Center Professor Dr. Leonard Fleck has a new article in the January 2018 issue of Cambridge Quarterly of Healthcare Ethics. The article, “First Come, First Served in the Intensive Care Unit: Always?,” was written by Dr. Fleck and Timothy F. Murphy.
Abstract: Because the demand for intensive care unit (ICU) beds exceeds the supply in general, and because of the formidable costs of that level of care, clinicians face ethical issues when rationing this kind of care not only at the point of admission to the ICU, but also after the fact. Under what conditions—if any—may patients be denied admission to the ICU or removed after admission? One professional medical group has defended a rule of “first come, first served” in ICU admissions, and this approach has numerous moral considerations in its favor. We show, however, that admission to the ICU is not in and of itself guaranteed; we also show that as a matter of principle, it can be morally permissible to remove certain patients from the ICU, contrary to the idea that because they were admitted first, they are entitled to stay indefinitely through the point of recovery, death, or voluntary withdrawal. What remains necessary to help guide these kinds of decisions is the articulation of clear standards for discontinuing intensive care, and the articulation of these standards in a way consistent with not only fiduciary and legal duties that attach to clinical care but also with democratic decision making processes.
The full text is available online through Cambridge University Press (MSU Library or other institutional access may be required to view this article).
Kevin Foley, MD, and Leonard Fleck, PhD, presented at the Bioethics for Breakfast event on December 8, 2016, offering perspective and insight on the topic, “Advanced Dementia and the ICU Siren’s Song: When We Build It, Why Do They Come?”
When nursing home patients with late-stage Alzheimer’s or other advanced forms of dementia develop sepsis or pneumonia, should they be sent to an ICU and hooked up to a ventilator? This is the question that was posed in a couple recent medical journal articles. This question can be seen as a medical care issue, an ethics issue, and a policy issue. Is this practice in the best interest of these patients? Why does this seem to be happening with greater frequency? Is there an ethically preferable alternative? Given the relative scarcity of ICU beds, is this a good use of an ICU bed? Are there changes in policy and practice that need to be considered? What should those changes look like?
We start with a statistical picture. About 7.4% of adults over age 75 live in nursing homes; that rises to 16% for adults over age 85. Somewhere between 50% and 70% of nursing home patients have some form of dementia. For the vast majority of these patients who have dementia, their caregivers see comfort care as the goal of care. In spite of that, many of these patients receive more aggressive care than they desire. A common enough scenario is that these patients in late-stage dementia (no longer able to take food by mouth) develop a pneumonia, perhaps related to aspiration as a result of trying to provide food by mouth, and staff at the nursing home cannot provide what they see as necessary medical treatment. Such patients are then sent to a hospital Emergency Department. A palliative care consult would be appropriate at this point but most Emergency Department physicians are reluctant to request such a consult because of pre-existing beliefs and lack of knowledge. This deficiency has more recently been addressed in two publications, one of which is a consensus statement from the Society of Academic Emergency Medicine. See Naomi George et al. “Shared Decision Making to Support the Provision of Palliative and End-of-Life Care in the Emergency Department: A Consensus Statement and Research Agenda.”Academic Emergency Medicine 23 (2016): 1394-1402. See also Jason Bowman et al. “Acceptability and Reliability of a Novel Palliative Care Screening Tool Among Emergency Department Providers.”Academic Emergency Medicine 23 (2016): 694-702.
If these patients with late-stage dementia reach the ICU, then intensivists in the ICU are faced with another set of ethical issues. Very often they will judge that these patients have a very poor prognosis that can be made worse by the surgical placement of feeding tubes to correct for the inability of these patients to be fed by mouth. But the intensivists may have to deal with a family member who is a surrogate decision maker or a court-appointed guardian in the case of an unbefriended patient, and those individuals may, for various reasons, insist on more aggressive life-sustaining care. Those decision makers might represent the earlier expressed wishes by that patient, or fears of legal repercussions in the case of court-appointed guardians. Physicians then might need to be extraordinarily persuasive to prevent what they regard as choices that are contrary to the best interests of those patients. They may feel that they are being paternalistic in considering overriding what might be the preferences of that patient (albeit likely less informed than desirable at the time). Still, the American Medical Association Council on Ethical and Judicial Affairs says explicitly that physicians have as a first obligation not harming their patients in these circumstances. Consequently, they have the professional responsibility to act against the expressed wishes of that surrogate decision maker when that individual wishes to make a medical decision clearly contrary to the best interests of that patient. Obviously, the physician should make every effort to explain sensitively why such decisions are necessary.
These sorts of conversations can be very painful and confrontational. It is clearly better to avoid them through a more preventive approach. At the very least when patients are first diagnosed as being in the very early stages of dementia, conversations regarding various scenarios in late stage dementia should be addressed with both the patient and any surrogate decision maker. It may be difficult for those individuals to imagine vividly enough and accurately enough what those late stages might really be like when the issue of feeding tubes, ICU care, or use of ventilators might be broached. What some research has shown is that videos of patients in late-stage dementia allow for a much more accurate understanding of what choosing life-sustaining care might mean, the consequence of which is that virtually no one is then motivated to want such care in those circumstances.
Kevin Foley, MD, FACP, AGSF
Associate Professor and Associate Chair for Senior Health
Department of Family Medicine
Michigan State University College of Human Medicine
Director of Education and Clinical Operations
Division of Geriatrics and Gerontology
Michigan State University Clinical Center
Leonard M. Fleck, PhD
Professor of Philosophy and Medical Ethics
Center for Ethics and Humanities in the Life Sciences
College of Human Medicine
Michigan State University
About Bioethics for Breakfast: In 2010, Hall, Render, Killian, Heath & Lyman invited the Center for Ethics to partner on a bioethics seminar series. The Center for Ethics and Hall Render invite guests from the health professions, religious and community organizations, political circles, and the academy to engage in lively discussions of topics spanning the worlds of bioethics, health law, business, and policy. For each event, the Center selects from a wide range of controversial issues and provides two presenters either from our own faculty or invited guests, who offer distinctive, and sometimes clashing, perspectives. Those brief presentations are followed by a moderated open discussion.
The work of Center Professor Dr. Leonard Fleck appears in the new book Prioritization in Medicine: An International Dialogue, published by Springer. Dr. Fleck’s chapter is titled “Just Caring: Fair Innings and Priority Setting.”
Dr. Fleck also has an article in the current APA Newsletter on Philosophy and Medicine (Volume 15 Number 2) titled “Just Rationing in the ICU: What Benefits Count?” The current issue can be accessed on the American Philosophical Association website, or you can go directly to the PDF.
Earlier this month, Center Professor Dr. Len Fleck attended the American Philosophical Association’s Eastern Division meeting in Washington D.C. Dr. Fleck organized and chaired a session for the Philosophy and Medicine Committee, titled “Removing Patients from the ICU: Is It Ever Morally Justifiable?”
The very real problem that precipitated this session is that on any given day in the United States most ICUs are at 100% capacity. There are no empty beds, and there are patients coming in from surgery or serious accidents who have a real need for that ICU bed, who can clearly benefit from that bed, while a patient already in the ICU may be near death but may “need” that bed for two extra days of life. Dr. Fleck and team’s key ethical question was this: Does that patient already in the ICU have a compelling moral right to remain there just by virtue of the fact that they were there first?
Of the session’s four panelists, Marion Danis, MD, from National Institutes of Health took the position that ICUs have a specific medical and moral purpose, and when a patient can no longer benefit from that level of care, they no longer have a right to occupy that bed. That is, step-down care is more appropriate, medically and morally. Tim Murphy, PhD, of University of Illinois-Chicago critically assessed different possible moral bases for admission to an ICU. He asked: Is admission to an ICU a gift, a promise, a covenant, a contract or a duty? Each of these conceptions would have different implications with respect to removal from an ICU. Rosamond Rhodes, PhD, of Mt. Sinai Medical Center (New York) argued that admission to or discharge from an ICU should be governed by the moral norm of “avoiding the worst outcome,” ethically speaking. She added that following that rule might not be possible in the real world, given legal and regulatory outcomes. Finally, Luke Gelinas, PhD, Harvard University Fellow, argued that clinical uncertainty with regard to prognosis ought to be given serious weight, especially with respect to the decision to remove someone from the ICU in favor of someone judged likely to have a better prognosis “waiting at the door of the ICU.”
Dr. Fleck asks: What do you think are the appropriate ethical considerations that should govern such decisions, given that you might be a future possible patient in the ICU or “at the door” of a full ICU?