city-wide palliative/ethics grand rounds next session 11/19/07 barry smith suny distinguished...
TRANSCRIPT
City-Wide Palliative/Ethics City-Wide Palliative/Ethics
Grand RoundsGrand Rounds
Next Session 11/19/07Next Session 11/19/07
Barry Smith Barry Smith SUNY Distinguished Professor SUNY Distinguished Professor
Julian Park ProfessorJulian Park Professor
The Future of Biomedical InformaticsThe Future of Biomedical Informatics
Jack P. Freer, MDJack P. Freer, MD
UBUB• Professor of Clinical MedicineProfessor of Clinical Medicine• Palliative Medicine Course CoordinatorPalliative Medicine Course Coordinator
Kaleida HealthKaleida Health• Ethics Committee ChairEthics Committee Chair• Palliative Care Consultation (Gates)Palliative Care Consultation (Gates)
CME DisclosureCME Disclosure
• No commercial supportNo commercial support
• No unapproved or off-label usesNo unapproved or off-label uses
BreathlessnessBreathlessness
Jack P. Freer, MDJack P. Freer, MDProfessor of Clinical MedicineProfessor of Clinical Medicine
University at BuffaloUniversity at Buffalo
Learning ObjectivesLearning Objectives
• Understand pathophysiology of Understand pathophysiology of dyspnea dyspnea
• Be familiar with basic modalities of Be familiar with basic modalities of treatment treatment
• Be capable of sound ethical reasoning Be capable of sound ethical reasoning in intubation/ventilation decisionsin intubation/ventilation decisions
• Be able to guide coherent decisions Be able to guide coherent decisions based upon good medicine and good based upon good medicine and good ethicsethics
DyspneaDyspnea
• PathophysiologyPathophysiology
• TreatmentTreatment
• Decision Making/Ethical IssuesDecision Making/Ethical Issues
Dyspnea: Dyspnea: shortness of breath, breathlessnessshortness of breath, breathlessness
• Rapid breathingRapid breathing• Incomplete exhalationIncomplete exhalation• Shallow breathingShallow breathing• Increased work/effortIncreased work/effort• Feeling of suffocationFeeling of suffocation• Air hungerAir hunger• Chest tightnessChest tightness• Heavy breathingHeavy breathing
Dyspnea: Dyspnea: shortness of breath, breathlessnessshortness of breath, breathlessness
• Rapid breathing…Rapid breathing…• Incomplete exhalation…Incomplete exhalation…• Shallow breathing…Shallow breathing…• Increased work/effort…Increased work/effort…• Feeling of suffocation…Feeling of suffocation…• Air hunger…Air hunger…• Chest tightness…Chest tightness…• Heavy breathing…Heavy breathing…
COPD, pulm vasc disCOPD, pulm vasc dis
Asthma,Asthma,
Asthma, Neuro-musc, Chest wallAsthma, Neuro-musc, Chest wall
COPD, Interstitial, Asthma, N-m, CwCOPD, Interstitial, Asthma, N-m, Cw
COPD, CHFCOPD, CHF
COPD, CHF, PregnancyCOPD, CHF, Pregnancy
AsthmaAsthma
AsthmaAsthma
Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553
DyspneaDyspnea
• Cancer (dyspnea common)Cancer (dyspnea common)1.1. Obvious cause (lung mets, effusion etc)Obvious cause (lung mets, effusion etc)
2.2. Co-morbid conditions (COPD/CHF)Co-morbid conditions (COPD/CHF)
3.3. No evidence of 1. or 2. (?cachexia)No evidence of 1. or 2. (?cachexia)
• Non-malignant (COPD, CHF)Non-malignant (COPD, CHF)
Dyspnea in CancerDyspnea in Cancer
• Cancer related causesCancer related causes• Treatment related causesTreatment related causes• General medical condition causesGeneral medical condition causes
Cancer Related CausesCancer Related Causes
• Airway obstruction by tumorAirway obstruction by tumor• Lung parenchyma replacementLung parenchyma replacement• Pleuro-pericardial effusionPleuro-pericardial effusion• Lymphangitic carcinomatosisLymphangitic carcinomatosis• SVC syndromeSVC syndrome• AscitesAscites
Treatment Related CausesTreatment Related Causes
• PneumonectomyPneumonectomy• Radiation fibrosisRadiation fibrosis• ChemotherapyChemotherapy
– Cardiac toxicityCardiac toxicity– Pulmonary toxicityPulmonary toxicity
General Medical ConditionsGeneral Medical Conditions(both related and unrelated to cancer)(both related and unrelated to cancer)
• COPDCOPD• CHFCHF• AsthmaAsthma• InfectionInfection• AnemiaAnemia
• PneumothoraxPneumothorax• Pulmonary embolusPulmonary embolus
Pulmonary hypertension• Psychosocial/Spiritual• …
Mechanism of DyspneaMechanism of Dyspnea
Mechanical ReceptorsMechanical Receptors• LungLung• Chest wallChest wall• Upper airwayUpper airway
Mechanism of DyspneaMechanism of Dyspnea
Sense of Respiratory EffortSense of Respiratory Effort
• ““Effort” major factor in breathlessnessEffort” major factor in breathlessness• Simultaneous motor cortex signals Simultaneous motor cortex signals
– Efferent to respiratory musclesEfferent to respiratory muscles– Signal to sensory cortexSignal to sensory cortex
Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553
Mechanism of DyspneaMechanism of Dyspnea
Sense of Respiratory EffortSense of Respiratory Effort
• ““Effort” major factor in breathlessnessEffort” major factor in breathlessness• Simultaneous motor cortex signals Simultaneous motor cortex signals
– Efferent to respiratory musclesEfferent to respiratory muscles– Signal to sensory cortexSignal to sensory cortex– Mismatch enhances sense of effortMismatch enhances sense of effort– Probably similar signals from brainstemProbably similar signals from brainstem
Mechanism of DyspneaMechanism of Dyspnea
Chemical ReceptorsChemical Receptors
• HypercapniaHypercapnia• HypoxiaHypoxia
Mechanism of DyspneaMechanism of Dyspnea
HypercapniaHypercapnia
• Early studies in normal subjects Early studies in normal subjects suggested COsuggested CO22 not a factor not a factor
• Probably mediated by pHProbably mediated by pH
Mechanism of DyspneaMechanism of Dyspnea
HypoxiaHypoxia
• Some evidence of effectSome evidence of effect• Still…Still…
– Some patient hypoxic—not SOBSome patient hypoxic—not SOB– Some patients SOB—not hypoxic Some patients SOB—not hypoxic – Some hypoxic/SOB pts show little Some hypoxic/SOB pts show little
improvement with Oimprovement with O22 therapy therapy
Treatment of DyspneaTreatment of Dyspnea
• Treat underlying causesTreat underlying causes• OxygenOxygen• Nebulized bronchodilatorsNebulized bronchodilators• OpioidsOpioids• BenzodiazepinesBenzodiazepines• Nebulized opioids used by some but no Nebulized opioids used by some but no
solid evidence of efficacysolid evidence of efficacy• Fans across faceFans across face
Decision Making/Ethical IssuesDecision Making/Ethical Issues
• Opioids and hastening deathOpioids and hastening death• Withdraw vs. Withhold Withdraw vs. Withhold • DNIDNI
Resistance to Opioids for DyspneaResistance to Opioids for Dyspnea
• Hasten death; “kill patient” Hasten death; “kill patient”
• Response:Response:– Tolerance to respiratory depressionTolerance to respiratory depression– Slowing respirations may improve oxygenationSlowing respirations may improve oxygenation
Resistance to Opioids for DyspneaResistance to Opioids for Dyspnea
• However, failing to intubate and ventilate a However, failing to intubate and ventilate a patient in severe respiratory failure will patient in severe respiratory failure will result in death (with or without opioids). result in death (with or without opioids).
– Opioids may hasten that deathOpioids may hasten that death– Double effectDouble effect
Withhold LST vs. WithdrawWithhold LST vs. Withdraw
• Logical/clinical difference?Logical/clinical difference?– Therapeutic trialsTherapeutic trials– Duty to start or stop independent of whether the Duty to start or stop independent of whether the
treatment is already in placetreatment is already in place
• Legal difference? NOLegal difference? NO• Religious differenceReligious difference• Psychological differencePsychological difference
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
• Quality of life Quality of life (prior to vent decision)(prior to vent decision)
• ReversibilityReversibility
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Trial—withdraw laterTrial—withdraw later
• Acceptable quality of life Acceptable quality of life • Reversible conditionReversible condition
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Trial—withdraw laterTrial—withdraw later
• Acceptable quality of lifeAcceptable quality of life• Reversible conditionReversible condition• Clear timetable, endpoints to gauge Clear timetable, endpoints to gauge
“success” of the trial“success” of the trial
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Trial—withdraw laterTrial—withdraw later
• Acceptable quality of life Acceptable quality of life • Reversible conditionReversible condition• Clear timetable, endpoints to gauge Clear timetable, endpoints to gauge
“success” of the trial“success” of the trial• Legally appointed agent to act on behalf of Legally appointed agent to act on behalf of
the patientthe patient
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Die without intubation/ventilation (“DNI”)Die without intubation/ventilation (“DNI”)
• Poor quality of life Poor quality of life • Irreversible processIrreversible process
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Die without intubation/ventilation (“DNI”)Die without intubation/ventilation (“DNI”)
• Poor quality of lifePoor quality of life• Irreversible processIrreversible process
– Prior “reversible process,” tough weanPrior “reversible process,” tough wean
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Die without intubation/ventilation (“DNI”)Die without intubation/ventilation (“DNI”)
• Poor quality of lifePoor quality of life• Irreversible processIrreversible process
– Prior “reversible process,” tough weanPrior “reversible process,” tough wean• Crystal clear informed consent: Crystal clear informed consent: NONO need need
for last minute “clarification.”for last minute “clarification.”
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Die without intubation/ventilation (“DNI”)Die without intubation/ventilation (“DNI”)
• Poor quality of lifePoor quality of life• Irreversible processIrreversible process
– Prior “reversible process,” tough weanPrior “reversible process,” tough wean• Crystal clear informed consent: Crystal clear informed consent: NONO need need
for last minute “clarification.”for last minute “clarification.”• Scrupulous symptom managementScrupulous symptom management
Withhold vs. Withdraw VentilatorWithhold vs. Withdraw Ventilator
Trial / WithdrawTrial / Withdraw• Good QoLGood QoL• ReversibleReversible
________________________________• Clear EndpointsClear Endpoints
– TimeframeTimeframe– OutcomesOutcomes
• Proxy Proxy
WithholdWithhold• Poor QoLPoor QoL• IrreversibleIrreversible
________________________________• Clear Consent Clear Consent
– No last minute No last minute “clarifications”“clarifications”
• Symptom TreatmentSymptom Treatment
Dying Without IntubationDying Without Intubation
Decision making:Decision making: • Broad planning based on goals of treatmentBroad planning based on goals of treatment• Positive treatment directed toward ALL goalsPositive treatment directed toward ALL goals• Reversibility/Quality of lifeReversibility/Quality of life• Treat respiratory failure symptomaticallyTreat respiratory failure symptomatically
– No intubation/ventilationNo intubation/ventilation
Dying Without IntubationDying Without Intubation
DocumentationDocumentation • Document rationale in detailDocument rationale in detail• Document informed consent discussionDocument informed consent discussion• Detailed symptomatic planDetailed symptomatic plan
CommunicationCommunication• Clear discussions with nurses, familyClear discussions with nurses, family• Explain what to expectExplain what to expect• Avoid focus on “Avoid focus on “notnot””
Dying Without IntubationDying Without Intubation
What if the patient changes his mind?What if the patient changes his mind?
Dying Without IntubationDying Without Intubation
Failure to document the informed Failure to document the informed consent discussion can lead to consent discussion can lead to last minute “clarification” about last minute “clarification” about decision (and patient “changing decision (and patient “changing mind” about intubation).mind” about intubation).
Dying Without IntubationDying Without Intubation
Failure to provide adequate Failure to provide adequate symptom relief can lead to symptom relief can lead to suffering (and patient “changing suffering (and patient “changing mind” about intubation).mind” about intubation).
Respiratory Death Respiratory Death without Intubation/Ventilationwithout Intubation/Ventilation
• ……can be the most appropriate and ethically can be the most appropriate and ethically defensible option.defensible option.
• ……can be part of a comprehensive palliative can be part of a comprehensive palliative plan based on the patient’s goals of care.plan based on the patient’s goals of care.
• ……can NOT be summarized in 3 letters.can NOT be summarized in 3 letters.
EditorialEditorial