Navigating the Final Priorities of End of Life Care
By Douglas A. Colquhoun, MB ChB, from the IARS, AUA and SOCCA 2019 Annual Meetings*
The educational program of the SOCCA 2019 Annual Meeting closed on Friday, May 18 with a fascinating panel discussion on end-of-life issues faced in the ICU. The panel, entitled, “Final Priorities: Ethics and Quality of Life,” was hosted by Allison Dalton MD, Assistant Professor of Anesthesiology at the University of Chicago, and featured Nicholas Sadovnikoff, MD, Assistant Professor of Anesthesiology at the Harvard Medical School, May Hua, MD, MS, Assistant Professor at Columbia University, and Michael Nurok, MB ChB, PhD, Director of the Cardiac Surgery ICU at Cedars-Sinai Medical Center.
In his presentation, Dr. Sadovnikoff traced the history of ethics committees and their historical origins in the allocation of access to dialysis services. The earliest committee at the Swedish Medical Center was notable for the inclusion of nonphysicians in medical decision-making and the development of criteria for allocation of dialysis, which at that time was an extremely scarce resource. These committees and subsequent high profile legal cases led to the requirement by the Joint Commission in 1992 that all institutions develop ethics committees. In modern practice, the ethics committee has three key roles: clinical consultation, policy development, and education.
With conflict over goals of care and issue of proxy, decision makers make up around half of consultation requests. Dr. Sadovnikoff went on to explore the concept of “potentially inappropriate treatments” and the tension between family and medical team members. He discussed four pitfalls, which may be encountered in exploring these issues with families – starting conversations very late in the disease process, placing excessive focus on “minutiae” such as individual lab values, fear by the medical team offering advice, and expecting instant decisions from families. He went on to discuss the principles of ethics consultation when in the engagement of stakeholders, gathering of facts and convening meetings to attempt to move towards consensus.
Dr. Hua described evolving models of palliative care. She discussed the problem with a traditional approach of sudden and late involvement or consideration of hospice care. Instead, she advocated for an approach whereby palliative care is considered and delivered alongside life-prolonging care with a more gradual transition in focus as the clinical situation warrants. This also incorporates postbereavement support. She argued that the core goal of palliative care was relieving suffering which should be accessible for all patients. This would allow the early involvement in the care of ICU patients.
In recognizing the cultural shift this may require, she challenged the underlying assumption that the death of a patient in the ICU represents failure of care. She outlined the potential harms of aggressive ICU care and causing patient suffering. Dr. Hua presented two models for the delivery of palliative care: one focused on delivery by the ICU team and one focused on delivery by a specialist team, recognizing that there may only be times where these models may overlap. Her presentation closed with an example of a program, which would allow ICU teams to deliver more effective support to dying patients and their families.
The session closed with a presentation from Dr. Nurok where he discussed ideas of value and cost at the end of life. He outlined the increased economic scrutiny, which health systems are under from payers seeking to optimize outcomes and minimize cost. Noting the high cost of critical care and its high utilization near the end of life, he challenged conventional wisdom and contended that there were in fact substantial challenges in attempting to reduce costs in such patients. Pointing to evidence regarding poor prognostic abilities of ICU clinicians and inability to manage reallocation of resources, he indicated a relative infeasibility of this approach to reduce the overall cost of care. Using a thought experiment, he discussed the tradeoff between cost of care and its likelihood of delivery of a good outcome. He argued that, in fact, was a false choice, because care without benefit should not be considered regardless of the resource utilization.
*Coverage from the SOCCA Education Session IV: Final Priorities: Ethics and Quality of Life during the SOCCA 2019 Annual Meeting