ACEP News - June 2008 - (Page 16)

ACEP NEWS • J U N E 2 0 0 8 NEWS B Y W A LT E R L I M E H O U S E , M . D . FROM THE COLLEGE course, and if pulseless electrical activity occurs, pronounce her dead. Suffering we can treat; she is sedated already. No duty now to turn off the AICD before the son, substituting for patient, consents. “Maybe,” you answer the son’s question and leave on the AICD. 05:55—The sister arrives and sits with her mother, her brother, and the chaplain. 06:15—The brother says turn off the AICD and ventilator now. The sister says thank you. The GRIEV_ING protocol includes gathering, using available resources, identifying the provider, the patient, and family knowledge of the patient’s condition, educating the family about immediate events, verifying current condition, allowing space for the family to absorb the situation, and inquiring about family questions. The protocol has other practical elements (nut and bolts). While the family sits with this imminently dying mother, a health care team member may start procedures to discuss any organ transplant options. After the patient dies, the chaplain can assist with funeral arrangements. One can give contact information and offer to answer any later questions.1 Clinician perspectives on medically ineffective treatment must recognize that stopping treatment because of quantitative or qualitative ineffectiveness may fail to address patient values. Quantitative ineffectiveness implies less than a 1% chance of improvement; qualitative ineffectiveness only preserves permanent unconsciousness or fails to end dependence upon intensive care. However, patient values may include intermediate subjectively important, potentially achievable goals. Recognizing these values may lead to negotiated compromise, respecting both patient and health care provider autonomy, and providing the fairest outcome for all.2 ■ References 1. “Delivering the News with Compassion,” the GRIEV_ING death notification protocol. Found at www.acep.org/practres.aspx by clicking on “GME,” then “faculty resources.” 2. C. Taylor, “Medical Futility and Nursing.” Journal of Nursing Scholarship. 1995;27:301-6. DR. LIMEHOUSE is a member of ACEP’s Ethics Committee. He is an assistant professor of emergency medicine at the Medical University of South Carolina in Charleston. Futility Is in the Eye of the Beholder This case essay models use of the GRIEV_ING death notification protocol, supported by ACEP, in the setting of an imminently dying patient and offers differing perspectives on what constitutes medically ineffective treatment. 23:15—A 79-year-old woman arrives via private auto. She is diabetic with two prior myocardial infarctions, has an indwelling AICD, and presents with moderate to severe chest pain for 2 hours, similar to her prior MIs. Her vital signs are initially stable. The chest x-ray shows cardiomegaly, with AICD wires intact, mild pulmonary vascular congestion, and normal mediastinum. The electrocardiogram shows sinus rhythm with long-standing left bundle branch block. The bedside troponin levels are normal. You are called to the bedside when she develops wide-complex tachycardia, hypotension, and syncope. The AICD fires, and a sinus rhythm results. The third time this happens, the patient doesn’t awaken, develops snoring respirations, and requires endotracheal intubation and ventilation. Although her blood pressure gradually declines, the patient regains a palpable pulse after each episode. She has not required chest compressions. 01:45— Three more episodes of ventricular tachycardia or fibrillation ensue; the AICD converts each episode to sinus rhythm. The bedside troponin level is now elevated at 0.13. She is on a lidocaine infusion and requires dobutamine and nitroglycerin to sustain blood pressure and reduce pulmonary congestion. The ICUs are full, so this patient is boarding in the ED, with the cardiology fellow at the bedside. 03:10—The AICD has converted two more episodes of wide-complex tachycardia. The patient is on the maximum dose of lidocaine when the cardiology fellow comes to you. “The AICD is working properly, but this can’t go on much longer,” he says. “I want to shut off the AICD. What do you think?” Meanwhile back in “Introduction to Clinical Ethics”: Do good, do no harm, allowing for autonomy in fairness to all. OK, autonomy. Is Ms. X awake and capable of decision-making? No. Any family here? Grab the chaplain and find out. The nurses have taken the son of Ms. X and the son’s wife to a conference room. After you introduce yourself, the cardiology fellow, and chaplain, Mr. X affirms for you that he is the patient’s son, that his one sister is en route from a city 6 hours away, and that his father is dead. You elicit that he understands his mother had experienced several hours of chest pain prior to arriving, that she has known coronary disease, that she wanted an AICD to help with cardiac rhythm problems, and that she is not doing well now. Confirming Ms. X is not doing well, you relate, along with the cardiology fellow that, while she is tenuously stable, she also is dying. The AICD is doing its job but prolonging her suffering and dying. Silence. 03:55— The nurse calls the cardiology fellow back to bedside—the AICD has fired twice more and converted another episode of wide-complex tachycardia to sinus rhythm. Silence. Yes, says the son, but may it also keep her alive until his sister gets here? Back to autonomy. Did Ms. X talk with you about what to do as her life ends? What would your mother want done now? The son confirms the absence of a living will or health care power of attorney. But he knows she accepted the AICD to help with her cardiac rhythm, that she talked about dying at home or at least with family, and that if at all possible, she would want his sister at her bedside when she died. The cardiology fellow, you say, believes we should turn off the AICD to stop any suffering caused by the repeated firing. You explain that the AICD will not fix her condition and repeated firing may damage her heart further, and that the cardiologist believes that this is medically ineffective and should stop. Silence. He says yes, she is dying, but may it keep his mother alive until his sister arrives? Intro to clinical ethics. Do no harm— do people accept risks to reach a goal? Do good—what good may the sister’s arriving provide? Autonomy—her son, her available surrogate, affirms what the patient would wish. What of fairness—does allowing the AICD to continue violate the cardiology fellow’s professional integrity? 04:15—You invite the son, his wife, and the chaplain into the treatment room to sit with the patient. The AICD fires and sinus rhythm returns. The patient is now hypotensive, despite vasopressors. You take the fellow aside, informing him of the son’s request and the patient’s wishes. The fellow protests—why continue what prolongs her dying? Yes, but is prolonging her life for 2 or 3 hours possible? Intro to ethics. A physician has no obligation to provide medically ineffective treatment—how about treatment to reach a psychosocial objective? No obligation to attempt resuscitation—allow the pathophysiology to follow its natural eACLS™ The smart choice for initial and refresher ACLS training. eACLS™, brought to you by the American College of Emergency Physicians (ACEP), provides the opportunity to participate in ACLS training in both traditional classroom settings and online. This highly interactive course has two components: didactic and skills. Complete the didactic portion in the classroom or at your own pace using the online program. Complete the skills with an eACLS™ Course Coordinator and you are eligible to receive a nationally recognized course completion card. 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ACEP News - June 2008 Contents News - Time to Move Tricks of the Trade - Revealing Tips Focus On - Dengue Fever Practice Trends - EMTALA Results

ACEP News - June 2008

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