Lecture 6

Forgoing Life-sustaining Treatments

And the Conflict of Values

扁鹊 病有六不治 驕恣不論於理，一不治也； 輕身重財，二不治也； 衣食不能適，三不治也； 陰陽并藏氣不定，四不治也； 形羸不能服藥，五不治也； 信巫不信醫，六不治也；有此一者，則重難治也

《史记 · 扁鹊列传》 《 古今圖書集成醫部全錄卷五百四 醫術名流列 傳 》

Karen Ann Quinlan

coma since 1975

Died: 1986

Should we operate on Baby Doe?

This oft-published photograph, taken in the late 1980s, shows Terri in her mid-20s alive and well. (St. Petersburg Times)

On Feb. 25, 1990, Terri collapsed from an apparent cardiac arrest. She was deprived of oxygen for five minutes, suffering the brain damage that left her in what the courts later ruled was a persistent vegetative state. She was 26 years old.

In early 1990, Mr. Schiavo says he awoke to a thud in the dead of night and found his wife passed out on the floor. Together, the Schindlers and Mr. Schiavo learned that Ms. Schiavo's heart had stopped and that she had suffered drastic brain damage before the paramedics arrived. Doctors say a potassium deficiency, possibly caused by an eating disorder, led to her collapse.

Here, in November 1990, Mr. Schiavo visits with his wife at College Harbor Nursing Home.

(NYTImes)

The Schindlers used this undated photo of Terri, her hair styled, eyes outlined by mascara, as evidence to counter Michael Schiavo's contention in 2003 that she was in a persistent vegetative state.

Response or reflex?In this image taken from four hours of videotape, the Schindlers argued that Terri was able to respond to her mother.

Ms. Schiavo with her mother, Mary Schindler, in late 2001.

Court verdict

Michael Schiavo asked a court’s permission to remove his wife’s feeding tube, 1998

A court in Florida determined that Terri Schiavo had wished not to be kept alive artificially, 2000

Further legal battles Feeding tube removed, March 18,

2005

Example of patient autonomy inrefusing life-sustaining treatment

A 70 year-old man with chronic lung diseasehas spent 3 months in the hospital to comeoff the ventilator. When he goes intorespiratory failure again, he, being mentallycompetent and psychologically fit, decidesthat there is no quality of life and requestsnot to have artificial ventilation again.

Medical futility in life-sustaining treatment

2 broad categories

• Futility in sustaining life (physiologicfutility)

• Futility in restoring the patient tomeaningful survival (broad sense offutility)

Determination of physiologicfutility

Clinical reasoning or experience suggests thata life-sustaining treatment is highly unlikelyto achieve its purpose of sustaining life.

Examples of physiologic futilityExamples of physiologic futility

Performing CPR in terminal patients with Performing CPR in terminal patients with disseminated malignancydisseminated malignancy

Performing CPR in a patient with multi-Performing CPR in a patient with multi-trauma or sepsis who is in severe shock trauma or sepsis who is in severe shock with multi-organ failure despite maximally with multi-organ failure despite maximally intensive therapy.intensive therapy.

What is wrong with providingfutile treatment?

Risks, harms and burdens to the patient

Benefits to

the patient

CPR: Why Not?CPR: Why Not? (Dr. Jane Chan, QMH)(Dr. Jane Chan, QMH)

More harm than More harm than goodgood

Patient autonomyPatient autonomy

Medical futilityMedical futility

Harmful effects of CPRHarmful effects of CPR– Bodily injuryBodily injury– Take away the dignity of dying.Take away the dignity of dying.– Prolong the dying process.Prolong the dying process.

Patient refusal by living will Patient refusal by living will or advance directiveor advance directive– President NixonPresident Nixon

Terminal conditions for which Terminal conditions for which CPR is thought to be futileCPR is thought to be futile

Benefits of withholding CPRBenefits of withholding CPR (Dr. Jane Chan, QMH)(Dr. Jane Chan, QMH)

Avoid unnecessary bodily injury Avoid unnecessary bodily injury and prolongation of life.and prolongation of life.

Allow the patient the dignity and Allow the patient the dignity and peacefulness of dying.peacefulness of dying.

Allow family and friends to gather Allow family and friends to gather at the bedside during the final at the bedside during the final moments.moments.

Choice for the patient and family:Choice for the patient and family:

“Hi-tech” dying“Hi-tech” dying vis-à-vis vis-à-vis natural natural dyingdying

when the hi-tech intervention when the hi-tech intervention is not going to alter the dying is not going to alter the dying

processprocess(Dr. Jane Chan, QMH)(Dr. Jane Chan, QMH)

The hi-tech dying processThe hi-tech dying process (Dr. Jane Chan, QMH)(Dr. Jane Chan, QMH)

Family’s access to the patient is limited Family’s access to the patient is limited by ongoing bedside activities.by ongoing bedside activities.

Patient is subjected to the trauma of Patient is subjected to the trauma of CPR.CPR.

The dying process may be temporarily The dying process may be temporarily halted by life-sustaining devices.halted by life-sustaining devices.

Patient connected to tubes and lines.Patient connected to tubes and lines.

The natural dying processThe natural dying process (Dr. Jane Chan, QMH)(Dr. Jane Chan, QMH)

Family gathering aroundFamily gathering around

HandholdingHandholding

GriefingGriefing

The patient’s last breath is the The patient’s last breath is the patient’s last breathpatient’s last breath

2002

2003

終於得享安息

2005.10.17

Decision-making process in clear-cut case of physiologic futility

• The doctor has no ethical obligation to providefutile treatment.

• The decision is normally made by the doctor i/c.

• The decision should be communicated to thefamily so that the family understands andsupports the thought-process behind thedecision.

Determination of the broadersense of futility

• Involves exploring what “meaningfulsurvival” means to the patient, to the lovedones and to the care team.

• The three parties may differ in their QOLconsiderations, and in their anticipated end-points of medical treatment.

Life-sustaining treatment andQOL

In caring for patients requiring life-sustainingtreatment, we cannot possibly avoid QOLconsiderations, as it is not an appropriategoal of medicine to prolong life at all costs,with no regard to its quality or the burdensof the treatment.

BMA 1999

Anticipated end-points ofmedical treatment

The pt The lovedones

The careteam

Pt to live longer

Pt to live with good QOL

Pt to live w/o suffering

Care team not to do harm to pt

Pt to live such that the lovedones can work out their ownpsychologic states

Care team to provide fair accessto treatment by all

Determination of the broadersense of futility:

A consensus-building process

Risks, harms Justice

and burdens

Health care team

Decision on

Mental Patient’s Prognosis & life-sustaining

competence values & wishes anticipated QOL treatment

Guardian/parent/

family

p.v.s. and euthanasia

Issue 1: Is a patient in p.v.s. a dying patient? (NB: persistent ≠ permanent)

Or is s/he only temporarily incapacitated?

Issue 2: is artificial hydration and nutrition a medical treatment?

Or is it a humane support to a temporarily disabled person?

Persistent Vegetative State

A persistent vegetative state, which sometimes follows a coma, refers to a condition in which individuals have lost cognitive neurological function and awareness of the environment but retain noncognitive function and a perserved sleep-wake cycle.

http://healthlink.mcw.edu/article/921394859.html

It is sometimes described as when a person is technically alive, but his/her brain is dead.

However, that description is not completely accurate. In persistent vegetative state the individual loses the higher cerebral powers of the brain, but the functions of the brainstem, such as respiration (breathing) and circulation, remain relatively intact.

Spontaneous movements may occur and the eyes may open in response to external stimuli, but the patient does not speak or obey commands.

Patients in a vegetative state may appear somewhat normal. They may occasionally grimace, cry, or laugh.

Response or reflex?In this image taken from four hours of videotape, the Schindlers argued that Terri was able to respond to her mother.