More ethical care possible with long-term ICU patients?
More ethical care possible with long-term ICU patients?
History of cardiac arrest has ethical implications
The history of cardiac arrest as an indication for resuscitation is "loaded with implications for current standards of care," says Daniel Brauner, MD, associate professor of medicine at the University of Chicago. At one point in time, resuscitation was used only in very limited instances, he explains.
"The resuscitation we practice now can really be traced back to open cardiac massage, which was first used at the turn of the last century and through the 1940s almost exclusively for people whose hearts had stopped in the OR, usually as a consequence of anesthesia," he says.
Open resuscitation became increasingly popular and was moved out of the operating room in the 1950s, as the indications for the procedure expanded to include those with other, mostly iatrogenic or else primarily cardiac, causes for their heart to stop, adds Brauner. "With the move to closed chest compression in the 1960s, it became increasingly widespread," he says. "In a few years, it was the standard of care for nearly everybody who died in the hospital."
Default status of CPR
When the do not resuscitate order was established in the 1970s, this "sealed the default status" of cardiopulmonary resuscitation (CPR), says Brauner, by opting everyone in who didn't opt out. "The default application of CPR displaced the primacy of the question: Is this the best thing for my patient at this moment?' and replaced it with faith in a larger project that promised to, and did, save some patients through the prompt and skillful application of CPR," he says.
Doctors were then charged with convincing patients who would not benefit from the procedure to opt out, says Brauner, which served as a model for the advance directive paradigm. "Other procedures that would no longer benefit patients became defaults whether or not they would help the patient," he adds. "Of course, there is always some uncertainty. That needs to be acknowledged." (See related stories on ethical concerns with do not resuscitate orders, and identifying goals for ethical care, below.)
What's needed, argues Brauner, is "better present care. This involves a higher level of honesty from physicians about what therapies may actually help and which ones won't, along with a willingness to discuss prognosis." Some patients may not want to be considered for any non-palliative care, and that wish should be respected, but the vast majority of patients want care that has a reasonable chance of helping, and not therapies like CPR at the end of life, which doesn't, he says.
Less attention should be paid to the patient's resuscitation status, argues Brauner. "This won't help in the vast majority of patients who are dying, and is often used as a signifier for level of aggressiveness of care, even though it should only speak to the application of CPR. It should actually be the last question," he explains.1
Brauner acknowledges that CPR is "a great therapy for unexpected iatrogenic events and primarily cardiac-related arrests. But more attention should be paid to the real issues that arise in every patient's disease trajectory. We need fewer general guidelines, and more attention to the individual circumstances of each patient."
Reference
- Brauner DJ. Later than sooner: A proposal for ending the stigma of premature do-not-resuscitate orders. J Am Geriatrics Society 2011;59(12):2366-2368.
Source
- Daniel Brauner, MD, Associate Professor of Medicine, University of Chicago. Phone: (773) 702-6985. Email: [email protected].
- Paul B. Hofmann, DrPH, FACHE, President, Hofmann Healthcare Group, Moraga, CA. Phone: (925) 247-9700. Email: [email protected].
ID goals in ICU for more ethical care When conducting ethics rounds in intensive care units (ICUs), Paul B. Hofmann, DrPH, FACHE, president of Hofmann Healthcare Group, Moraga, CA, often encounters significant ethical issues often associated with longer-stay patients. "Consequently, I strongly encourage hospitals to develop guidelines to assist staff in addressing these issues," he says. Hofmann is currently assisting a hospital in developing guidelines for improved ICU management of longer-stay patients, which describe similarities that characterize these patients and identify goals for ethical care. Among the goals he cites are:
Hofmann says the guidelines should be developed by a multidisciplinary team and be reviewed and approved in the same manner as other clinical guidelines and policies. He also recommends a process be designed to monitor use of the guidelines and to evaluate their effectiveness. |
DNR discussion: Is it an "absurd choice"? Consider patient as a whole A discussion about whether to choose to have a do not resuscitate (DNR) order is a typical starting point for a provider to have a "goals of care" conversation with a patient, says Daniel Brauner, MD, associate professor of medicine at University of Chicago, and this is often the moment when patients are finally given their prognosis. "They are given this choice, which has become a hallmark of ethical medicine. But for many patients, it's an absurd one — do you want CPR that probably won't help you, or do you want us to let you die?" Brauner says. "If they make the wrong decision, doctors may call ethics or palliative care consults to help patients come to the "right" decision. The patient is supposed to have the choice, but it's a bit of a charade." The "goals of care" discussion, during which the DNR question is often discussed, becomes the moment when doctors finally admit their inability to offer any meaningful non-palliative therapy, says Brauner. "It is generally thought of as a moment of patient autonomy, but this may be more illusory," he adds. "In some ways, it's analogous to the mob selling protection. We promise to protect patients from ourselves, if they agree to opt out of the default therapies that we will subject them to regardless if we think they will help them or not." In many cases, the price patients pay is to give up being considered for potentially aggressive care that may actually help them, says Brauner. "The problem is that what these actual therapies may be in the future is hard to predict," he says. "Instead, patients and their families are forced into a binary choice — to pick either aggressive or palliative care in advance." Patients are being offered choices that really aren't relevant, since many of the therapies offered, like resuscitation, won't help the vast majority of people, says Brauner. "They may languish a little longer on a ventilator. But CPR won't alter the ultimate outcome for most patients," he says. "By forcing patients to opt out of these non-effective therapies, we automatically opt everybody else in. The current model is that default therapies will be applied based on isolated indications: CPR for cardiac arrest, dialysis for renal failure, feeding tube for not eating, and intubation for respiratory failure." Patients are subjected to these interventions by default based on isolated indications, instead of considering the patient as a whole at a particular point in their disease trajectory, says Brauner. "Part of the reason is that doctors fear they'll be viewed as withholding therapies, and may be uncomfortable admitting they are unable to do anything therapeutic in the non-palliative sense, for the patient," he adds. Brauner says that in order to truly improve the current system, physicians have to be more truthful about the limitations of what medicine has to offer. "Many patients come with the expectation that any problem can be fixed, and this is reinforced by the rhetoric and advertising of medicine today," he says. "Patients continue to receive everything' until it becomes obvious that our aggressive therapies are not working." It is at that point that the intensivist or hospitalist may bring in the palliative care team. "The meteoric rise of palliative care comes out of that need. It takes better care of people because the default model of care exposes patients to unnecessary harm," says Brauner, adding that another problem with the advance directive model is that patients can't really know how aggressive they want their care to be until they know the chances of it actually helping them, and doctors will frequently not know this until the situation arises. "The whole idea of having to decide beforehand what you would want in the future, for patients that may still benefit from medical interventions, is an impossible situation." |
The history of cardiac arrest as an indication for resuscitation is "loaded with implications for current standards of care," says Daniel Brauner, MD, associate professor of medicine at the University of Chicago. At one point in time, resuscitation was used only in very limited instances, he explains.
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