A 50 year old man is brought into the Emergency Department after acute flexion injury to the neck while surfing.  He is unable to move both arms or kgs and has a sensory level at C4·5.   He ls a heavy smoker with a history of chronic bronchitis.

(e) At 21 days he is ventilator dependent. He appears frustrated and angry. His wife be ves that he wished to die and she requests withdrawal of therapy. What will you do?

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College Answer

(e) This ethical and communication question requires resort to basic principles. This is an open scenario because clinical details helping with prognostication  are  not  revealed. The candidate should not conclude that the prognosis is either hopeless or optimistic for functional recovery at this stage or that the wife has his interests at heart or that she knows his wishes.

Suggested steps in handling this problem include: 
(i)       Information gathering. As  much clinical and radiological information  as possible about prognosis and further function should be accumulated. Infonnation should also be gathered about his social setting, his lifestyle and previously expressed wishes, his family's resources to provide therapy at home.

(ii)      Communication. Over a period of time in family conferences this infonnation should be clearly explained. Time should be set aside to sit down with all the close relatives in  a  quiet  environment. Efforts should be made to  involve the  patient via communication aids (eg. Passy Muir valve, Pitt tube, Lip reading}.

(iii)     Specific issues. Causes for the patients agitation should be sought. Depression treated. Fi.nancial issues should be addressed with the social worker.

(iv)    Actions then should be based on : 
- respect for human life. 
- respect for human dignity. 
- respect for individual autonomy. 
- respect for social justice. 
- assessment of the benefit and harm of continued therapy.

A competent patient is entitled to withdraw consent to treatment but it is early in his course. The responsibility of the doctor is to ensure that the patient is competent. is fully informed and the treating team has a consensus. This will take time.

WHEN LIFE SUPPORT IS QUESTIONED EARLY IN THE CARE OF PATIENTS WITH CERVICAL·LEVEL QUADRIPLEGIA  NEJM 1993;328;7;PSQ6..9

Discussion

Normally, decisions can be made to limit or withdraw the therapy if any of the following conditions are satisfied:

  • The therapy is considered unlikely to succeed on grounds of basic physiology (i.e. it would be scientifically impossible for it to achieve the intended goals)
  • The therapy is known to fail in the vast majority of attempts under these conditions, and the attempt has known and serious adverse consequences
  • The therapy would (if successful) lead to a quality of life which is unacceptable to the patient, or (if the patient or family cannot comment) which would lead to a quality of life which "falls well below the threshold considered minimal by general professional judgment"
  • The therapy leads to the preservation of a state which is unacceptable for the patient, eg. the therapy merely preserves unconsciousness and dependence on intensive medical care.
  • There are parties (including other medical professionals and important figures from the patient's family) who agree that the cost or outcome of the therapy would be unacceptable to the patient.

As the patient themselves can participate, this is the most important opinion to consider.  That Patterson paper the college quotes (NEJM, 1993) is actually quite a good overview of what it takes to withdraw consent for therapy. The following conditions must be satisfied:

  • The patient is conscious and there are no medical reasons to suspect that their cognition or judgment are impaired (this is where a psychologist or psychiatrist comes in to consider depression or psychosis)
  • The patient is competent. 
  • The patient has the capacity to absorb all the required information, offered to them in a way they find acceptable. That information must include material on:
    • Long-term rehabilitation
    • Appropriate technological devices
    • Impact on mobility, continence, respiratory processes, etc
    • Depression and quality of life
  • The patient is able to process the information
  • The patient is able to form a reasoned internally consistent decision
  • The patient is able to articulate this decision in a manner which witnessess find unequivocal
  • The decision is consistent with their known values

The "medical consensus" issue does not matter as much if the patient himself decides that ongoing treatment is completely against his wishes.

References

References

Patterson, David R., et al. "When life support is questioned early in the care of patients with cervical-level quadriplegia." (1993): 506-509.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine.Journal of critical care 34 (2016): 125-130.

Palda, Valerie A., et al. "“Futile” care: Do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses." Journal of critical care 20.3 (2005): 207-213.

Sibbald, Robert, James Downar, and Laura Hawryluck. "Perceptions of “futile care” among caregivers in intensive care units." Canadian Medical Association Journal 177.10 (2007): 1201-1208.

Danbury, C. M., and C. S. Waldmann. "Ethics and law in the intensive care unit." Best Practice & Research Clinical Anaesthesiology 20.4 (2006): 589-603.

Myburgh, John, et al. "End-of-life care in the intensive care unit: Report from the Task Force of World Federation of Societies of Intensive and Critical Care Medicine." Journal of critical care 34 (2016): 125-130.

Schneiderman, Lawrence J. "Defining medical futility and improving medical care." Journal of bioethical inquiry 8.2 (2011): 123.

Ardagh, Michael. "Futility has no utility in resuscitation medicine." Journal of medical ethics 26.5 (2000): 396-399.

Schneiderman, Lawrence J., Kathy Faber-Langendoen, and Nancy S. Jecker. "Beyond futility to an ethic of care." The American journal of medicine 96.2 (1994): 110-114.

Waisel, David B., and Robert D. Truog. "The cardiopulmonary resuscitation-not-indicated order: futility revisited." Annals of internal medicine 122.4 (1995): 304-308.