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City-Wide Palliative/Ethics Grand Rounds

City-Wide Palliative/Ethics Grand Rounds. Next Session 11/19/07 Barry Smith SUNY Distinguished Professor Julian Park Professor The Future of Biomedical Informatics. Jack P. Freer, MD. UB Professor of Clinical Medicine Palliative Medicine Course Coordinator Kaleida Health

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City-Wide Palliative/Ethics Grand Rounds

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  1. City-Wide Palliative/Ethics Grand Rounds Next Session 11/19/07 Barry Smith SUNY Distinguished Professor Julian Park Professor The Future of Biomedical Informatics

  2. Jack P. Freer, MD UB • Professor of Clinical Medicine • Palliative Medicine Course Coordinator Kaleida Health • Ethics Committee Chair • Palliative Care Consultation (Gates)

  3. CME Disclosure • No commercial support • No unapproved or off-label uses

  4. Breathlessness Jack P. Freer, MD Professor of Clinical Medicine University at Buffalo

  5. Learning Objectives • Understand pathophysiology of dyspnea • Be familiar with basic modalities of treatment • Be capable of sound ethical reasoning in intubation/ventilation decisions • Be able to guide coherent decisions based upon good medicine and good ethics

  6. Dyspnea • Pathophysiology • Treatment • Decision Making/Ethical Issues

  7. Dyspnea: shortness of breath, breathlessness • Rapid breathing • Incomplete exhalation • Shallow breathing • Increased work/effort • Feeling of suffocation • Air hunger • Chest tightness • Heavy breathing

  8. Rapid breathing… Incomplete exhalation… Shallow breathing… Increased work/effort… Feeling of suffocation… Air hunger… Chest tightness… Heavy breathing… COPD, pulm vasc dis Asthma, Asthma, Neuro-musc, Chest wall COPD, Interstitial, Asthma, N-m, Cw COPD, CHF COPD, CHF, Pregnancy Asthma Asthma Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553 Dyspnea: shortness of breath, breathlessness

  9. Dyspnea • Cancer (dyspnea common) • Obvious cause (lung mets, effusion etc) • Co-morbid conditions (COPD/CHF) • No evidence of 1. or 2. (?cachexia) • Non-malignant (COPD, CHF)

  10. Dyspnea in Cancer • Cancer related causes • Treatment related causes • General medical condition causes

  11. Cancer Related Causes • Airway obstruction by tumor • Lung parenchyma replacement • Pleuro-pericardial effusion • Lymphangitic carcinomatosis • SVC syndrome • Ascites

  12. Treatment Related Causes • Pneumonectomy • Radiation fibrosis • Chemotherapy • Cardiac toxicity • Pulmonary toxicity

  13. COPD CHF Asthma Infection Anemia Pneumothorax Pulmonary embolus Pulmonary hypertension Psychosocial/Spiritual … General Medical Conditions(both related and unrelated to cancer)

  14. Mechanism of Dyspnea Mechanical Receptors • Lung • Chest wall • Upper airway

  15. Mechanism of Dyspnea Sense of Respiratory Effort • “Effort” major factor in breathlessness • Simultaneous motor cortex signals • Efferent to respiratory muscles • Signal to sensory cortex

  16. Manning HL, Schwartzstein RM; Pathophysiology of Dyspnea. NEJM (1995), 333:1547-1553

  17. Mechanism of Dyspnea Sense of Respiratory Effort • “Effort” major factor in breathlessness • Simultaneous motor cortex signals • Efferent to respiratory muscles • Signal to sensory cortex • Mismatch enhances sense of effort • Probably similar signals from brainstem

  18. Mechanism of Dyspnea Chemical Receptors • Hypercapnia • Hypoxia

  19. Mechanism of Dyspnea Hypercapnia • Early studies in normal subjects suggested CO2 not a factor • Probably mediated by pH

  20. Mechanism of Dyspnea Hypoxia • Some evidence of effect • Still… • Some patient hypoxic—not SOB • Some patients SOB—not hypoxic • Some hypoxic/SOB pts show little improvement with O2 therapy

  21. Treatment of Dyspnea • Treat underlying causes • Oxygen • Nebulized bronchodilators • Opioids • Benzodiazepines • Nebulized opioids used by some but no solid evidence of efficacy • Fans across face

  22. Decision Making/Ethical Issues • Opioids and hastening death • Withdraw vs. Withhold • DNI

  23. Resistance to Opioids for Dyspnea • Hasten death; “kill patient” • Response: • Tolerance to respiratory depression • Slowing respirations may improve oxygenation

  24. Resistance to Opioids for Dyspnea • However, failing to intubate and ventilate a patient in severe respiratory failure will result in death (with or without opioids). • Opioids may hasten that death • Double effect

  25. Withhold LST vs. Withdraw • Logical/clinical difference? • Therapeutic trials • Duty to start or stop independent of whether the treatment is already in place • Legal difference? NO • Religious difference • Psychological difference

  26. Withhold vs. Withdraw Ventilator • Quality of life (prior to vent decision) • Reversibility

  27. Withhold vs. Withdraw Ventilator Trial—withdraw later • Acceptable quality of life • Reversible condition

  28. Withhold vs. Withdraw Ventilator Trial—withdraw later • Acceptable quality of life • Reversible condition • Clear timetable, endpoints to gauge “success” of the trial

  29. Withhold vs. Withdraw Ventilator Trial—withdraw later • Acceptable quality of life • Reversible condition • Clear timetable, endpoints to gauge “success” of the trial • Legally appointed agent to act on behalf of the patient

  30. Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) • Poor quality of life • Irreversible process

  31. Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) • Poor quality of life • Irreversible process • Prior “reversible process,” tough wean

  32. Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) • Poor quality of life • Irreversible process • Prior “reversible process,” tough wean • Crystal clear informed consent: NO need for last minute “clarification.”

  33. Withhold vs. Withdraw Ventilator Die without intubation/ventilation (“DNI”) • Poor quality of life • Irreversible process • Prior “reversible process,” tough wean • Crystal clear informed consent: NO need for last minute “clarification.” • Scrupulous symptom management

  34. Trial / Withdraw Good QoL Reversible ________________ Clear Endpoints Timeframe Outcomes Proxy Withhold Poor QoL Irreversible ________________ Clear Consent No last minute “clarifications” Symptom Treatment Withhold vs. Withdraw Ventilator

  35. Dying Without Intubation Decision making: • Broad planning based on goals of treatment • Positive treatment directed toward ALL goals • Reversibility/Quality of life • Treat respiratory failure symptomatically • No intubation/ventilation

  36. Dying Without Intubation Documentation • Document rationale in detail • Document informed consent discussion • Detailed symptomatic plan Communication • Clear discussions with nurses, family • Explain what to expect • Avoid focus on “not”

  37. Dying Without Intubation What if the patient changes his mind?

  38. Dying Without Intubation Failure to document the informed consent discussion can lead to last minute “clarification” about decision (and patient “changing mind” about intubation).

  39. Dying Without Intubation Failure to provide adequate symptom relief can lead to suffering (and patient “changing mind” about intubation).

  40. Respiratory Death without Intubation/Ventilation • …can be the most appropriate and ethically defensible option. • …can be part of a comprehensive palliative plan based on the patient’s goals of care. • …can NOT be summarized in 3 letters.

  41. Editorial

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