Sick Patients, Grieving Families, and a Selection of Issues in Ethics Allen Roberts, MD Professor of Clinical Medicine Georgetown University Hospital

“On that day, men will gather in great mead halls and sing of the day when physicians, like giants, walked the earth.” - Richard Selzer Notes on the Art of Surgery

A day in the life of the intensivist… Rounds Codes Family meetings Admissions Procedures Academic conferences

The ICU Team Physicians Nurses Respiratory therapists Nutrition specialists Clinical pharmacologists Available: Pastoral Care Palliative Care International Services

The week of February 25… 175 ICU patient visits, ventilator adjustments, miscellaneous interventions and procedures. Most will survive, but… 37 year old man with rapidly progressive pneumonia, respiratory failure, septic shock, died. 48 year old man with severe streptococcal infection of the major muscle groups of both legs. Septic shock, respiratory failure; emergent surgery to remove non-viable tissue. Will survive, but with extensive rehab. 29 year old man with influenza A, complicated by pneumonia, respiratory and kidney failure, died. Three patients with liver failure of various causes. All died while awaiting a transplant.

The cords of death encompassed me; the torrents of destruction assailed me… Psalm 18:4

ICU Glossary: basics Intubation and mechanical ventilation Pressors Renal-replacement therapy: dialysis, continuous vs intermittent Prognosis, severity of illness, APACHE “Full Code” vs “DNR” “Comfort measures” Withdrawal of Care

Pastoral Care and Clinical Medicine: Intersections Family meetings: Diagnosis Prognosis What’s changed now that the patient is in the ICU Realistic goals of care Family & social support Faith tradition Preparation for death Family care following death

Ministry in the Unit: Meeting with the Family Early-on after ICU admission Purpose: - inform the family and establish goals of care diagnosis, prognosis, statistics v gestalt - establish who is the spokesperson - identify family dynamics encourage unity - establish a follow-up meeting

Meeting the Family Most meetings go smoothly - include residents, nurses & medical students Mentality: - family is in tsunami-mode - spectrum: concerned <–> distraught <–> openly hostile Gage need for “Security” Focus on problems at hand Sit close to the door

Ethical Issues in the ICU Most ethics issues center around the beginning or the end of life Ethical dilemmas at the end of life are the necessary consequence of advanced, life saving and life-sustaining medical care.

End-of Life Scenarios The natural end-point of a terminal disease - malignancy - liver failure - neuromuscular disease Extreme old age chronological vs physiological age Complication of long-term care Severe, acute illness which advances relentlessly despite aggressive, multi-modality measures - age non-specific

Medical-Pastoral Questions Keep everything going and wait for recovery? Wait for God to intervene with a miracle? Allow natural death/shift to providing comfort? What would the patient want? What does the family want? What’s ‘the right thing?’ How to make a decision that everyone can live with ….? When is continuing care futile?

A Selection of Ethical Issues The Georgetown mantra: beneficence, non-maleficence, autonomy, and justice The evolution of patient (family ) autonomy What’s technically possible vs what’s the right thing to do (or not do) Concept of futility vs ‘no benefit’

Principles of End-of-Life Counseling in the ICU Confidence in the diagnosis and prognosis Provide for comfort and consolation Provide for pastoral care, if desired That which ends the patient’s life is the underlying disease process, NOT the withdrawal of biological life-sustaining measures Medical decisions made by MDs in close dialogue with family “Let’s make decisions we can look back on 10 years form now and know we did right.”

Withdrawing Care Morphine concept of the “double-effect” Dose to relieve evidence of distress (not dosed to end life) Shut off all pressors Remove the ventilator Allow the family proximity, if desired

Georgetown Ethics Initiatives Identify clinical data points which suggest that survival in the ICU is unlikely If these criteria are met, establish a “Goals of Care” meeting with family early, with Pastoral Care and Palliative Care presence Establish who will serve as the surrogate decision maker for the patient Time limits on interventions of questionable benefit Ethics Community monitoring of all ICU “comfort-measure” deaths

Contemporary Ethics Issues Patient/family autonomy vs physician’s right of conscience - lessons learned from the abortion debate - Christian Medical/Dental Association lobby Physician-assisted suicide - legal in Oregon, Montana, Nevada - getting press time in professional journals Transplantation ethics - technical success way ahead of ethics dialogue - the vetting process for living donors The perfect storm….

Other things to think about… “Spirituality” in medicine Sharing Jesus with our patients Praying with patients Christian medical professionalism Medical errors and complications - full disclosure