment must be made in writing, signed and witnessed, and specifically state that the person understands that refusing such treatment will likely result in their death.3 A key problem with advanced directives is that it may be unclear whether the directive applies to the patient’s current situation. For this reason, advanced directives that specify acceptable goals of treatment may be more useful than advanced directives that refuse or request specific therapies.5 Organ donor registration is one important type of advanced directive. There is controversy over how this type of advanced directive operates, with many clinicians still seeking the assent of the registered organ donor’s family before proceeding to donation.6 In December 2015 Wales introduces an ‘opt-out’ donor registry, in which everyone is presumed to consent to organ donation unless they have registered an objection. This ‘consent by omission’ may be seen to carry less weight than written advanced directives.
Resource allocation Intensive care consumes a significant proportion of the healthcare budget. Rationing refers to the allocation of necessarily limited resources between potential patients. Intensive care physicians are frequently involved in bedside rationing decisions; for example, fairly allocating ICU beds between potential patients, or even allocating their own time and attention between patients.11 There is a tension between promoting beneficence for individual patients and promoting justice, or the fair division of healthcare resources between patients. A utilitarian approach to rationing attempts to maximize the overall health benefits achieved from the point of view of all potential patients. In situations of scarcity the clinician must estimate patients’ relative need for, and relative potential to derive enduring benefit from, ICU care. Such estimation is inexact and the clinician’s own biases or values may colour their decision making.
Best wishes determinations In the absence of evidence of the patient’s likely wishes, the clinician determines treatment based on the patient’s best interests. This paternalistic model of decision making prioritizes beneficence and non-maleficence ahead of patient autonomy. Despite its frequent pejorative use, paternalism is not a normative term. Paternalism can be an acceptable model of decision making, especially in emergency situations. In determining the patients’ best interests, the clinician is obliged to consider the views of the family, carers or loved ones.3 The family can effectively advocate for their relative, and also represent the
a
In Scotland, the Adults with Incapacity (Scotland) Act 2000 applies.
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
2
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Modra L, Hilton A, Ethical issues in resuscitation and intensive care medicine, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2015.10.006
ETHICS
Summary
Ethical implications of extra-corporeal membrane oxygenation (ECMO) C
C
The four principles of biomedical ethics described by Beauchamp and Childress provide a useful approach to the complex ethical problems that arise in intensive care medicine. The clinician’s challenge lies in specifying the content of these principles as they pertain to a particular dilemma, and adjudicating between these considerations. The increasing ethical complexity of intensive care medicine is well illustrated by considering the ethics of undertaking extra-corporeal membrane oxygenation (ECMO) (Box 2). A
ECMO is an emerging technology with increasing caseload worldwide The ethical dilemmas posed by this new technology are similar to those associated with more established technology such as renal replacement therapy. They are: The ethics of undertaking highly invasive, expensive organ support in the face of uncertain prognosis When to offer ECMO and when to withdraw ECMO support How old is ‘too old’ for ECMO?
C
C
C
REFERENCES 1 Beauchamp TL, Childress JF. Principles of biomedical ethics. 6th edn. Oxford: Oxford University Press, 2009. 2 British Medical Association. Advance decisions and proxy decision-making in medical treatment and research: guidance from the BMA’s Medical Ethics Department. London. 2007, http:// bma.org.uk/practical-support-at-work/ethics/mental-capacity (accessed 9 Aug 2015). 3 The Mental Capacity Act 2005 (England and Wales) http://www. legislation.gov.uk/ukpga/2005/9/section/1 (accessed 9 Aug 2015). 4 Buchanan A. Mental capacity, legal competence and consent to treatment. J R Soc Med 2004; 97: 415. 5 Detering KM, Hancock AD, Reade MC, Silvester W. The impact of advance care planning on end of life care in elderly patients: randomised control trial. BMJ 2010; 340: c1345. 6 Modra LJ, Hilton AK. Ethical issues in organ transplantation. Anaesth Intensive Care Med 2015; 16: 321e3. 7 Curtis JR, Vincent J-L. Ethics and end-of-life care for adults in the intensive care unit. Lancet 2010; 375: 1349. 8 Boumendil A, Somme D, Garrouste-Orgeas M, Guidet B. Should elderly patients be admitted to the intensive care unit? Intensive Care Med 2007; 33: 1252e62. 9 Gavrin JR. Ethical considerations at the end of life in the intensive care unit. Crit Care Med 2007; 35(suppl 2): S87. 10 Wilkinson DJC, Truog RD. The luck of the draw: physician-related variability in end-of-life decision-making in intensive care. Intensive Care Med 2013; 39: 1128e32. 11 Truog RD, Brock DW, Cook DJ, et al. Rationing in the intensive care unit. Crit Care Med 2006; 34: 959. 12 Luce JM, White DB. A history of ethics and law in the intensive care unit. Crit Care Clin 2009; 25: 231. 13 Abrams DC, Prager K, Blinderman CD, Burkart KM, Brodie D. Ethical dilemmas encountered with the use of extracorporeal membrane oxygenation in adults. Chest 2014; 145: 876e82. 14 Crow S, Fischer A, Schears R. Extracorporeal life support: utilization, cost, controversy and ethics of trying to save lives. Semin Cardiothorac Vasc Anesth 2009; 13: 183e91.
ECMO can be implemented in the event of cardiac arrest (E-CPR). The decision to implement E-CPR is difficult, as it must be made quickly based on limited clinical information Some are concerned E-CPR could become the default ‘standard of care’, with significant resource implications13 Undertaking randomised controlled trials of ECMO is ethically fraught as it is unclear if true clinical equipoise exists.14 In the case of E-CPR, patients randomised to standard advanced life support would have an extremely high mortality.
Box 2
Ideally, all patients who have a genuine need for ICU care are accommodated, although this leads to a dilution of resources between more patients-itself a form of rationing. Some patients are inevitably excluded from the ICU because their immediate needs are judged to be relatively less than other potential patients at the time. Communicating this decision to the patient and their family is extremely difficult. Luce and White emphasize that it is deceptive to claim that a patient has nothing to gain from ICU admission (‘not sick enough’ or ‘too sick’) when in fact they have been denied ICU admission due to a shortage of beds.12 However, openly disclosing rationing decisions to patients and families may lead to significant anger or distress, particularly if the patient dies after being denied access to the ICU. Given the increasing demand for intensive care beds, it is important to ensure that people who do not want ICU admission have the opportunity to formally record their wishes prior to critical illness. Advanced care planning encompasses a facilitated discussion between a patient and their family about end of life care, with the opportunity to appoint a surrogate or make an advanced directive. This important intervention not only improves patient and family satisfaction with end of life care, but also decreases the patient’s likelihood of dying in ICU.5
ANAESTHESIA AND INTENSIVE CARE MEDICINE --:-
3
Crown Copyright Ó 2015 Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Modra L, Hilton A, Ethical issues in resuscitation and intensive care medicine, Anaesthesia and intensive care medicine (2016), http://dx.doi.org/10.1016/j.mpaic.2015.10.006