College Answer

After 3 weeks in ICU this 72 year old lady with severe CAL is entitled to the opportunity of a frank discussion about advance care planning. The aim of this question was to explore discharge planning to prepare Mrs X and family for eventualities. Much will depend on what has been learnt about her disease and whether the admission was the result of inexorable deterioration of her lung disease or precipitated by a reversible event. A group conference should be organised before discharge.

The general plan being:
-     prepare for the discussion by providing a suitable environment, gaining the medical facts, getting a medical consensus on a contingency plan
-     establish what the family and patient know
-     determine how much information they want. How open and frank a discussion.
-     explain the medical information and a proposed medical plan
-     assess the response of the patient/family and respond to their emotion, questions and disagreements
-     establish general, accepted goals for long term care
-     finalise a  plan
Details will include Mrs X’s desire for intubation if necessary in the future, the use of non-invasive ventilation etc

That  night  she  develops  sputum  retention  and  becomes  drowsy. Her daughter demands  ICU admission

(f)   What will you do?

The response will depend on the results of the conference, and the plan reached.  If her daughter demands ICU admission for Mrs X it is best to
-     assess the medical appropriateness of admission at this time
-     assess alternative or more appropriate avenues of management
-     discuss with admitting consultant to agree on a plan
-     communicate with Mrs X’s daughter and arrive at a mutually agreeable plan bearing in mind that the stated wishes of Mrs X are paramount

A  review  of  events  of  the  day  should  be  undertaken  to  ascertain  if  there  is  a  cause  for  this deterioration eg sedation, narcotic administration, sepsis, pneumothorax.
If readmission appears to be appropriate then there is no problem.
If it is not, because of terminal irreversible condition or it is against the clear wishes of Mrs X, the feelings and motivation of the daughter will need to be addressed and answered.

Discussion

In the discussion with the family, 

• Consider beneficence: is aggressive therapy in the patient's best interest? 
• Consider non-maleficience: is aggressive therapy going to burden the patient? In this case, mechanical ventilation will certainly relieve the work of breathing, but will likely commit the patient to a prolonged course of ICU stay.
• Consider fidelity: the patient or their surrogate decisionmaker need to be given a honest breakdown of exactly what the therapy will require, and what the goals of it will be. This should involve a discussion of prolonged ventilation and its complications, and the very real possibility of tracheostomy.
  • Consider utility (rather than futility): is the therapy going to be helpful? As far as what "helpful" means, one needs to defer to the values of the patient and their family as well as to the objective physiological effectiveness of the therapy. Would they be comfortable with a therapy which merely prolongs life in a state of dependence on intensive care services?
  • Invoke the principle of autonomy. The outcome achieved by this therapy: is this outcome one which the patient would find satisfactory? This is worth talking about in the first scenario.
• Decisions can then 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.