Ethics in Critical Care Case File

Ethics in Critical Care Case File

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 7

A 25-year-old male organ donor in the ICU is diagnosed as brain dead after suffering  a closed head trauma in a motorcycle accident. He is intubated on an AC mode  with a  rate of 16 breaths/minute, Yt 450 ml,  F102 35%. Arterial blood gas (ABG)  data are: pH 7.36, Paco2 36 mm Hg,  Pao2 150 mm Hg on fractional inspired oxygen   concentration (F102)  of 35%. The transplant team and operation room team  are alerted. The blood pressure  (BP)  is 110 mm Hg systolic and 60 mm Hg diastolic,  heart rate (HR) is 110 beats/minute and regular; temperature is 96°Fahrenheit  (F), weight 70 kg, and height 62 in. Electrolyte values are sodium (Na+) 155  mEq/L,  potassium (K⁺) 4  mEqfL,  chloride (CI^-)  105  mEq/L,  bicarbonate  (HC03)  20 mEq/L.  His urine output is 150 ml/h.

⯈ What are the most appropriate next steps while awaiting organ transplant? 

⯈ What is the most important parameter that impacts on organ survival?

ANSWER TO CASE

Ethics in Critical Care

Summary: This 25 -year-old patient is brain dead and is an organ donor. Life support should continue while striving to maintain physiologic and laboratory variables "within normal limits" to preserve organ integrity until procurement of the organ by the transplant team. 

• Next steps while awaiting organ transplantation: Maintain the patient/donor's physiologic parameters as close to normal as possible. 
• Most important criteria for organ survival: Time is of the essence in this situation. Coordinate all paperwork and required testing ASAP. Decreased time equals increased cell or organ survival.

ANALYSIS

Objectives

1. To understand basic care for brain death in adult organ donor patients.
2. To understand the physiologic changes involved in organ donors.

Considerations

This unfortunate 25 -year-old man suffered a motor vehicle and has been diagnosed as brain dead, presumably due to global and irreversible loss of brain stem function. This patient is a candidate to be an organ or tissue donor, which is identified based on prior wishes such as indicated in an advanced directive or an organ donor card, and based on discussion with the family. Significant emotional issues may be involved with a loved one; thus, a specially trained hospital staff member or a representative of an organ procurement organization speaking to the family can help the family through some of the difficult decisions and respecting the family's wishes. The declaration of brain death requires establishing the patient being in a coma and with no evidence of brain stem reflexes (such as breathing independently, pupil reaction to light, eye movement, or arms and legs pulling away from noxious stimuli) . To produce the best outcome for organs, keeping the patient's physiological processes as normal as possible is important: BP, RR, oxgynation, and fluid/electrolyte status. A coordinated team approach is likewise optimal to help the family through the grieving process, working with the medical team, and communicating with the transplant team.

Approach To:

General Organ Donor Issues

In this situation common sense judgments of critical care are applied. Guidelines generally include optimizing cardiovascular and pulmonary function, fluid and elec­trolyte balance, identification and treatment of infection, and the administration of hormones. The Donor Risk Index shows how these "fixed" criteria are interrelated with the variable criteria. Donor organs are influenced by the prevailing systemic physiology ( eg, oxygen delivery, blood electrolyte composition, regional and sys­temic cytokines). General parameters of optimal care are addressed as well as indi­vidual factors that may affect a transplantable organ (see Table 7-1).

TREATMENT TIME

Minimize the time between collection and implantation of the   donor organ. Spe­cialized centers seriously dedicated to following the best practice guidelines have had a major impact in increasing satisfactory treatment. Transplantation specialists encourage modestly elevated blood glucose levels. Neuroglycopenia during insulin therapy ceases to be a concern in the brain-dead donor. The immunosuppressive effect induced by hyperglycemia might benefit the recipient. 

Coagulopathy and Transfusion Therapy

The optimal hemoglobin and hematocrit levels for donor patients are outlined in Table 7-1. The requirement for oxygen uptake is now freed from consideration of the brain, a major oxygen-consuming organ. The reduction in cardiac output lowers oxygen delivery to transplantable organs. Items of particular concern are the inflam­matory mediator bur  den, acute lung injury, and possible transmission of viruses to the recipient. The potential effect of a compromised immune status due to transfusion is unknown. Multiple blood transfusions usually improve transplant success. Hemor­rhage is not desirable, but "intrinsic" anticoagulation may be beneficial for organ perfusion. Infusion of the  coagulation factors contained in  fresh, frozen plasma and platelet concentrates have been associated with transfusion related acute lung injury in critically ill medical patients (TRALI), which is indistinguishable from 

ARDS. Recombinant factor VIIa represents a special concern. Although often used for off-label indications during traumatic and neurosurgical bleeding, the value of this factor has not been evaluated in donors.  Platelet transfusion likewise may pre­cipitate lung injury and release proinflammatory substances. The benefit or poten­tial harm of supplemental platelet infusions when antiplatelet drugs have recently been used to treat thrombocytopenia remains unknown. 

Body Temperature and Hormone Replacement 

After brain death, most donors develop mild to moderate hypothermia, which may aid in reducing metabolism in donor organs. The harmful side effects of hypothermia include increased polyuria, alterations in coagulopathy, and dysrhythmias. Polyuria may respond to the administration of vasopressin and fluids.

Primary hypoadrenalism may result from brain death or the donor's antecedent injuries or diseases. Corticosteroids above "stress dosages" are commonly used to support lung transplantation. Supplemental mineralocorticoids may correct donor hyponatremia, but this is balanced with the high incidence of coexisting diabetes insipidus. Additional doses of corticosteroids or an IV infusion may be needed if donor care extends beyond 8 to 12 hours. More organs can be recovered when various synergistic combinations of hormones are used. Corticosteroid therapy is an exception and if it is not used for lung support, it is still given for full stress coverage, especially when hypotension persists despite adequate fluid and vasoactive drug treatment. Thyroid hormone therapy is widely accepted for routine administration as well as a "rescue" medication to treat hypotension that is refractory to inotropic or vasopressor agents. The recommended dose of triiodothyronine (T3) is 2 to 3 mg per hour intravenously.

Polyuria, which commonly occurs after brain death, places organs at risk due to subsequent hypovolemia, hypotension, and hypoperfusion. Etiologies of polyuria include physiologic diuresis, residual effects of diuretics given for the treatment of intracranial hypertension, osmotic diuresis due to residual mannitol, hyperglycemia, or diabetes insipidus (DI). Polyuria from causes other than DI usually does not produce significant hypernatremia. Hypernatremia after transplantation is associated with reduced liver function. Sodium levels > 155 mEq/L are the accepted maximum. Intravenous replacement with balanced salt solutions or hypotonic saline is recommended when the urine output is above 150 to 200 mL/h. Significant hyperglycemia may develop if excess dextrose and water solutions are used, and should be treated. Aqueous vasopressin may be administered in repeated intravenous boluses (5-10 U) or titrated as an infusion t o treat polyuria. Desmopressin (DDAVP) i s also effective as an intravenous bolus (0.5-2 micrograms) repeated as necessary to achieve the desired urine output.

Nutrition, Reperfusion, and Preconditioning

Nutrients may facilitate glycogen deposition in the liver, enhance the availability of fatty acids and glutamine useful to the heart, and provide omega-3 fatty acids or amino acids helpful for renal protection. The administration of coenzyme CoQ10 has some promise a s a cardiac protectant. Studies have shown that CoQ10 lowers blood pressure slightly and potentially protects the heart against decreasing the synthesis of this enzyme in the heart, which can be depleted by Statin use.

Injury to transplanted organs occurs via the production and release of free radicals and other harmful substances at the time of organ implantation, rewarming, and reperfusion. In addition, injury is seen when significant hypotension is followed by resuscitation and improved tissue perfusion to the transplanted organ. An episode of controlled hypotension, however, may precondition some organs (especially the liver) before explantation, by increasing its tolerance to reperfusion injury after implantation. Dopamine use is not beneficial in preventing such injury.

Conclusion

Donor care is often a complex undertaking. Providing the best possible organs to awaiting recipients demands careful attention to multiple variables. The paucity of evidence-based data is a challenge to the critical care, organ procurement, and transplantation teams. "Do-not-resuscitate" ( DNR) orders are ethical issues that frequently occur in the ICU. These orders should be displayed clearly on the patient's chart. If such orders are not present, the patient can be asked about their wishes for resuscitation following a cardiac arrest or life-threatening arrhythmia. Like many other medical decisions, deciding whether or not to resuscitate a patient who suffers a cardiopulmonary arrest involves a careful consideration of the potential likelihood for clinical benefit balanced with the patient's preferences for the intervention and its likely outcome. Decisions to forego cardiac resuscitation are often difficult because of real or perceived differences in these considerations.

WHEN SHOULD CPR BE ADMINISTERED?

Cardiopulmonary resuscitation (CPR) and advanced cardiac life support (ACLS) are a set of specific medical procedures designed to establish circulation and breathing in a patient. CPR and ACLS are designed to maintain perfusion to vital organs while attempts are made to restore spontaneous breathing and cardiac rhythm by bedside defibrillation. If the patient stops breathing or cardiac arrest occurs in the hospital, the standard care is to perform CPR in the absence of a  valid physician's order to withhold it. Paramedics responding to an arrest in the field are required to administer CPR. 

Hospitals have policies, which describe circumstances under which CPR can be withheld. Some general situations which justify withholding CPR are 

• When CPR is judged to be of no medical benefit. 
• When the patient with the capacity to make serious decisions clearly indicates that he/she does not want CPR, with signed documents confirming these wishes clearly written in medical rather than legal language. 
• When the patient displays an impaired decision-making capacity, a surrogate can make the decisions for the patient. The surrogate can clearly indicate that the patient does not wish to receive CPR. 

CPR is futile when it offers the patient no clinical benefit; in these circumstances, physicians are ethically justified in with holding resuscitation. Clearly, it is impor­tant to define  what it means to "be of benefit." The distinction between merely providing measurable effects ( eg, normalizing the serum potassium) and providing significant health benefits is helpful in this deliberation.

One approach to defining benefit examines the probability of an   intervention leading to a desirable outcome. CPR has been prospectively evaluated in a wide variety of clinical situations. Knowledge of the probability of success with CPR could be used to determine its futility. 

CPR might also seem to lack benefit when the patient's quality of life is so  poor that no meaningful improvement is expected with resuscitation. Judging "quality of life" tempts prejudicial statements about patients with a  chronic illness or disability. There is substantial evidence that patients with such chronic conditions often rate their qual ity of life much higher than would healthy people. There is probably a consensus that patients in a permanent unconscious state possess a quality of life that few would accept. Therefore, CPR is usually considered "futile" for patients in a persistent vegetative state. 

There is no obligation to provide CPR when it is judged to be medically futile. Nevertheless, in keeping with the principle of autonomy, the patient and/or their family should still have a role in the decision about a do-not-resuscitate (DNR) order. In many cases, the patient/family, upon being given a caring but frank understand­ing of the clinical situation, will agree with the DNR order. In such cases a DNR order can be written at that time. Each hospital should have specific procedures for writing a valid DNR order. In all cases, the order must be written or cosigned by the attending physician. A decision to withhold CPR may also arise from a patient's expressed wish that CPR not be performed. If the patient understands the existing medical condition and possesses an intact decision-making capacity, then the DNR request should be honored. 

Ethicists and physicians are divided over how to proceed if the family members dis­agree. A DNR order can only be written with full patient/family agreement. Every rea­sonable effort should be made to explain all details of the  medical situation with involved parties, which usually will lead to a  resolution of the conflict. In difficult cases, an ethics consultation can prove helpful. Nevertheless, CPR should generally be provided to such patients, even if judged futile. The so-called "slow-codes," where half-hearted efforts at resuscitation are made, are not ethically justified. Such actions undermine the patient's rights and violate the code of physician-patient trust. In most instances, the decision to initiate or deny CPR occurs at a  time when the patient is unable to participate in deci­sion making, and their preference is unknown. There are 2 general approaches to this dilemma: Advanced directives and Surrogate decision makers.

Advanced Directive 

The advanced directive is a document that details the kinds of decisions the patient would like to have made if he/she is unable to participate at the time when the criti­cal decision must be made. This document may list or indicate specific decisions (eg, living will); otherwise it may designate a specific person to make health-care decisions for them (ie, durable power of attorney for health-care and surrogate). There is some controversy of how literally living wills should be interpreted. Prefer­ences expressed in a   living will are most compelling when they reflect long-held, consistently stable views of the   patient. This can often be determined by conversa­tions with family members, close friends, or health-care providers who have had a long-term relationship with the patient. 

Surrogate Decision Maker 

In the absence of a written document, the law recognizes a hierarchy of family relationships in determining which family member should be the official "spokes­person." See Table 7-2. 

CONCLUSIONS

Basic medical treatment should not be withheld, but established medical and ethical practices should be performed. When confronted with decisions regarding interventions with CPR, the healthcare team should demonstrate respect for personal autonomy and provide informed consent. DNR orders should not be converted into do-not-treat or do-not-rescue orders without adequate documentation from a proper source. Emergencies do not alter the standards of medical care, but the best possible care should be rendered under the circumstances, within the patient's informed consent. The standard of care is the same in sickness and in health, including medical/surgical emergencies.

CLINICAL CASE CORRELATION

• See also Case 3  (Scoring Systems and Patient Prognosis)

COMPREHENSION QUESTIONS

7.1 Mr H is a 24-year-old man who resides in a skilled nursing facility, where he is undergoing rehabilitation from a cervical spine injury. The injury left him as a quadriplegic. He has normal cognitive function and no problems with respiration. He is admitted to your service for treatment of pneumonia. The resident suggests antibiotics, chest physiotherapy, and hydration. The intern says "he should be a DNR, based on medical futility." In which of the following clinical scenarios does CPR intervention offer the most benefit?

A. ICU patient with acute stroke

B. Patient with metastatic cancer

C. Patient in septic shock

D. Patient with renal failure

E. Patient with severe pneumonia

7.2 An 82-year-old woman with colon cancer and liver metastases was admitted for chemotherapy. Because of her poor prognosis, she is asked about a DNR order, but she requests to be "a full code." Which is the most appropriate management of this patient?

A. Explain to the patient that her signing a DNR order means the patient will need to be placed in hospice care.

B. Emphasize to the patient with compassion that a decision should be made in the next several hours in case a cardiac arrest occurs.

C. Sharing this decision with family members is rarely helpful since guilt is often a complicating factor.

D. Discuss with the patient that DNR will not mean the patient will receive less care.

ANSWERS TO QUESTIONS

7.1 D. Renal failure can be treated both acutely and chronically with dialysis. The other answer choices are associated with higher medical futility, meaning that an intervention such as CPR may offer no chance of significant benefit to the patient. Interventions can be considered futile if the probability of success (discharged alive from the hospital) is < 1 % and/or the quality of life is below the minimum acceptable to the patient. In the scenario from this question, the patient's probability of survival after CPR is below average, based on his quadriplegia and mild pneumonia. In fact, in cases of severe pneumonia and respiratory failure survival is < 1 % . His quality of life is not without value. Since he is fully awake and alert, Mr H could be asked about his view of the quality of his life. A discussion about likely scenarios should he have a cardiac arrest and need CPR is important. Thereafter, Mr H can tell you if he prefers to have CPR or nothing done in the event of an arrest. No judgment about the possible utility or futility of CPR based on Mr H's current condition can be reached without a discussion. The decision about resuscitation should occur only after consulting with the patient and family members about his situation and reaching a joint decision.

7.2 D. This patient is elderly and has a diagnosis of metastatic cancer. Out of hospital survival would not be expected should this patient require CPR. Thus CPR for Ms W could be described as a "futile" effort. The patient does not meet other criteria for futility. It is important that she is of sound mind. A DNR order should not be written even if a CPR would be judged as useless unless there is patient or family concurrence. Patients must be given time to understand the seriousness of their diagnosis. Periodic readdressing the question of CPR with them and their family should be continuing. This is best done in the context of other medical decisions that occur during the patient's care. Emphasize that a DNR order does not mean the patient will be abandoned or receive a lower standard of care.

CLINICAL PEARLS

⯈ A  coordinated approach to the donor patient and family  is crucial, to address emotional and spiritual needs, optimize the physiological param­eters, and work together with the transplant team. 

⯈ While there is limited data guiding this area, expert opinion recommends a  maintenance  or restoration  of normal physiologic  and laboratory parameters. 

⯈ Cardiovascular instability often occurs during the evolution of brain death due to catecholamine surges, cytokine production, and neurovascular changes. 

⯈ Aggressive critical care interventions can correct cardiovascular instabil­ity and reverse or preserve normal organ functions, allowing transplanta­tion to proceed. 

⯈ More  research  is needed to define the level of physiological variability that is acceptable in organ donors.

References

Annas OJ . Standard of care: in sickness and in health and in emergencies. N Eng! ] Med. 2010;362: 2 1 26-2 1 3 1 . 

Chemiack EP. Increasing use o f DNR orders i n the elderly worldwide: whose choice i s it? ] Med Ethics . 2002 Oct;28 ( 5 ) :303 -3 0 7 . 

Deutschman C, Neligan P. Evidence-Based Practice of Critical Care. Philadephia: Saunders, Elsevier; 2010. 

Holmquist M, Chabalewski F, Blount T, et al. A critical pathway: guiding care for organ donors. Crit Care Nurse 1 999 ; 1 9 :84-98. 

Loscalzo J. Harrison's Pulmonary and Critical Care Medicine. New York: McGraw-Hill; 2010. 

Wood KE, Becker BN , McCartney JG, et al. Care of the potential organ donor. N Engl ] Med . 2004;3 5 1 : 2730-2739.

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