The business of ethics in the life of the critically ill

When facing critical illness, ethical considerations loom large, guiding decisions that profoundly affect individuals and their loved ones. In such scenarios, principles like autonomy, beneficence, non-maleficence, and justice become paramount.

Autonomy, the right to self-determination, acknowledges the patient's ability to make decisions regarding their care. However, in cases like the 84-year-old who underwent aneurysm surgery, cognitive impairment or advanced age may compromise autonomy, necessitating surrogate decision-making.

Beneficence and non-maleficence dictate the obligation to act in the patient's best interest while avoiding harm. The story of the 84-year-old illustrates this balance. While surgery aimed to prolong life, it inadvertently led to limitations, such as the inability to engage fully in activities like playing with grandchildren.

Justice concerns the fair distribution of resources and burdens. In the context of critical illness, it prompts questions about equitable access to care and allocation of medical resources. For instance, the emotional toll on the family of the baby who didn't survive may raise questions about the allocation of resources for neonatal care.

These ethical principles intersect with personal narratives, such as the 84-year-old's desire to participate in family activities or the grief of losing a baby. They guide clinicians, families, and policymakers in navigating complex decisions, seeking to uphold dignity, respect, and the best possible outcomes amidst challenging circumstances.

1. Ethical Issues in the Critically Ill Karthik Ponnappan T MD DM Organ Transplant Anesthesiology and Critical Care

2. How many of you would suggest surgery for a 84 year old with abdominal aortic dissection?

3. He is a 84 year old pensioner who goes to gym daily He plays the Lego bricks daily with his 6 year old and 8 year old grandsons. He sometimes feels back pain.

4. How many of you would suggest surgery for a 84 year old with abdominal aortic dissection now?

5. The business of ethics the study of morality, careful and systematic reflection on, and analysis of moral decisions and behavior

6. The Declaration of Geneva “The health of my patient will be my first consideration,” International Code of Medical Ethics “A physician shall act in the patient’s best interest when providing medical care.”

7. The four principles of Medical Ethics Autonomy Beneficience Non-maleficience Justice

8. Meet Samuel Jones He is a 66 year old retired gentleman planning to spend his years with wife and grandchildren He has IPF , refractory to oxygen therapy He opts for aggressive treatment, and consents to lung transplantation listing

9. Lucky to get a transplant? 5 weeks after listing, his IPF worsens His LAS rises and he gets the transplant priority

10. After 8 months in ICU Ventilator dependent – fungal pneumonia Sever debilitation, delirious, bed sores Mrs Jones distraught and frustrated

11. After 8 months in ICU Mrs. Jones “He hadn’t signed up for this,” “just wanted to take him home to die.” junior doctors , “They only care about their numbers, not what happens to their patients. I guess we’ll see what happens on day 366” .”

12. The informed Consent Principle One: Informed Consent is a Process not an Event

13. Every person has a different view on what is worse than death!! Things that patients have quoted as worse than death: Nasogastric tube Bowel and Bladder incontinence Prolonged time on ventilator Reassess and discuss, as decisions and perceptions change with time!

14. Prognostication Principle Two: Prognostication is an Enterprise with Moral Dimensions

15. Mistakes we make Physicians typically err on the side of continuing life-sustaining treatment Tendency to rely on anecdotes or their most recent experience when providing prognostic assessments

16. Best Case Worst Case tool Kruser et al. 2015 “Best case/worst case”: Qualitative evaluation of a novel communication tool Journal of the American Geriatrics Society

17. End of Life discussions

18. Prognosticate acccurately

19. Prognosticate accurately

20. Patient Autonomy and Decision‑Making Capacity Principle Three: Autonomy is a Property of Decisions and of Persons

21. Preferences that Persist over time, appear deeply held, and are consistent with other patient values  what the patient “ actually wants .” Or, in the language of bioethics, more likely to be autonomous decisions. “Life restricted to an ICU is not an acceptable quality of life”

22. Assessment for Capacity for Everyday Decision making ACED Lai JM, Karlawish J. Assessing the capacity to make everyday decisions: a guide for clinicians and an agenda for future research. Am J Geriatr Psychiatry 2007

23. Short ACED Lai JM, Karlawish J. Assessing the capacity to make everyday decisions: a guide for clinicians and an agenda for future research. Am J Geriatr Psychiatry 2007

24. If incompetent, Mishra et al 2017. End-of-life care: Consensus statement by Indian Academy of Pediatrics .  Indian pediatrics

25. Balancing Program Metrics and Individualized Patient Care Principle Four: There is an Ethical Difference Between Reasons and Motives When Recommending Continued Life‑Sustaining Treatment

26. UNOS provides licence to transplant centers based on 1 year survival So the mortality immediately after 1 year is high Centers pursue aggressive life saving measures upto one year!! Maxwell 2014 Impact of the lung allocation score on survival beyond one year. American Journal of Transplantation

27. Obligations to Organ Donors and to Other Potential Recipients Principle Five: Ethical Considerations Related to the Donor and Other Potential Recipients are Relevant but not Overriding

28. Ethics is important Do we need an ethics team? No outcome difference!! Don’t Outsource Palliative and Ethical Discussions to another team!!

29. Resolving Ethical issues Withdrawing and Withholding life support –explicit protocols ICU policies- explicit- clear objectives Communication - Interdisciplinary - Family

30. Don’t let your patient feel this way

31. Why were they in a hurry to see her die? “We were told so many times that Evy was incompatible with life. Evy was compatible. She was compatible with our family. She was a sister, a daughter, a niece, and she was our baby. Traditionally, parents teach important lessons to their children as they grow. In Evy’s case, despite her short life, she taught us the value of life, of love, of relationships, and of the fragility of life. We hope that she will, also, change the lives of others”

32. Thank You Contact Mail- [email protected] Twitter- kpwanderer