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March 2001
Volume 65 |
Number 3
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| Prospective
Planning for Interventions in Patients Near the End of Life |
Carl C. Hug, Jr., M.D.,
Ph.D.
Committee on Ethics
The marvels of science and technology applied to medicine have
extended life expectancy and created an ever-expanding number
of survivors of chronic disease and acute, life-threatening illnesses.
When these survivors are threatened with a new disease or an acute
exacerbation of their chronic illness, there is a strong inclination
to intervene because of the availability of numerous therapeutic
options, the high expectations of medicine and the demand to do
something!
At the same time, there is growing concern among U.S. citizens
about living with disability and pain, ending up in a nursing
home, being abandoned, being dependent on machines and extending
biological life (lung and heart function) but not meaningful life.
As Morrie Schwartz said to Ted Koppel on Nightline: For me, Ted,
living means I can be responsive to the other person. It means
I can show my emotions and my feelings. Talk to them. Feel with
them. When that is gone, Morrie is gone.
Physicians, including anesthesiologists, are frequently confronted
with dilemmas about the appropriateness of risky interventions
and the balance of potential benefits versus risks. The risks
include not only death and the pain and suffering related to the
intervention but, even more importantly, the burdens of lingering
disability, loss of independence and a poor quality of life.
Until the 1960s, the physician made decisions about therapeutic
interventions with guidance from the Hippocratic principles of
beneficence (do good) and nonmaleficence (do no harm). But in
the last 40 or so years, the principle of autonomy has become
a mainstay of medical ethics. Autonomy is derived from the Greek
autos (self) and nomos (rule). Now the patient makes decisions
with the guidance and agreement of the physician.
It seems that two questions bring the critical issues of medical
decision-making into focus for the patient as well as for the
physician, family members and friends: 1) What are your goals
for this intervention? 2) What risks and burdens are unacceptable
to you?
Medicine has been described as the science of uncertainty and
the art of probability. We have available all sorts of statistics
on which to base predictions of outcomes. Seldom are the statistics
so clear-cut as to make life-and-death decisions easy. Of course,
they can be presented in a way that makes for no-brainer decisions:
95 percent of patients have their hearts fixed with this operation;
only 5 percent of patients die. Who would not take those odds?
But what about complications such as kidney failure and sepsis
that are listed in fine print on the consent form? Each complication
has a risk statistic, and the compilation of all risks of all
potential complications is mind-boggling to patients and physicians
alike. Seldom is there a certainty of a bad outcome. Hence, there
is always hope until the actual intervention is made on each individual
patient. The only way to be sure is to try and see. A therapeutic
trial offers the following answer to the two questions posed above:
If your goals for this intervention are unlikely to be realized,
if burdensome and unacceptable disabilities are likely to persist,
then we will allow nature to take its course. We will withdraw
life-supporting measures.
It should be recognized that there are no significant ethical,
moral or legal distinctions between withholding versus withdrawing
life-supporting measures in the critically ill patient near the
end of life. If anything, the moral burden of proof may be heavier
when the decision is made to withhold treatments than when it
is to withdraw treatments.
Surgical Trial
A surgical trial scenario might read as follows: An 80-year-old
woman develops angina pectoris and mild heart failure that impairs
her self-sufficiency. She is fiercely independent and fears permanent
confinement to a nursing home. Coronary bypass is agreed to with
the goal of relieving her symptoms and maintaining her self-sufficiency.
She understands and accepts the use of life-supporting measures
necessary to get her through the operation, which will include
cardiopulmonary bypass, hemodynamic resuscitation, mechanical
ventilation and other intensive care measures. She accepts these
standard routines of perioperative care for the cardiac surgical
patient for a time sufficient to allow recovery from anesthesia
and the acute insults of surgery. But once it is clear that she
has sustained a complication that is as disabling as her current
symptoms, all extraordinary measures will be stopped and nature
will be allowed to take its course.
The intent is to restore her self-sufficiency and to reduce or
eliminate her pain and dyspnea. But if the effort fails, the patient
(or more likely her proxy) is free to refuse further treatment
and to have life-supporting extraordinary measures (including
such aids as a feeding tube) withdrawn. This surgical trial is
not a form of euthanasia or physician-assisted suicide.
The key to appropriate implementation of a surgical trial is
thorough preoperative planning by the patient, the health care
proxy and physicians and surgeons who will be involved in the
patient's care. All must understand the patient's wishes in terms
of the goals to be achieved and the burdens to be avoided. These
should be accurately described in the patient’s medical record
and communicated to the family members and friends by the proxy
and to the nurses and other care givers by the physician. Continuing
communication about the patient's progress, or lack thereof, is
essential. The patient or proxy should be informed about any significant
complication as soon as it arises, and a decision should be made
either to treat (perhaps on a try-and-see basis) or not to treat
it. The decision to forego further interventions is virtually
a do-not-resuscitate (DNR) decision. In some states, specific
permission is required from the proxy to enter a DNR order on
the chart.
| Medicine
has been described as the science of uncertainty and the art
of probability. We have available all sorts of statistics
on which to base predictions of outcomes. Seldom are the statistics
so clear-cut as to make life-and-death decisions easy. |
But remember that DNR has another meaning: Do Not Relax.
In other words, all the existing, agreed-upon life-supporting
and comfort care measures need to be continued to the very end,
and the family members and friends need reassurance that the patient
will not be abandoned. When it is clear that the complication
or the patient's deterioration precludes achievement of the patient's
goals and/or imposes a burden that the patient previously declared
to be unacceptable, then withdrawal of life-support measures is
appropriate.
Prospective planning of surgical trials may take considerable
time and effort on the physician's part, but it has the advantages
of 1) respecting the patient's autonomy, 2) making life and death
decisions easier or at least more acceptable to all concerned,
3) reducing feelings of guilt and uncertainty among family members
and 4) avoiding recrimination against the proxy who has to make
the decisions.
Sooner or later, every one of us will face these dilemmas for
our patients, family members and friends, and for ourselves. Although
we prepare for death in regard to insurance, last wills and testaments,
tax-avoiding trusts, and the like, it would be prudent to spend
time informing ourselves and our loved ones about how we wish
to be cared for at the end of life. We can designate a health
care proxy by executing a legal document giving that person durable
power of attorney for health care decisions on our behalf should
we become incompetent; and it may be worthwhile to draw up a so-called
living will.
Morrie Schwartz said: Everyone knows they're going to die, but
nobody believes it. If we did, we would do things differently.
To know you’re going to die and to be prepared for it at any time:
That's better.
Bibliography:
Albom M. Tuesdays with Morrie. New York: Bantam Doubleday
Dell; 1997.
Hug CC Jr. Rovenstine Memorial Lecture. Patient values, Hippocrates,
science, and technology: What we (physicians) can do versus what
we should do for the patient. Anesthesiology. 2000; 93:556-564.
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Carl
C. Hug, Jr., M.D., Ph.D., is Professor of Anesthesiology and
Pharmacology, Emory University School of Medicine, and Attending
Physician in Cardiothoracic Anesthesiology and Intensive Care,
Emory University Hospital, Atlanta, Georgia. |
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