Ethics in Pulmonary and

Critical Care Medicine

Mark J. Rosen, MD, FCCP
Director, Global Education and
Strategic Development
Past-President 2006-2007
Professor of Medicine
Hofstra North Snore-LIJ
School of Medicine
D|sc|osure
l am an employee of ACC
no relauonshlp wlLh lndusLry
ConlcL of lnLeresL ls noL a Loplc ln Lhls
sesslon
Lth|cs |n CCM
Leorninq Objecnves
AL Lhe end of Lhe sesslon, paruclpanLs wlll be able
Lo:
LlsL Lhe key prlnclples of eLhlcal conslderauons ln
medlcal declslon-maklng
uescrlbe crlLerla for lnformed consenL
ulscuss prlnclples of wlLhholdlng and
wlLhdrawlng Lherapy
uene braln deaLh and llsL llmlLauons Lo
denluons
Lth|cs |n CCM
Princip/es
Many (or mosL) of our cllnlcal dllemmas lnvolve
conlcung lnLeresLs among:
auenLs
lamllles
Care Leam
Care semng
Whos paylng
SocleLal values
1he law
Lth|cs |n CCM
Princip/es
Skllls
know Lhe medlclne
know some bloeLhlcs
Communlcauon
ConlcL resoluuon
Many physlclans are noL good aL Lhls
Lack Lralnlng
Lack comforL
Lack nanclal lncenuve
Lth|cs |n CCM
1he 6eorqetown Montro
AuLonomy: Lhe pauenL has Lhe rlghL Lo accepL or
refuse any LreaLmenL
8enecence: Lhe cllnlclan should acL ln Lhe besL
lnLeresL of Lhe pauenL
nonmalecence: rsL, do no harm
!usuce: dlsLrlbuuon of llmlLed resources musL be falr
Lth|cs |n CCM
1he 6eorqetown Montro
And Lwo more:
ulgnlLy: pauenL ooJ careglver
1ruLhfulness and honesLy
Wh|ch of the fo||ow|ng |s true about panent
autonomy?
A. AuLonomy generally overrldes oLher conslderauons
8. AuLonomy ls lrrelevanL lf a pauenL does noL have
Lhe capaclLy Lo make declslons
C. Crlucal dlsagreemenLs beLween pauenLs and
physlclans musL be reconclled by an lndependenL
parLy
u. hyslclans are obllgaLed Lo provlde care LhaL
pauenLs wanL, even lf lL ls noL expecLed Lo beneL
Lhe pauenL
Autonomy
auenLs have Lhe rlghL Lo make lnformed and
unforced declslons
When pauenLs lack menLal capaclLy, LhaL rlghL falls
Lo a surrogaLe
AuLonomy depends on lnformed consenL
LlmlLs
1he declslon musL be legal
1he declslon musL be reasonable
1he pauenL musL have menLal capaclLy
8enehcence and Nonma|ehcence
We are noL obllgaLed Lo provlde care LhaL wlll noL
beneL Lhe pauenL
Powever, beneL ls dened by Lhe pauenL or
surrogaLe
1hese conlcLs are oen frusLraung, buL useful
Iusnce
We are oot charged wlLh rauonlng healLh care
dollars aL Lhe bedslde
We should advocaLe for rauonal healLh pollcles LhaL
would provlde proper care Lo Lhose who need lL,
whlle educaung Lhe publlc abouL Lhe llmlLs of care
?ou are asked Lo evaluaLe a 90-year-old man
who ls broughL from home wlLh fever,
producuve cough and resplraLory dlsLress. Pe
has advanced Alzhelmer dlsease, cared for aL
home by famlly for 4 years, buL has been
profoundly demenLed. Pe cannoL
communlcaLe wlLh hls famlly, and ls fed
Lhrough a gasLrosLomy. Pe ls now obLunded.
Whlle breaLhlng 40 oxygen, Lhe pP ls
7.32, Lhe aCC
2
30 mm Pg, and Lhe aC
2

33 mm Pg. nonlnvaslve venulaLory
supporL by mask ls sLarLed, SaC2
lncreases from 87 Lo 93, and he
appears more comforLable.
?ou Lalk wlLh Lhe famlly abouL lnLubauon and
cardlopulmonary resusclLauon, and palllauve
care wlLhouL llfe-susLalnlng measures. 1hey
acknowledge Lhe pauenLs menLal lncapaclLy
and funcuonal llmlLauons, buL lnslsL LhaL
everyLhlng should be done Lo prolong hls llfe
because we know he wanLs Lo llve. Whlle
havlng Lhls dlscusslon, Lhe oxygen saLurauon
decllnes Lo 83 and hls breaLhlng becomes
labored.
Wh|ch of the fo||ow|ng shou|d you do now?
A. lnform Lhem LhaL Lhe pauenL wlll noL be lnLubaLed
because mechanlcal venulauon would be medlcally
fuule
8. Advlse Lhem LhaL Lhe pauenL should noL be
lnLubaLed because he wlll suer
C. Advlse Lhem LhaL Lhe pauenL should noL be
lnLubaLed because hls quallLy of llfe ls so poor
u. Advlse Lhem LhaL Lhe pauenL should noL be
lnLubaLed because of Lhe hlgh cosLs of hls care
L. lnLubaLe Lhe pauenL
Lth|ca| Dec|s|on-Mak|ng for Most of Us
SLep 1. Apply Lhe baslc prlnclples of auLonomy,
benecence, nonmalecence and [usuce
SLep 2. LvaluaLe pauenL preferences, medlcal
beneLs and harms (and how Lhey lmpacL on access
Lo care and socleLal cosLs)
SLep 3. Ask for help
Informed Consent
whots the digerence between copocity ond competency?
CapaclLy
AblllLy Lo make a meanlngful lnformed declslon
Changes over ume
CompeLency: legal denluon made ln a courL of law
based lo pott on menLal capaclLy
Care Leam, famllles, courLs
CapaclLy requlred for legal compeLence varles wlLh
serlousness of declslon
Buchanan A. J R Soc Med 2004;97:415-420
Informed Consent
valld only when a pauenL has Lo make volunLary
cholces among LreaLmenL opuons
auenLs wlLh psychlaLrlc dlsorders may have capaclLy
Lo make medlcal declslons
sychlaLry consulLauon should be reserved for cases
where a cllnlclan belleves Lhe pauenL ls maklng an
lrrauonal declslon, or when Lhere ls uncerLalnLy
abouL capaclLy
Informed Consent
Ponents without copocity
ConsenL from surrogaLe
lf no surrogaLe, subsuLuLed [udgemenL: proceed as
mosL pauenLs wlLh capaclLy would choose
WlLhdrawlng llfe supporL from a pauenL wlLh no
capaclLy and no surrogaLe problemauc
Wh|ch of the fo||ow|ng |s true about w|thho|d|ng or
w|thdraw|ng ||fe support |n a panent w|thout dec|s|on-
mak|ng capac|ty?
A. Cnce sLarLed, ordlnary LreaLmenLs llke anubloucs
musL be conunued
8. ln mosL sLaLes, lL ls lllegal wlLhouL clear and
convlnclng evldence
C. Cral advance dlrecuves are legally valld ln mosL
sLaLes
u. ueslgnaLed healLh care agenLs' lnsLrucuons Lo
wlLhdraw llfe supporL musL be adhered Lo
W|thdrawa| of L|fe Support
ltloclples
auenLs and Lhelr surrogaLes have Lhe auLhorlLy Lo
decllne or wlLhdraw any lnLervenuon, provlded Lhey
are lnLellecLually and psychologlcally compeLenL Lo
make LhaL declslon
WlLhdrawlng care ls morally, eLhlcally and legally
equlvalenL Lo wlLhholdlng care
1he "Doub|e Lect"
Some acuons have good and bad eecLs
An acuon ls accepLable lf Lhe lnLended aecL was
only Lhe good one
1he acuon ls allowed only lf Lhe bad eecL ls
Lolerable, forseeable and unavoldable, and lf overall,
Lhe good ouLwelghs Lhe harm
Acuons should mlnlmlze Lhe harm
"Doub|e Lect" at Lnd of L|fe
llqolls
PasLenlng deaLh ls an lnevlLable or llkely slde
eecL of oplaLe admlnlsLrauon" lalse
PasLenlng of deaLh ls a welcome slde-eecL:
aLernallsuc?
W|thdrawa| of L|fe Support
Mechanlcal venulauon
vasopressors
8enal replacemenL Lherapy
Pydrauon
SupplemenLal oxygen
nuLrluon
SCCM Consensus Statement
kecommeoJouoos
Auenuon Lo Lhe pauenL, Lhe famlly and Lhe
cllnlcal Leam
reparauon
rocesses
Crit Care Med 2001;29:2332-48
SCCM Consensus Statement
NeeJs of tbe fomlly
1o be wlLh Lhe dylng person
1o be helpful Lo Lhe dylng person
1o be lnformed of changes ln condluon
1o undersLand whaL ls belng done and why
1o be assured of Lhe pauenL's comforL
Crit Care Med 2001;29:2332-48
SCCM Consensus Statement
NeeJs of tbe fomlly
1o be comforLed
1o venulaLe emouons
1o be assured LhaL Lhelr declslons were rlghL
1o ndlng meanlng ln Lhe dylng of a loved one
1o be fed, hydraLed and resLed
Crit Care Med 2001;29:2332-48
SCCM Consensus Statement
NeeJs of tbe loueot
Conslder rewrlung all orders, reecung
changes ln Lhe goals of care
8educe Lhe level of monlLorlng, LesLs, and
procedures
Change medlcauons accordlngly
Crit Care Med 2001;29:2332-48
SCCM Consensus Statement
NeeJs of tbe loueot
Assess and LreaL paln and suerlng
Cplolds (morphlne, fenaLanyl)
8enzodlazeplnes
neurolepucs for dellrlum
5top neurormuscular blocklng agenLs
1lLraLe Lo deslred eecL
AnuclpaLory doslng prlor Lo Mv wlLhdrawal
(lncrease dose 2x-3x)
Crit Care Med 2001;29:2332-48
SCCM Consensus Statement
1etmlool xtobouoo v. 1etmlool weoninq
1ermlnal exLubauon: remove Lube aer
admlnlsLerlng sedauves/analgeslcs
uoes noL prolong dylng process
Morally LransparenL
1ermlnal weanlng: gradually reduce venulaLor
semngs and llC
2
Mlnlmlze llkellhood of alr hunger, vlslble slgns of
dlsLress
ulmlnlsh moral burden on famlly (less acuve)
Crit Care Med 2001;29:2332-48
Does Adm|n|stranon of 8enzod|azep|nes
and Narconcs nasten Death?
73 pauenLs wlLh who had Mv wlLhdrawn aL end of
llfe
no relauonshlp beLween hourly doses ln hours
before wlLhdrawal and ume Lo deaLh
lor every 1 mg/hr lncrease ln dose of benzos aer
wlLhdrawal of Mv, ume Lo deaLh locteoseJ by 13
mlnuLes
Chan JD, et al. CHEST 2004;126:286-93
W|thdrawa| of Venn|atory Support
Consensus of famlly, physlclans and sLa ln accord
wlLh Lhe pauenLs wlshes
Speclc dlscusslon of procedures
Assurance LhaL pauenL wlll remaln comforLable, wlLh
goals of sedauon and analgesla communlcaLed Lo
sLa
Auend Lo Lhe famlly
Auend Lo Lhe pauenL LhroughouL Lhe dylng process
8ra|n Death
1981 resldenLs Commlsslon: lrreverslble cessauon of
all funcuons of Lhe eoute braln (lncludlng bralnsLem)

1993 Amerlcan Academy of neurology:
Coma
Absence of bralnsLem reexes
Apnea

Wl[dlcks LlM, eL al. neurology 2010,23:1911-18
8ra|n Death
xclosloos
Severe hypoLhermla
Severe hypoLenslon
Severe meLabollc dlsLurbances
urug lnLoxlcauon
neuromuscular blocklng agenLs
A dlsorder LhaL would preclude an apnea LesL

8ra|n Death
cooftmototy 1ests
LLC: bot Lhere ls lnLerobserver varlablllLy, false
posluves (barblLuraLes, anesLheucs, subcorucal
neuronal acuvlLy)
1ranscranlal uoppler: buL Lakes sklll
Cerebral anglography
1echneuum lmaglng

8ra|n Death
Are Lhere pauenLs who fulll Lhe cllnlcal crlLerla
of braln deaLh who recover braln funcuon?

never reporLed aer dlagnosls of braln deaLh
uslng 1993 AAn crlLerla
Wl[dlcks LlM, eL al. neurology 2010,23:1911-18
8ra|n Death
WhaL ls an adequaLe observauon perlod Lo
ensure LhaL cessauon of neurologlc funcuon ls
permanenL?

nobody knows
Wl[dlcks LlM, eL al. neurology 2010,23:1911-18
8ra|n Death
Are complex moLor movemenLs LhaL falsely
suggesL reLalned braln funcuon someumes
observed ln braln deaLh?

?es: sponLaneous and reex movemenLs,
venulaLor auLocycllng
Wl[dlcks LlM, eL al. neurology 2010,23:1911-18
8ra|n Death
WhaL ls Lhe comparauve safeLy of Lechnlques
for deLermlnlng apnea?

no good sLudles, buL apnelc oxygenauon
appears Lo be safe
Wl[dlcks LlM, eL al. neurology 2010,23:1911-18
a|||anve Care for Advanced Lung
Cancer
131 pauenLs wlLh meLasLauc non-small
lung cancer randomlzed Lo recelve
sLandard oncology care vs. palllauve care
wltb sLandard care
Temel JS, et al. N Engl J Med 2010;363:733-742
Twelve-Week Outcomes of Assessments of Mood
Temel JS et al. N Engl J Med 2010;363:733-742
Temel JS et al. N Engl J Med 2010;363:733-742