Question 30

A 40 year old man with end stage motor neurone disease takes a deliberate, lethal, benzodiazepine overdose. As he becomes sleepy, he tells his wife what he has done, and asks that she stay with him as he dies. They had discussed his wish to commit suicide before, rather than suffer the indignity and distress of respiratory failure in hospital. He has an advanced directive not to be ventilated in the event of respiratory failure. His power of attorney is a barrister who is also a close friend of both the patient and his wife.

She panics, however, as he becomes unconscious and calls an ambulance. Finding him unconscious and in drug induced respiratory failure, the ambulance intubates and ventilates him and delivers him to the hospital Emergency Department. You are the intensive care specialist on call and are asked to take him to your ICU for ongoing care.

Outline the principles of management

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College Answer

This is a complex scenario. Answers should include some discussion of patient autonomy, the relevance of the medical diagnosis of end stage motor neurone disease (MND) versus overdose, determination whether anyone carries medical power of attorney, and support for the wife.

One reasonable approach, and factors to consider include:
•    Take him to ICU as ventilation has been instituted as a lifesaving measure in a clinical circumstance which has not been described in his advance directive.
•    Continue ventilation until the wishes of the patient can be determined either from him or from the advance directive.
•    Withdrawal of ventilation can only be made when you consider him dying from end stage respiratory failure from MND, even if this has been triggered by a deliberate overdose. This is provided the advance directive confirms his wish not to receive ventilatory support for this indication.
•    Ventilation cannot be withdrawn if he is still in the benzodiazepine overdose stage as this would be assisting suicide which is illegal and also outside the limits of the advance directive.
•    Wife must be reassured that she did the right thing and has not betrayed his trust.
•    Confirm nature of power of attorney – financial or health and discuss these issues with that person.
Any reasonable approaches to management were given credit if adequately supported in the candidate’s answer.

Discussion

Broadly, a generic approach to these problems should resemble the following:

Establish the utility of therapy. As CICM themselves put it, "there is no obligation to initiate therapy known to be ineffective, nor to continue therapy that has become ineffective".
Where possible, manage acute issues. If the patient is acutely unwell and no decision regarding their treatment limitations has been made, then it may be appropriate to rescue them in the acute setting. This might mean going ahead with such burdensome therapies as intubation.
The argument for this course of action is:
- To disregard uncertainty regarding prognosis and patient wishes may result in "false positive" situations where potentially beneficial treatments are withheld inappropriately
- Resuscitation may offer some relief of symptoms (eg. decreased effort of breathing following intubation, and the relief of pain by the associated anaesthesia)
Establish medical consensus. Agreement should be sought between the medical teams and the ICU team regarding what is appropriate in the management of the patient. The ethical concepts of beneficience, non-maleficence and autonomy need to be considered.
Establish competence. The patient's right to self-determination is not degraded by mental illness or anaesthesia, but their ability to make reasoned judgements about their future certainly is. If the patient is not competent, family members may act as surrogate decisionmakers.
Establish responsibility. Typically the patient themself is responsible for making decisions regarding their health. If the patient is incompetent, one needs to establishing who is the "person responsible". This may be the nominated enduring guardian or "medical power of attorney".
Establish broad consensus. There should ideally be an agreement between the medical consensus and the views of the patient and persons responsible. Important features of this process are:
- Adequate time should be allowed
- Adequate information (eg. factors taken into account in reaching the medical consensus) should be fully offered
- Responsibility for decisonmaking does not rest solely with the next-of-kin - this should be abundantly clear
- Issues should be discussed in the forum of a family conference, with input from a multidisciplinary care team involving nurses and social workers.
Document the consensus decision. Important components need to include:
- Basis for the decision needs to be clearly documented
- The document should identify those amongst whom the consensus has been reached
- A completed Advanced Care Directive in writing
- A plan for escalation of therapy with clearly defined limits
- A clear plan of symptom control
Provide high-quality end of life care. This is characterised by:
- Adequate pain and symptom management
- Avoiding the inappropriate prolongation of dying
- A sense of control over the process
- Strengthening relationships with loved ones
- Relieving the burden on loved ones
  (Singer et al, 1999)

References

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.

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.

Corke, Charlie, William Silvester, and Rinaldo Bellomo. "Avoiding nosocomial dysthanasia and promoting eleothanasia." Critical Care and Resuscitation 12.4 (2010): 221.

Dickens, Bernard M., Joseph M. Boyle Jr, and Linda Ganzini. "Euthanasia and assisted suicide." The Cambridge textbook of bioethics (2008): 72.

Singer, Peter A., Douglas K. Martin, and Merrijoy Kelner. "Quality end-of-life care: patients' perspectives." Jama 281.2 (1999): 163-168.

CICM Document IC-14, "ANZICS Statement on withholding and withdrawing treatment"

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