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Clinical Ethics Series: To Intubate or Not to Intubate?

by Robert D. Orr, MD, CM
Today's Christian Doctor - Fall 2006

This case is the first in a series of case presentations regarding ethical dilemmas in clinical practice. Pages are designed for ease in copying, for use in personal study, group discussion, or distribution to staff or colleagues. The goal of this series is to address those ethical dilemmas faced by patients, families, and healthcare professionals, offering careful analysis and recommendations that are consistent with biblical standards. The format and length are intended to simulate an actual consultation report that might appear in a clinical record and are not intended to be an exhaustive discussion of the issues raised. The following consultation report is based on a real ethical dilemma that led to a request for an ethics consultation. Some details have been changed to preserve patient privacy.


Question: Should this patient be intubated and given ventilatory support when her children disagree about further management?

HISTORY:
This 77-year-old woman has a long history of chronic obstructive pulmonary disease and a two-year history of progressive short-term memory loss with occasional confusion. She was admitted at 5 a.m. yesterday because of progressive shortness of breath and an elevated level of carbon dioxide in her blood, indicating respiratory failure. She has been treated aggressively with non-invasive ventilatory assistance (BiPAP), steroids, bronchodilators, and empiric antibiotics, but is only slightly improved. Investigation has found no reversible precipitating condition such as pneumonia or heart failure, but it is still hoped that the rest afforded her by the BiPAP will allow her to improve. However, unless a reversible complication can be identified, and unless the patient shows significant improvement, it is likely that this presents end-stage lung disease.

The patient has no written advance directive. Her three children agreed yesterday that the BiPAP ventilatory assistance should be used while searching for reversible conditions and to allow one daughter the time to travel from out of state.

Her intensive care physician met with the three children late this afternoon, explained the poor prognosis, and based on his understanding of her wishes, he recommended against more invasive ventilatory assistance, which would require intubation. Two of the children opted for comfort care without intubation, but one felt the patient should be intubated if she should deteriorate further. The patient, on no sedation, appears comfortable but responds only to noxious stimulation and is unable to engage in meaningful discussion. Her ICU physician requested an ethics consultation.

The ethics consultant met with her three children. They described her as a witty, fiery, “women’s libber” (before it was fashionable) who worked in clothing sales for many years, retiring fifteen years ago. Her husband died three years after she retired. She was a chronic heavy smoker and knew that she had severe chronic lung disease. She had been intubated for a few days about four years ago and required six weeks of rehab. Since that time, she has been quite debilitated and her oldest daughter, the one who wants her to be intubated, has lived with her. Remarkably, mother and daughter never talked about the future use of vent support. However, the patient had made it very clear to all of her children that she didn’t want even routine medical treatment (she was seen at home by the visiting nurses who talked with her physician by phone) and absolutely would not tolerate nursing home or rehab care again. The patient has been a lifelong observant Roman Catholic. Her priest saw her just a few days prior to this admission and heard her confession.

In light of their understanding that, if she were to be intubated, she would almost certainly be unweanable and would require long-term vent support in a chronic care facility, two of her children are certain that their mother would choose against intubation. The other is not convinced, and would very much like to give her mother every opportunity for survival. She contemplated going to court to try to override her siblings, but when faced squarely with the dismal prognosis and our understanding of her mother’s wishes about long term institutional care, she reluctantly withdrew her objection.

ASSESSMENT:
This patient has some chance of surviving this episode using current treatment, but virtually no chance of returning to her baseline of function if she should deteriorate to the point of needing intubation. She has expressed her opposition to institutional care, but one daughter is reluctant to rule out any efforts aimed at postponing her death.

DISCUSSION:
When treatment decisions must be made for a patient who has lost decision-making capacity, whether from cognitive impairment or critical illness, those decisions should be made jointly by her professional caregivers and those who best know her wishes and values. The standard to be sought is a “substituted judgment,” i.e. choosing what the patient would choose if she were able, rather than choosing what either the physician or family thinks best. Only when there is no way to know the patient’s values or wishes do we drop to the lower “best interests” standard.

In this case, the patient has experienced ventilator support in the past and has said she didn’t want it again, especially for long-term use. She has clearly expressed a strong aversion to institutional care. Her present condition is such that, should she deteriorate further and be intubated, it might be possible to postpone her death, but she would then require the institutional care which she has rejected. Though one daughter, her caregiver and friend, would like to do everything to postpone death, her other two children are, with sadness, willing to accept the physician’s recommendation and the limits set by the patient.

RECOMMENDATIONS:
It is ethically permissible to continue current therapy, but to write orders to limit treatment (Do Not Resuscitate, Do Not Intubate) in the event that she should deteriorate.

In this situation, comfort care becomes the primary goal, even while current therapy continues in an effort to reverse her sudden decline.

Efforts should be made to involve the Catholic hospital chaplain or the patient’s priest in her ongoing care.
[End of Consultation Report]

FOLLOW-UP:
Orders for no resuscitation and no intubation were written by the ICU physician. Her own priest administered the Anointing of the Sick.

Two days after the consultation, the patient developed rapid atrial fibrillation, unresponsive to medication. Electroshock was not used, but further treatment of this cardiac arrhythmia using electroshock was discussed. Based on our understanding of her values and her previously stated wishes, it would be ethically permissible to recommend against using electroshock. However, if her family believes she would want to try it, it would likewise be permissible to use it with adequate sedation so as to prevent patient discomfort, with the understanding that if it did not work, that would be accepted as a sign that her body has succumbed. Her children are 2:1 against using this modality of treatment.

Eight days after the consultation, the daughter who lived with the patient and had been requesting more treatment paged the ethics consultant and reported that the patient was somewhat improved, no longer using BiPAP, but still unable to discuss her wishes. She called because she wanted an opinion on the use of electroshock if it should be needed. The ethics consultant told her that this was not outside the realm of accepted practice as long as: (a) the patient was given adequate sedation/analgesia, and (b) it was agreed that, if her heart stopped during treatment, further resuscitation would not be used.

Ten days after the consultation, the patient slowly deteriorated over a period of twelve hours and she died without further efforts at resuscitation.

Ethical Considerations for Christian Physicians

Most ethics consultations are done in secular institutions. The clinical ethicist must be aware of the principles generally accepted in secular ethics, such as:

• Nonmaleficence — “First of all, do no harm”
• Beneficence — Seek the patient’s best interests
• Autonomy — Allow the patient to make his or her own value-based decisions
• Justice — Treat like patients alike

This consultation report focuses on trying to learn what the patient would choose if she were able, using “substituted judgment.” Also involved in the dilemma are the concepts of patient capacity, surrogacy, consent, limitation of treatment, and conflict resolution.

When a Christian clinician confronts such dilemmas, he or she must be aware of the current standards of clinical ethics, but in addition must be aware of biblical principles which may modify how these secular precepts are interpreted. Relevant considerations in this case include:

• The sanctity of human life — Each person, regardless of the quality of his or her life has the imago Dei within; thus, each life is of inestimable worth.
• The finitude of human life — Since the Fall, each person will experience death unless Jesus returns first.
• The sovereignty of God — God is ultimately in control of each of our lives.
• Human dominion and stewardship — God has given us authority over much of nature, and expects us to be accountable for how we use our lives and resources.
• Quality of life — Though each human life is sacred, each also has quality — good, bad, or indifferent. Persons may use their assessment of their own quality of life as one factor in making decisions about the use or non-use of specific treatments.
• The ministry of healthcare — Caring for another person, whether as a healthcare professional, family member, friend, or parishioner is an act of spiritual ministry.


ABOUT THE AUTHOR

Robert D. Orr, MD, CM

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