Article
Characteristics and Outcomes of Ethics Consultations in an Oncologic Intensive Care Unit
Journal of Intensive Care Medicine 1-7 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066614538389 jic.sagepub.com
Louis P. Voigt, MD1,2, Prabalini Rajendram, MD1, Andrew G. Shuman, MD2, Sunil Kamat, MD1, Mary S. McCabe, RN, MA2, Natalie Kostelecky, RN1, Stephen M. Pastores, MD1, and Neil A. Halpern, MD1
Abstract Objective: To evaluate the frequency, characteristics, and outcomes of ethics consultations in critically ill patients with cancer. Design, Setting, and Methods: This is a retrospective analysis of all adult patients with cancer who were admitted to the intensive care unit (ICU) of a comprehensive cancer center and had an ethics consultation between September 2007 and December 2011. Demographic and clinical variables were abstracted along with the details and contexts of the ethics consultations. Main Results: Ethics consultations were obtained on 53 patients (representing 1% of all ICU admissions). The majority (90%) of patients had advanced-stage malignancies, had received oncologic therapies within the past 12 months, and required mechanical ventilation and/or vasopressor therapy for respiratory failure and/or severe sepsis. Two-thirds of the patients lacked decisionmaking capacity and nearly all had surrogates. The most common reasons for ethics consultations were disagreements between the patients/surrogates and the ICU team regarding end-of-life care. After ethics consultations, the surrogates agreed with the recommendations made by the ICU team on the goals of care in 85% of patients. Moreover, ethics consultations facilitated the provision of palliative medicine and chaplaincy services to several patients who did not have these services offered to them prior to the ethics consultations. Conclusion: Our study showed that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients’ surrogates in the majority of cases. Additionally, these consultations identified the need for an increased provision of palliative care and chaplaincy visits for patients and their surrogates at the end of life. Keywords ethics consultations, end of life, intensive care unit, cancer, palliative care
Introduction Ethics consultations are designed to analyze and resolve ethical issues or conflicts that arise among health care providers, patients, and surrogates.1 These disagreements may be due to differences in strongly held beliefs and values, differing views regarding the goals of care, ineffective communications, inadequate psychosocial support, or any permutation thereof.2-5 The role of the ethics consultant is to facilitate communication and to apply moral reasoning, ethical principles, and regulatory guidelines to mediate discordant values and viewpoints or refocus the social or clinical conflict. Ethical conflicts typically occur in the intensive care unit (ICU) because of the unpredictable nature of acute lifethreatening illnesses, the speed at which clinical decisions must be made, the urgency of deploying life-sustaining technologies, and the shifts from curative or supportive therapies to end-oflife (EOL) care.6-8 Not only are these transitions of care difficult for surrogates to process, but frequently the conversations
surrounding these events are conducted with ICU physicians that are barely known to them.9,10 Several studies have shown that ethics consultations are beneficial in resolving EOL care disputes in the ICU, decreasing the use of life-sustaining therapies, and reducing ICU length of stay (LOS).1,11,12
1 Department of Anesthesiology and Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA 2 Ethics Consultation Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Received December 6, 2014, and in revised form February 18, 2014. Accepted for publication March 7, 2014. Corresponding Author: Louis P. Voigt, Department of Anesthesiology and Critical Care Medicine, Ethics Consultation Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY 10065, USA. Email: [email protected]
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Patients with cancer have an illness trajectory that arguably differs from patients afflicted with other potentially fatal conditions.13 Medical oncologists and oncologic surgeons, as well as patients and families, frequently struggle accepting terminal conditions.14,15 Oncologists may be reluctant to engage in EOL discussions, especially when early phase clinical trials are available.16-20 The lack of advance directives and the loss of decision-making capacity in many ICU patients may contribute to conflicts at the EOL.21 Furthermore, advance directives specifying limitations in care are often ignored in the critically ill oncologic population by the patient, family, and clinical staff, giving rise to disagreements among the family or health care providers as to their applicability and relevance.22-25 The objectives of this study were to evaluate the frequency, characteristics, and outcomes of ethics consultations of patients admitted to an oncologic ICU.
Patients and Methods Using ICU, hospital, and ethics databases, we retrospectively identified all adult patients who were admitted to a 20-bed medical–surgical ICU at Memorial Sloan Kettering Cancer Center (MSKCC) and had an ethics consultation performed between September 2007 and December 2011. We also identified the total number of hospital admissions and hospital-wide ethics consultations during this time period. MSKCC is a 470bed academic, tertiary care, National Cancer Institute designated comprehensive cancer center in New York City. The ICU is staffed by full-time intensivists (who are the attending physicians of record), critical care medicine fellows, acute care nurse practitioners, physician assistants, anesthesiology residents, critical care nurses, and social workers. Patient representatives, integrative medicine specialists, and chaplains are also valued members of the multidisciplinary ICU team. Hospital policy allows ethics consultations to be requested by any health care provider, patient, or family member. Ethics consultations are conducted by 1 or 2 members of a subgroup of the institution’s ethics committee. The consultants have training in medical ethics (nurses with advanced degrees, social workers, psychiatrists, surgeons, and intensivists) and participate in an established 24/7 call schedule. Most consultants have clinical experience of more than 10 years in ethics. Upon the initiation of the ethics consultation, the consultant identifies the relevant clinical staff and patients/surrogates and meets with them to ascertain the issues prompting the consultation and to try to reach an agreement on the plan of care. Ethics consultations are documented in the medical records. The following variables were collected on ICU admission and during the ICU stay: age, gender, religious affiliation, race, marital status, primary admitting service, cancer type (hematological, gastrointestinal [GI], breast, thoracic, genitourinary, head and neck, and miscellaneous), cancer stage, interval since cancer diagnosis, oncologic therapies (ie, chemotherapy, radiation therapy, surgery, and image-guided interventions such as radiofrequency ablation of primary or metastatic tumors, angiogram/embolization for GI bleeding,
catheter drainage of fluid collections and effusions, stent placements, etc) administered within either 1 year and 30 days prior to hospital admission and during the current hospital admission, main reasons for ICU admission (determined from ICU attending admitting notes), Mortality Probability Model II score on ICU admission,26,27 and use of lifesustaining treatments including mechanical ventilation, vasopressors, and continuous renal replacement therapy (CRRT) or hemodialysis (HD). The dates of hospital, ICU admission and ethics consultation, and ICU and hospital (pre-ICU, ICU, and post-ICU) LOS and mortality were assessed. The 6-month mortality rate was also recorded. Data collected for the ethics consultations included clinical background of the ethics consultant (profession and duration of ethics practice) and identification of the individuals requesting the ethics consultation (ICU team members, non-ICU clinicians, patients, and surrogates). We determined the patient’s decision-making capacity (based on assessment by the ICU attending physicians at the time of the ethics consultation), presence of advance directive and/or health care agent or surrogate, and resuscitation status pre- and post-consultation. The ICU and ethics consultation notes were analyzed to determine the reasons for the consultations using an established coding schema.28 We categorized the treatment conflicts regarding EOL care between the patients/surrogates and the ICU teams into 3 groups: limitation of life-sustaining treatments (LOLST; ie, mechanical ventilation, vasopressor medications, or CRRT/HD), withdrawal of life-sustaining treatments (WOLST; ie, mechanical ventilation, vasopressor medications, and/or CRRT/HD), and ‘‘other’’ (ethical conflicts related to code status, refusal of recommended therapeutic procedures, disclosure and truth telling, absence of a consenting surrogate decision maker, and requests for change of physicians). We did not include specific discussions about code status in the LOLST group because decisions about cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) orders do not necessarily imply any other limitations of care. For each of the 3 groups, we established whether or not an agreement was reached with the patients/surrogates to follow the recommendations of the ICU team or for the ICU team to continue life-sustaining interventions (ie, mechanical ventilation, vasopressors, and CRRT/HD) in accordance with the patients/surrogates’ preferences, and we determined the outcome of all patients. Finally, we identified whether chaplaincy and palliative medicine consultations were obtained prior to ethics consultations and whether these services were recommended by the ethics consultants. In our hospital, palliative medicine assists patients with symptom management and EOL care and is independent of the ethics consultation service. Descriptive statistics on the collected data were conducted using Microsoft Excel 2010 (Redmond, Washington). Continuous variables are presented as mean + standard deviation or median and interquartile range (25th to 75th percentile). The study was granted a waiver of informed consent by the institutional review board.
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Table 1. Patients’ Demographic Data, Religious Affiliations, and Cancer Crosswalk. Variables Demographic data Age, years Male Race White Black Asians Other Marital status Married Single Divorced Widow Other Religion Jewish Catholic Christian Muslim Hindu None/not recorded Primary admitting service Medicine Surgery Cancer type Hematological Gastrointestinal Breast Thoracic Genitourinary Miscellaneous (sarcoma and melanoma) Head and neck
Mean + SD or n (%) 64 + 13 28 (53) 39 (73) 9 (17) 3 (6) 2 (4) 23 (43) 13 (25) 7 (13) 7 (13) 3 (6) 19 (36) 17 (32) 10 (19) 1 (2) 1 (2) 5 (9) 40 (76) 13 (24) 14 (26) 12 (23) 8 (15) 7 (13) 5 (9.5) 5 (9.5) 2 (4)
Abbreviations: SD, standard deviation, n, number of patients.
Results During the 4-year study period, 201 (0.2%) ethics consultations were requested for 102 279 hospital admissions. Of these ethics consultations, 53 (26%) were placed for 5010 ICU admissions (1%) during the same time period.
Table 2. Patients’ Clinical and Outcome Data. Variables Reason for ICU admission Respiratory failure Respiratory insufficiency Severe sepsis and/or septic shock Neurologic catastrophe Bleeding Renal failure Abdominal catastrophe Postcardiac arrest Severity of illness score on ICU admission MPM II score Life-sustaining therapies Mechanical ventilation during ICU stay Vasopressor use during ICU stay Mechanical ventilation and vasopressors CRRT/HD Outcome data ICU LOS, days Hospital LOS, days ICU mortality Hospital (ICU and post-ICU discharge) mortality Six-month mortality
n (%), Mean + SD or Median (IQR) 16 10 7 7 5 4 3 1
(30) (19) (13) (13) (10) (7) (6) (2)
0.51 + 0.26 44 38 35 7
(83) (72) (66) (13)
9 25 27 41
(5-18) (10-42) (51) (77)
49 (92)
Abbreviations: n, number of patients; SD, standard deviation; IQR, interquartile range; ICU, intensive care unit; MPM II, Mortality Probability Model II; CRRT, continuous renal replacement therapy; HD, hemodialysis; LOS, length of stay.
admission. Nearly half (n ¼ 26, 49%) of the patients were admitted to the ICU for respiratory insufficiency/failure, and the majority of patients required mechanical ventilation (n ¼ 44, 83%) or vasopressor therapy (n ¼ 38, 72%; Table 2). The ICU and hospital LOS were 9 and 25 days, respectively. In all, 27 (51%) patients died in the ICU and a total of 41 (77%) patients died in the hospital. Of the 12 hospital survivors, 6 were discharged to hospice and the other 6 were discharged to rehabilitation facilities (n ¼ 4) and home (n ¼ 2). At 6 months, only 4 of the 12 hospital survivors were alive, bringing the 6-month mortality of the entire cohort to 92% (Table 2).
Ethics Data Demographic and Clinical Data Demographic data, religious affiliations, race, marital status, primary admitting service, and cancer type are described in Table 1. In all, 48 (90%) patients had advanced-stage malignancy; 3 (6%) patients had early-stage cancer, and 2 (4%) had no evidence of active cancer. Prior to hospital admission, 59% (n ¼ 31) had a cancer diagnosis of less than 1 year, 15% (n ¼ 8) between 1 and 4 years, and 26% (n ¼ 14) of 5 years or more. The majority (n ¼ 47, 89%) received oncologic therapies within 1 year of admission. Slightly more than half (n ¼ 27, 51%) of the patients received image-guided interventions for cancer within 30 days of hospital admission and 46 (87%) patients received these interventions during the current hospital
More than half of the ethics consultations were performed by nurse ethicists (n ¼ 30, 57%) and by individuals with 10 or more years of experience (n ¼ 46, 85%). Ninety-four percent (n ¼ 50) of ethics consultations were requested by members of the ICU multidisciplinary team. Ninety-two percent (n ¼ 49) of the ethics consultations were for conflicts surrounding EOL care. Of these, 77% (n ¼ 41) were precipitated by disagreements in the goals of care between the ICU team and surrogates. At the time of ethics consultation, 26% (n ¼ 14) of patients had DNR orders, 77% (n ¼ 41) lacked decisionmaking capacity, 98% (n ¼ 52) had identifiable surrogates, and 13% (n ¼ 7) had an advance directive. Patients and/or surrogates participated in 100% of the ethics consultations. After
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ethics consultation, an additional 60% of patients had DNR orders. The median durations of hospital and ICU admissions to ethics consultation were 15 (7-24) and 6 (1-11) days, respectively. Prior to ethics consultation, the palliative medicine service was consulted in 34% (n ¼ 18) of patients and chaplaincy in 19% (n ¼ 10). After ethics consultation, recommendations were made for an additional 8 (15%) palliative care and 9 (17%) chaplaincy consultations. The 53 patients were categorized into 3 groups: LOLST, WOLST, and other.
Limitations of Life-Sustaining Treatments Group Among the 25 patients in the LOLST group, disagreements involved the surrogates and the ICU team for 23 patients; for the remaining 2 patients, the conflict was between physicians (n ¼ 1) and within the family (n ¼ 1). After ethics consultations, an agreement was achieved between the ICU team and patients/surrogates to limit life-sustaining interventions for 19 patients. Of these patients, 6 already had a DNR order prior to the ethics consultation; DNR orders were entered for the other 13 patients following the consultation. Of the 19 patients for whom an agreement was reached between the ICU team and patients/surrogates to limit interventions, 17 died in the ICU and 2 were discharged from the hospital. For the 6 patients where an agreement was not reached between the ICU team and patients/surrogates to limit care, aggressive interventions were actively pursued. None had a DNR order preconsultation. One patient had a DNR order instituted after the ethics consultation with the consent of the surrogate despite disagreement with the intensivists regarding several aspects of the care plan. Of these 6 patients, 1 died in the ICU and 5 survived to hospital discharge.
Withdrawal of Life-Sustaining Treatments Group There were 17 patients in the WOLST group. Disagreements involved the surrogates and the ICU team for 15 patients; for the other 2 patients, the conflict was between physicians (n ¼ 1) and within the family (n ¼ 1). After ethics consultation, agreement was reached to withdraw life-sustaining therapies for all 17 patients in this group. In all, 5 had DNR orders before ethics consultation and 12 more after consultation. Sixteen patients died in the ICU. One patient survived to ICU discharge (after discontinuation of mechanical ventilation) and subsequently died on the ward.
Other Group There were 11 patients in the other group. The conflicts were between patients and their family members (n ¼ 5), patients and the ICU team (n ¼ 3), and surrogates and ICU team (n ¼ 3). The conflicts centered on code status in 7 patients. The ethical issues included confidentiality of health care information (n ¼ 5), truth telling (n ¼ 1), initiation of DNR orders (n ¼ 1), surrogate decision-making surrounding code status
(n ¼ 1), no surrogate for procedural consent (n ¼ 1), request for change in physician (n ¼ 1), and refusal of comfort measures while wanting CPR (n ¼ 1). The patient who declined comfort measures realized that death was imminent but wanted CPR while waiting for the surrogates to arrive. In 5 cases, family members disagreed with the patients’ decisions about goals of care and confidentiality. Some family members/surrogates acknowledged the patients’ autonomy but were not always supportive of the patients’ decisions. A small number of patients expressed concerns that the surrogates could reverse their decisions if they lost capacity. Thus, the ICU team sought the assistance of the ethics consultant to counsel the surrogate about his or her role with respect to the patient’s known and previously expressed preferences. Agreement between parties was achieved in 9 patients. For the remaining 2 patients, the requested change in physician was not honored and the patient who refused various treatment options while wanting CPR subsequently died in the ICU after receiving CPR. Of the 11 patients, 3 already had a DNR order preconsultation. Following the consultation, 3 additional patients/surrogates agreed to DNR orders (for a total of 6). In all, 6 patients died in the hospital (2 in the ICU and 4 after ICU discharge); the other 5 patients (including the patient whose request for a change in physician was declined) were discharged from the hospital.
Discussion Ethics consultations were rarely requested in our hospital or in the ICU. However, the 1% rate of ethics consultations initiated in our oncologic ICU is far higher than the general ethics consultation rate within our cancer center and is comparable to the 0.16% to 1% rate of elective ethics consultations for heterogeneous groups of critically ill patients.29,30 Conflicts at the EOL in ICUs in the United States may consume a lot of time and discussion but fortunately are relatively rare.31 The vast majority of families and physicians use a shared decision-making model and agree on the goals of care at the EOL.32 Specifically within our cancer center, we perceive a high degree of collaboration and agreement between the admitting services, the ICU team and surrogates in transitioning goals of care when standardor research-based cancer-directed therapies are no longer a viable option. Nevertheless, we found that there were occasional disagreements between the patients’ surrogates and the ICU team that could not be resolved and resulted in ethics consultations. As in prior studies, the core issues of these ethics consultations involved conflicts between patients/surrogates and–health care providers regarding recommendations for ongoing ICU and EOL care rather than common ethical quandaries.1,28,30,33,34 We hypothesize that a general lack of advance directives and the loss of decision-making capacity contributed to these discords.7 The conflicts between surrogates and ICU staff may have also been amplified by the short interval between the diagnosis of advanced cancer and the ICU admission and the recent delivery of oncologic therapies including image-guided interventions.
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The latter two circumstances (ICU admission and delivery of oncologic therapies) may have conferred some hope to the patients and his or her surrogates and triggered their reluctance to limit life-sustaining therapies. Agreement between the surrogates and the ICU team on the goals of care was achieved after ethics consultation in the vast majority (85%) of cases, a finding comparable to previously reported studies.28-30,35 We ascribe the high level of conflict resolution to the empathy and mediating skills of our ethics consultants in helping surrogates appreciate the problems and solutions differently or better than they perceived them when presented by the ICU team.36-38 Additionally, the ethics consultants encouraged the use of other personnel (chaplains and palliative medicine specialists) to achieve a more positive team effect.7,38 In the remaining 15% of cases, the differences between the ICU team and the surrogates could not be reconciled. The concept of limiting or withdrawing medical interventions and dealing with impending death may simply be unacceptable for a minority of surrogates. Their negative responses to such ICU proposals may have been rooted in their intimate knowledge of the patients’ characteristics, religious beliefs, or the surrogates’ own wishes.23,39-41 For these patients, aggressive interventions (ie, mechanical ventilation, vasopressor agents, and CRRT/HD) were continued as requested by the patients/surrogates and were actively administered by the ICU team. However, the continuation of care that is perceived to be futile and inappropriate certainly adds significant emotional stress to the ICU staff, which must be subsequently addressed.42-45 We found a high hospital survival rate in the small number of patients where an agreement to limit care was not achieved. This finding underscores the difficulties that we and other clinicians face in deciding whether to continue or deescalate life-sustaining interventions even when we are reasonably confident that our recommendations are appropriate given the clinical circumstances.46,47 Despite the development and refinement of prognostication models, the accurate prediction of mortality remains very challenging for critically ill patients with cancer.48,49 Certainly the surrogates’ resistance to the recommendations of the ICU team regarding care limitation or withdrawal may have reflected their appreciation of the uncertainties of medical prognostication.40,50 The high survival rate in this subgroup of patients prompted reflections by the ICU team of the relative ambiguity surrounding prediction of death in critically ill patients.21 Surprisingly, the majority of the ethics consultation cases did not already have prior palliative medicine consultations or chaplaincy visits. This finding highlighted room for quality improvement when caring for critically ill patients and their surrogates.10,51,52 Since the completion of our study, we have modified our approach to palliative medicine and chaplaincy services from a consultative model to an integrative model with embedded palliative care clinicians and chaplains in our multidisciplinary care team.53 Approximately a quarter of the ethics consultations already had a preexisting DNR order. Health care providers sometimes
presume that the presence of a DNR order provides clarity in EOL care.54 This was certainly not evident in the group of patients with a preexisting DNR order who still required ethics consultations. We and others found that the additional EOL and ethics discussions were indispensable for addressing management strategies for the clinical deterioration that commonly precedes death.54,55 Our study has several limitations. First, this is a retrospective study conducted in patients with cancer at a single tertiary cancer center. However, we believe that our findings are applicable and contributory to the EOL care discussions in critically ill patients with cancer that occur in any ICU environment. Second, although our ethics consultation classification was stratified in a systematic manner, any such categorization risks oversimplifying complex and highly individualized clinical and social constructs. Third, while 98% of our patients had identified surrogates, we did not track the socioeconomic status, educational level, or family dynamics of the surrogates. Fourth, we did not collect the number and duration of family meetings prior to and after initiation of ethics consultations. This information will be important in future prospective studies to determine the staffing requirements for ethics consultation teams. Finally, we were not able to ascribe the impact of the palliative medicine or chaplaincy visits on the incidence or outcome of ethics consultations.
Conclusion In summary, ethics consultations in critically ill patients with cancer were infrequently requested. The majority of these consultations involved disagreements between the patients’ surrogates and the ICU team regarding EOL care including proposed limitations and/or withdrawal of life-sustaining interventions. We found that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients’ surrogates in the majority of cases. Ethics consultation also facilitated the increased provision of palliative care and chaplaincy services for patients and their surrogates at the EOL. Acknowledgments We thank Ms. Claire Murray for her stewardship of the institutional ethics consultation database, Ms. Sarah Jewell from the Library Department for her assistance in reviewing the literature on ethics consultations, and Ms. Elaine Ciccaroni from the Medical Graphics service for preparation of the tables.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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36. Tarzian AJ, Asbh Core Competencies Update Task F. Health care ethics consultation: an update on core competencies and emerging standards from the American Society For Bioethics and Humanities’ core competencies update task force. Am J Bioethics. 2013;13(2):3-13. 37. Chwang E, Landy DC, Sharp RR. Views regarding the training of ethics consultants: a survey of physicians caring for patients in ICU. J Med Ethics. 2007;33(6):320-324. 38. Scheunemann LP, McDevitt M, Carson SS, Hanson LC. Randomized, controlled trials of interventions to improve communication in intensive care: a systematic review. Chest. 2011;139(3): 543-554. 39. Boyd EA, Lo B, Evans LR, et al. ‘‘It’s not just what the doctor tells me:’’ factors that influence surrogate decision-makers’ perceptions of prognosis. Crit Care Med. 2010;38(5):1270-1275. 40. Evans LR, Boyd EA, Malvar G, et al. Surrogate decision-makers’ perspectives on discussing prognosis in the face of uncertainty. Am J Respir Crit Care Med. 2009;179(1):48-53. 41. Marks MA, Arkes HR. Patient and surrogate disagreement in endof-life decisions: can surrogates accurately predict patients’ preferences? Med Decis Making. 2008;28(4):524-531. 42. Hamric AB, Blackhall LJ. Nurse–physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate. Crit Care Med. 2007;35(2):422-429. 43. Workman S, McKeever P, Harvey W, Singer PA. Intensive care nurses’ and physicians’ experiences with demands for treatment: some implications for clinical practice. J Crit Care. 2003;18(1): 17-21. 44. Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173(20):1887-1894. 45. Azoulay E, Timsit JF, Sprung CL, et al. Prevalence and factors of intensive care unit conflicts: the conflicus study. Am J Respir Crit Care Med. 2009;180(9):853-860.
46. Christakis NA, Lamont EB. Extent and determinants of error in doctors’ prognoses in terminally ill patients: prospective cohort study. BMJ. 2000;320(7233):469-472. 47. den Boer S, de Keizer NF, de Jonge E. Performance of prognostic models in critically ill cancer patients—a review. Crit Care. 2005; 9(4):R458-R463. 48. Schellongowski P, Benesch M, Lang T, et al. Comparison of three severity scores for critically ill cancer patients. Intensive care medicine. Mar 2004;30(3):430-436. 49. Berghmans T, Sculier JP. Is there any usefulness for a specific scoring system in assessing the prognosis of cancer patients admitted to the intensive care unit? Int Care Med. 2004;30(9): 1849; author reply 1850. 50. Zier LS, Burack JH, Micco G, et al. Doubt and belief in physicians’ ability to prognosticate during critical illness: the perspective of surrogate decision makers. Crit Care Med. 2008;36(8):2341-2347. 51. Hui D, Kim SH, Kwon JH, et al. Access to palliative care among patients treated at a comprehensive cancer center. Oncologist. 2012;17(12):1574-1580. 52. Stetz KM, Hanson WK. Alterations in perceptions of caregiving demands in advanced cancer during and after the experience. Hosp J. 1992;8(3):21-34. 53. Nelson JE, Bassett R, Boss RD, et al. Models for structuring a clinical initiative to enhance palliative care in the intensive care unit: a report from the IPAL-ICU project (improving palliative care in the ICU). Crit Care Med. 2010;38(9):1765-1772. 54. Smith CB, Bunch O’Neill L. Do not resuscitate does not mean do not treat: how palliative care and other modalities can help facilitate communication about goals of care in advanced illness. Mt Sinai J Med. 2008;75(5):460-465. 55. Upadya A, Muralidharan V, Thorevska N, Amoateng-Adjepong Y, Manthous CA. Patient, physician, and family member understanding of living wills. Am J Respir Crit Care Med. 2002; 166(11):1430-1435.
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Characteristics and Outcomes of Ethics Consultations in an Oncologic Intensive Care Unit
Journal of Intensive Care Medicine 1-7 ª The Author(s) 2014 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066614538389 jic.sagepub.com
Louis P. Voigt, MD1,2, Prabalini Rajendram, MD1, Andrew G. Shuman, MD2, Sunil Kamat, MD1, Mary S. McCabe, RN, MA2, Natalie Kostelecky, RN1, Stephen M. Pastores, MD1, and Neil A. Halpern, MD1
Abstract Objective: To evaluate the frequency, characteristics, and outcomes of ethics consultations in critically ill patients with cancer. Design, Setting, and Methods: This is a retrospective analysis of all adult patients with cancer who were admitted to the intensive care unit (ICU) of a comprehensive cancer center and had an ethics consultation between September 2007 and December 2011. Demographic and clinical variables were abstracted along with the details and contexts of the ethics consultations. Main Results: Ethics consultations were obtained on 53 patients (representing 1% of all ICU admissions). The majority (90%) of patients had advanced-stage malignancies, had received oncologic therapies within the past 12 months, and required mechanical ventilation and/or vasopressor therapy for respiratory failure and/or severe sepsis. Two-thirds of the patients lacked decisionmaking capacity and nearly all had surrogates. The most common reasons for ethics consultations were disagreements between the patients/surrogates and the ICU team regarding end-of-life care. After ethics consultations, the surrogates agreed with the recommendations made by the ICU team on the goals of care in 85% of patients. Moreover, ethics consultations facilitated the provision of palliative medicine and chaplaincy services to several patients who did not have these services offered to them prior to the ethics consultations. Conclusion: Our study showed that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients’ surrogates in the majority of cases. Additionally, these consultations identified the need for an increased provision of palliative care and chaplaincy visits for patients and their surrogates at the end of life. Keywords ethics consultations, end of life, intensive care unit, cancer, palliative care
Introduction Ethics consultations are designed to analyze and resolve ethical issues or conflicts that arise among health care providers, patients, and surrogates.1 These disagreements may be due to differences in strongly held beliefs and values, differing views regarding the goals of care, ineffective communications, inadequate psychosocial support, or any permutation thereof.2-5 The role of the ethics consultant is to facilitate communication and to apply moral reasoning, ethical principles, and regulatory guidelines to mediate discordant values and viewpoints or refocus the social or clinical conflict. Ethical conflicts typically occur in the intensive care unit (ICU) because of the unpredictable nature of acute lifethreatening illnesses, the speed at which clinical decisions must be made, the urgency of deploying life-sustaining technologies, and the shifts from curative or supportive therapies to end-oflife (EOL) care.6-8 Not only are these transitions of care difficult for surrogates to process, but frequently the conversations
surrounding these events are conducted with ICU physicians that are barely known to them.9,10 Several studies have shown that ethics consultations are beneficial in resolving EOL care disputes in the ICU, decreasing the use of life-sustaining therapies, and reducing ICU length of stay (LOS).1,11,12
1 Department of Anesthesiology and Critical Care Medicine, Critical Care Medicine Service, Memorial Sloan Kettering Cancer Center, New York, NY, USA 2 Ethics Consultation Service, Memorial Sloan-Kettering Cancer Center, New York, NY, USA
Received December 6, 2014, and in revised form February 18, 2014. Accepted for publication March 7, 2014. Corresponding Author: Louis P. Voigt, Department of Anesthesiology and Critical Care Medicine, Ethics Consultation Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue C-1179, New York, NY 10065, USA. Email: [email protected]
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Patients with cancer have an illness trajectory that arguably differs from patients afflicted with other potentially fatal conditions.13 Medical oncologists and oncologic surgeons, as well as patients and families, frequently struggle accepting terminal conditions.14,15 Oncologists may be reluctant to engage in EOL discussions, especially when early phase clinical trials are available.16-20 The lack of advance directives and the loss of decision-making capacity in many ICU patients may contribute to conflicts at the EOL.21 Furthermore, advance directives specifying limitations in care are often ignored in the critically ill oncologic population by the patient, family, and clinical staff, giving rise to disagreements among the family or health care providers as to their applicability and relevance.22-25 The objectives of this study were to evaluate the frequency, characteristics, and outcomes of ethics consultations of patients admitted to an oncologic ICU.
Patients and Methods Using ICU, hospital, and ethics databases, we retrospectively identified all adult patients who were admitted to a 20-bed medical–surgical ICU at Memorial Sloan Kettering Cancer Center (MSKCC) and had an ethics consultation performed between September 2007 and December 2011. We also identified the total number of hospital admissions and hospital-wide ethics consultations during this time period. MSKCC is a 470bed academic, tertiary care, National Cancer Institute designated comprehensive cancer center in New York City. The ICU is staffed by full-time intensivists (who are the attending physicians of record), critical care medicine fellows, acute care nurse practitioners, physician assistants, anesthesiology residents, critical care nurses, and social workers. Patient representatives, integrative medicine specialists, and chaplains are also valued members of the multidisciplinary ICU team. Hospital policy allows ethics consultations to be requested by any health care provider, patient, or family member. Ethics consultations are conducted by 1 or 2 members of a subgroup of the institution’s ethics committee. The consultants have training in medical ethics (nurses with advanced degrees, social workers, psychiatrists, surgeons, and intensivists) and participate in an established 24/7 call schedule. Most consultants have clinical experience of more than 10 years in ethics. Upon the initiation of the ethics consultation, the consultant identifies the relevant clinical staff and patients/surrogates and meets with them to ascertain the issues prompting the consultation and to try to reach an agreement on the plan of care. Ethics consultations are documented in the medical records. The following variables were collected on ICU admission and during the ICU stay: age, gender, religious affiliation, race, marital status, primary admitting service, cancer type (hematological, gastrointestinal [GI], breast, thoracic, genitourinary, head and neck, and miscellaneous), cancer stage, interval since cancer diagnosis, oncologic therapies (ie, chemotherapy, radiation therapy, surgery, and image-guided interventions such as radiofrequency ablation of primary or metastatic tumors, angiogram/embolization for GI bleeding,
catheter drainage of fluid collections and effusions, stent placements, etc) administered within either 1 year and 30 days prior to hospital admission and during the current hospital admission, main reasons for ICU admission (determined from ICU attending admitting notes), Mortality Probability Model II score on ICU admission,26,27 and use of lifesustaining treatments including mechanical ventilation, vasopressors, and continuous renal replacement therapy (CRRT) or hemodialysis (HD). The dates of hospital, ICU admission and ethics consultation, and ICU and hospital (pre-ICU, ICU, and post-ICU) LOS and mortality were assessed. The 6-month mortality rate was also recorded. Data collected for the ethics consultations included clinical background of the ethics consultant (profession and duration of ethics practice) and identification of the individuals requesting the ethics consultation (ICU team members, non-ICU clinicians, patients, and surrogates). We determined the patient’s decision-making capacity (based on assessment by the ICU attending physicians at the time of the ethics consultation), presence of advance directive and/or health care agent or surrogate, and resuscitation status pre- and post-consultation. The ICU and ethics consultation notes were analyzed to determine the reasons for the consultations using an established coding schema.28 We categorized the treatment conflicts regarding EOL care between the patients/surrogates and the ICU teams into 3 groups: limitation of life-sustaining treatments (LOLST; ie, mechanical ventilation, vasopressor medications, or CRRT/HD), withdrawal of life-sustaining treatments (WOLST; ie, mechanical ventilation, vasopressor medications, and/or CRRT/HD), and ‘‘other’’ (ethical conflicts related to code status, refusal of recommended therapeutic procedures, disclosure and truth telling, absence of a consenting surrogate decision maker, and requests for change of physicians). We did not include specific discussions about code status in the LOLST group because decisions about cardiopulmonary resuscitation (CPR) and do not resuscitate (DNR) orders do not necessarily imply any other limitations of care. For each of the 3 groups, we established whether or not an agreement was reached with the patients/surrogates to follow the recommendations of the ICU team or for the ICU team to continue life-sustaining interventions (ie, mechanical ventilation, vasopressors, and CRRT/HD) in accordance with the patients/surrogates’ preferences, and we determined the outcome of all patients. Finally, we identified whether chaplaincy and palliative medicine consultations were obtained prior to ethics consultations and whether these services were recommended by the ethics consultants. In our hospital, palliative medicine assists patients with symptom management and EOL care and is independent of the ethics consultation service. Descriptive statistics on the collected data were conducted using Microsoft Excel 2010 (Redmond, Washington). Continuous variables are presented as mean + standard deviation or median and interquartile range (25th to 75th percentile). The study was granted a waiver of informed consent by the institutional review board.
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Table 1. Patients’ Demographic Data, Religious Affiliations, and Cancer Crosswalk. Variables Demographic data Age, years Male Race White Black Asians Other Marital status Married Single Divorced Widow Other Religion Jewish Catholic Christian Muslim Hindu None/not recorded Primary admitting service Medicine Surgery Cancer type Hematological Gastrointestinal Breast Thoracic Genitourinary Miscellaneous (sarcoma and melanoma) Head and neck
Mean + SD or n (%) 64 + 13 28 (53) 39 (73) 9 (17) 3 (6) 2 (4) 23 (43) 13 (25) 7 (13) 7 (13) 3 (6) 19 (36) 17 (32) 10 (19) 1 (2) 1 (2) 5 (9) 40 (76) 13 (24) 14 (26) 12 (23) 8 (15) 7 (13) 5 (9.5) 5 (9.5) 2 (4)
Abbreviations: SD, standard deviation, n, number of patients.
Results During the 4-year study period, 201 (0.2%) ethics consultations were requested for 102 279 hospital admissions. Of these ethics consultations, 53 (26%) were placed for 5010 ICU admissions (1%) during the same time period.
Table 2. Patients’ Clinical and Outcome Data. Variables Reason for ICU admission Respiratory failure Respiratory insufficiency Severe sepsis and/or septic shock Neurologic catastrophe Bleeding Renal failure Abdominal catastrophe Postcardiac arrest Severity of illness score on ICU admission MPM II score Life-sustaining therapies Mechanical ventilation during ICU stay Vasopressor use during ICU stay Mechanical ventilation and vasopressors CRRT/HD Outcome data ICU LOS, days Hospital LOS, days ICU mortality Hospital (ICU and post-ICU discharge) mortality Six-month mortality
n (%), Mean + SD or Median (IQR) 16 10 7 7 5 4 3 1
(30) (19) (13) (13) (10) (7) (6) (2)
0.51 + 0.26 44 38 35 7
(83) (72) (66) (13)
9 25 27 41
(5-18) (10-42) (51) (77)
49 (92)
Abbreviations: n, number of patients; SD, standard deviation; IQR, interquartile range; ICU, intensive care unit; MPM II, Mortality Probability Model II; CRRT, continuous renal replacement therapy; HD, hemodialysis; LOS, length of stay.
admission. Nearly half (n ¼ 26, 49%) of the patients were admitted to the ICU for respiratory insufficiency/failure, and the majority of patients required mechanical ventilation (n ¼ 44, 83%) or vasopressor therapy (n ¼ 38, 72%; Table 2). The ICU and hospital LOS were 9 and 25 days, respectively. In all, 27 (51%) patients died in the ICU and a total of 41 (77%) patients died in the hospital. Of the 12 hospital survivors, 6 were discharged to hospice and the other 6 were discharged to rehabilitation facilities (n ¼ 4) and home (n ¼ 2). At 6 months, only 4 of the 12 hospital survivors were alive, bringing the 6-month mortality of the entire cohort to 92% (Table 2).
Ethics Data Demographic and Clinical Data Demographic data, religious affiliations, race, marital status, primary admitting service, and cancer type are described in Table 1. In all, 48 (90%) patients had advanced-stage malignancy; 3 (6%) patients had early-stage cancer, and 2 (4%) had no evidence of active cancer. Prior to hospital admission, 59% (n ¼ 31) had a cancer diagnosis of less than 1 year, 15% (n ¼ 8) between 1 and 4 years, and 26% (n ¼ 14) of 5 years or more. The majority (n ¼ 47, 89%) received oncologic therapies within 1 year of admission. Slightly more than half (n ¼ 27, 51%) of the patients received image-guided interventions for cancer within 30 days of hospital admission and 46 (87%) patients received these interventions during the current hospital
More than half of the ethics consultations were performed by nurse ethicists (n ¼ 30, 57%) and by individuals with 10 or more years of experience (n ¼ 46, 85%). Ninety-four percent (n ¼ 50) of ethics consultations were requested by members of the ICU multidisciplinary team. Ninety-two percent (n ¼ 49) of the ethics consultations were for conflicts surrounding EOL care. Of these, 77% (n ¼ 41) were precipitated by disagreements in the goals of care between the ICU team and surrogates. At the time of ethics consultation, 26% (n ¼ 14) of patients had DNR orders, 77% (n ¼ 41) lacked decisionmaking capacity, 98% (n ¼ 52) had identifiable surrogates, and 13% (n ¼ 7) had an advance directive. Patients and/or surrogates participated in 100% of the ethics consultations. After
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ethics consultation, an additional 60% of patients had DNR orders. The median durations of hospital and ICU admissions to ethics consultation were 15 (7-24) and 6 (1-11) days, respectively. Prior to ethics consultation, the palliative medicine service was consulted in 34% (n ¼ 18) of patients and chaplaincy in 19% (n ¼ 10). After ethics consultation, recommendations were made for an additional 8 (15%) palliative care and 9 (17%) chaplaincy consultations. The 53 patients were categorized into 3 groups: LOLST, WOLST, and other.
Limitations of Life-Sustaining Treatments Group Among the 25 patients in the LOLST group, disagreements involved the surrogates and the ICU team for 23 patients; for the remaining 2 patients, the conflict was between physicians (n ¼ 1) and within the family (n ¼ 1). After ethics consultations, an agreement was achieved between the ICU team and patients/surrogates to limit life-sustaining interventions for 19 patients. Of these patients, 6 already had a DNR order prior to the ethics consultation; DNR orders were entered for the other 13 patients following the consultation. Of the 19 patients for whom an agreement was reached between the ICU team and patients/surrogates to limit interventions, 17 died in the ICU and 2 were discharged from the hospital. For the 6 patients where an agreement was not reached between the ICU team and patients/surrogates to limit care, aggressive interventions were actively pursued. None had a DNR order preconsultation. One patient had a DNR order instituted after the ethics consultation with the consent of the surrogate despite disagreement with the intensivists regarding several aspects of the care plan. Of these 6 patients, 1 died in the ICU and 5 survived to hospital discharge.
Withdrawal of Life-Sustaining Treatments Group There were 17 patients in the WOLST group. Disagreements involved the surrogates and the ICU team for 15 patients; for the other 2 patients, the conflict was between physicians (n ¼ 1) and within the family (n ¼ 1). After ethics consultation, agreement was reached to withdraw life-sustaining therapies for all 17 patients in this group. In all, 5 had DNR orders before ethics consultation and 12 more after consultation. Sixteen patients died in the ICU. One patient survived to ICU discharge (after discontinuation of mechanical ventilation) and subsequently died on the ward.
Other Group There were 11 patients in the other group. The conflicts were between patients and their family members (n ¼ 5), patients and the ICU team (n ¼ 3), and surrogates and ICU team (n ¼ 3). The conflicts centered on code status in 7 patients. The ethical issues included confidentiality of health care information (n ¼ 5), truth telling (n ¼ 1), initiation of DNR orders (n ¼ 1), surrogate decision-making surrounding code status
(n ¼ 1), no surrogate for procedural consent (n ¼ 1), request for change in physician (n ¼ 1), and refusal of comfort measures while wanting CPR (n ¼ 1). The patient who declined comfort measures realized that death was imminent but wanted CPR while waiting for the surrogates to arrive. In 5 cases, family members disagreed with the patients’ decisions about goals of care and confidentiality. Some family members/surrogates acknowledged the patients’ autonomy but were not always supportive of the patients’ decisions. A small number of patients expressed concerns that the surrogates could reverse their decisions if they lost capacity. Thus, the ICU team sought the assistance of the ethics consultant to counsel the surrogate about his or her role with respect to the patient’s known and previously expressed preferences. Agreement between parties was achieved in 9 patients. For the remaining 2 patients, the requested change in physician was not honored and the patient who refused various treatment options while wanting CPR subsequently died in the ICU after receiving CPR. Of the 11 patients, 3 already had a DNR order preconsultation. Following the consultation, 3 additional patients/surrogates agreed to DNR orders (for a total of 6). In all, 6 patients died in the hospital (2 in the ICU and 4 after ICU discharge); the other 5 patients (including the patient whose request for a change in physician was declined) were discharged from the hospital.
Discussion Ethics consultations were rarely requested in our hospital or in the ICU. However, the 1% rate of ethics consultations initiated in our oncologic ICU is far higher than the general ethics consultation rate within our cancer center and is comparable to the 0.16% to 1% rate of elective ethics consultations for heterogeneous groups of critically ill patients.29,30 Conflicts at the EOL in ICUs in the United States may consume a lot of time and discussion but fortunately are relatively rare.31 The vast majority of families and physicians use a shared decision-making model and agree on the goals of care at the EOL.32 Specifically within our cancer center, we perceive a high degree of collaboration and agreement between the admitting services, the ICU team and surrogates in transitioning goals of care when standardor research-based cancer-directed therapies are no longer a viable option. Nevertheless, we found that there were occasional disagreements between the patients’ surrogates and the ICU team that could not be resolved and resulted in ethics consultations. As in prior studies, the core issues of these ethics consultations involved conflicts between patients/surrogates and–health care providers regarding recommendations for ongoing ICU and EOL care rather than common ethical quandaries.1,28,30,33,34 We hypothesize that a general lack of advance directives and the loss of decision-making capacity contributed to these discords.7 The conflicts between surrogates and ICU staff may have also been amplified by the short interval between the diagnosis of advanced cancer and the ICU admission and the recent delivery of oncologic therapies including image-guided interventions.
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The latter two circumstances (ICU admission and delivery of oncologic therapies) may have conferred some hope to the patients and his or her surrogates and triggered their reluctance to limit life-sustaining therapies. Agreement between the surrogates and the ICU team on the goals of care was achieved after ethics consultation in the vast majority (85%) of cases, a finding comparable to previously reported studies.28-30,35 We ascribe the high level of conflict resolution to the empathy and mediating skills of our ethics consultants in helping surrogates appreciate the problems and solutions differently or better than they perceived them when presented by the ICU team.36-38 Additionally, the ethics consultants encouraged the use of other personnel (chaplains and palliative medicine specialists) to achieve a more positive team effect.7,38 In the remaining 15% of cases, the differences between the ICU team and the surrogates could not be reconciled. The concept of limiting or withdrawing medical interventions and dealing with impending death may simply be unacceptable for a minority of surrogates. Their negative responses to such ICU proposals may have been rooted in their intimate knowledge of the patients’ characteristics, religious beliefs, or the surrogates’ own wishes.23,39-41 For these patients, aggressive interventions (ie, mechanical ventilation, vasopressor agents, and CRRT/HD) were continued as requested by the patients/surrogates and were actively administered by the ICU team. However, the continuation of care that is perceived to be futile and inappropriate certainly adds significant emotional stress to the ICU staff, which must be subsequently addressed.42-45 We found a high hospital survival rate in the small number of patients where an agreement to limit care was not achieved. This finding underscores the difficulties that we and other clinicians face in deciding whether to continue or deescalate life-sustaining interventions even when we are reasonably confident that our recommendations are appropriate given the clinical circumstances.46,47 Despite the development and refinement of prognostication models, the accurate prediction of mortality remains very challenging for critically ill patients with cancer.48,49 Certainly the surrogates’ resistance to the recommendations of the ICU team regarding care limitation or withdrawal may have reflected their appreciation of the uncertainties of medical prognostication.40,50 The high survival rate in this subgroup of patients prompted reflections by the ICU team of the relative ambiguity surrounding prediction of death in critically ill patients.21 Surprisingly, the majority of the ethics consultation cases did not already have prior palliative medicine consultations or chaplaincy visits. This finding highlighted room for quality improvement when caring for critically ill patients and their surrogates.10,51,52 Since the completion of our study, we have modified our approach to palliative medicine and chaplaincy services from a consultative model to an integrative model with embedded palliative care clinicians and chaplains in our multidisciplinary care team.53 Approximately a quarter of the ethics consultations already had a preexisting DNR order. Health care providers sometimes
presume that the presence of a DNR order provides clarity in EOL care.54 This was certainly not evident in the group of patients with a preexisting DNR order who still required ethics consultations. We and others found that the additional EOL and ethics discussions were indispensable for addressing management strategies for the clinical deterioration that commonly precedes death.54,55 Our study has several limitations. First, this is a retrospective study conducted in patients with cancer at a single tertiary cancer center. However, we believe that our findings are applicable and contributory to the EOL care discussions in critically ill patients with cancer that occur in any ICU environment. Second, although our ethics consultation classification was stratified in a systematic manner, any such categorization risks oversimplifying complex and highly individualized clinical and social constructs. Third, while 98% of our patients had identified surrogates, we did not track the socioeconomic status, educational level, or family dynamics of the surrogates. Fourth, we did not collect the number and duration of family meetings prior to and after initiation of ethics consultations. This information will be important in future prospective studies to determine the staffing requirements for ethics consultation teams. Finally, we were not able to ascribe the impact of the palliative medicine or chaplaincy visits on the incidence or outcome of ethics consultations.
Conclusion In summary, ethics consultations in critically ill patients with cancer were infrequently requested. The majority of these consultations involved disagreements between the patients’ surrogates and the ICU team regarding EOL care including proposed limitations and/or withdrawal of life-sustaining interventions. We found that ethics consultations were helpful in resolving seemingly irreconcilable differences between the ICU team and the patients’ surrogates in the majority of cases. Ethics consultation also facilitated the increased provision of palliative care and chaplaincy services for patients and their surrogates at the EOL. Acknowledgments We thank Ms. Claire Murray for her stewardship of the institutional ethics consultation database, Ms. Sarah Jewell from the Library Department for her assistance in reviewing the literature on ethics consultations, and Ms. Elaine Ciccaroni from the Medical Graphics service for preparation of the tables.
Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship, and/or publication of this article.
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Journal of Intensive Care Medicine
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