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The Ethics of Dying: A 21st Century Problem
If advances in resuscitation medicine have effectively redefined death, have the ethical considerations surrounding end-of-life care been reshaped as well? The answer is more complicated than you might think.
Over the last decade, significant breakthroughs in resuscitation science have enabled physicians to sustain patients who previously would have been declared dead, and in some cases, revive them. When cardiopulmonary circulation ceases due to conditions such as cardiac arrest, physicians may deploy extracorporeal membrane oxygenation (ECMO) to artificially circulate oxygenated blood through the body while treating the aneurysm, clot or other underlying cause of cardiac arrest. Simultaneously cooling the brain to therapeutic hypothermic levels can prevent catastrophic brain injury and death due to ischemia.
But despite the availability of potentially lifesaving modalities, much of what we know about resuscitation is rooted in the mid-20th century, according to critical care physician Sam Parnia, MD, Director of Resuscitation Research at Stony Brook University School of Medicine.
“[ECMO and brain cooling] are a couple of advances that have begun to take shape over the last 10 years in resuscitation science, but the way cardiac arrest is generally practiced and perceived is still in the 20th century, based on algorithms that were around in the 1960s,” Dr. Parnia says. “If you look at basic, ‘advanced’ cardiac support, the way it’s managed with chest compressions, ventilation, defibrillation, and epinephrine and other drugs — that was around in the ’60s.”
Twenty-first century resuscitation science has essentially reconstructed our formulation of death from a finite, chronological point to a process involving sequential failure of multiple anatomic systems. With such power comes great responsibility, so the saying goes, and this recapitulation of death warrants a new discussion of the ethical concerns surrounding resuscitation medicine, according to member and former Chair of the American College of Emergency Physicians’ Ethics Committee Arthur R. Derse, MD, JD, FACEP, Director of the Center for Bioethics and Medical Humanities and professor of bioethics and emergency medicine at the Medical College of Wisconsin.
“The limitations have always been: under what circumstances should [these methods] be used, and what is the availability of the technology — do we have it at the time we need it?” Dr. Derse asks. “[ECMO] has been out there as a challenge to us, just as hypothermia has been a challenge for us.”
Ethics of Absence
You’re walking down the road and have a heart attack. Luckily, a number of people saw you, called 911 and began performing CPR under the direction of the operator. The ambulance arrives, loads you in the back and zips you to the nearest hospital. Unfortunately for you, the ambulance takes you to a hospital that doesn’t have ECMO, while another hospital, miles away has it.
Dr. Parnia notes that your chances of receiving the highest quality care essentially boil down to potluck.
“What we’re basically saying is that we have this huge advancement, but on the other hand, how do we deal with the ethical issue that [it] is not universally available to patients?” Dr. Parnia asks.
A Systemic Problem
Dr. Parnia notes that widespread use of leading-edge resuscitation medicine is hampered by regulatory problems. While physician associations have put forth treatment guidelines, The Joint Commission failed to implement systemic regulation for cardiac arrest care following a three-year review of protocols ending in March.
“You wouldn’t just say for a heart attack, ‘Get someone to the cardiac catheterization lab and do [the procedure] in 60 minutes, but we’re not going to [enforce] it,’” Dr. Parnia says. “That’s the problem.”
Parnia says regulating entities should be held accountable but emphasizes that they are only half the problem.
“I want to be clear that, because society has not implemented the highest standards of care — which is a big problem — the reason we’re not able to succeed is a combination of patient factors and systemwide factors,” Dr. Parnia explains. “For example, someone who is 90 years old with multiple illnesses and living in a nursing home is very different from a 25-year-old basketball player or a 55-year-old man with a heart attack. These are the patient factors. Then there are the much wider social and systemwide factors. For instance, in one physician’s judgment, it may not be viable to apply these modalities, but this may simply reflect the fact that he or she may not have the expertise to manage these sophisticated and specialized critical care therapies, as they are not in the realm of his or her specialty. And, of course, in many cases, the systems themselves may not provide access to the proper treatment modalities required.”
When to Deploy
ECMO and brain cooling have demonstrated remarkable outcomes, but not all patients are indicated for such resuscitation techniques, explains Dr. Derse.
“We know of incredible cases of children submerged for long periods of time who have been brought back due to hypothermia and good condition,” Dr. Derse says. “That’s a significant subset of all people who are in cardiac arrest. Still, for the vast majority of individuals — who would mostly be elderly with underlying medical problems and cardiac arrest — who don’t present with these favorable rhythms, the likelihood for resuscitation is going to be extremely small.”
Dr. Parnia explains that ECMO and brain cooling should only be used when the patient’s underlying condition can be treated. For example, patients succumbing to a severe, antibiotic-resistant infection causing sepsis cannot be cured, no matter how long circulation is maintained throughout their bodies.
On the other hand, Dr. Parnia cites athletes dying on the field as exemplary candidates for resuscitation. For these people, who have no uncurable underlying disease but fall victim to severe cardiac arrest, Dr. Parnia explains that ECMO and brain cooling can be used to prevent cellular death while physicians work to fix the anatomical problem causing arrest. These people can potentially be ‘brought back from the dead.’
‘What is a Life Worth Living?’
So, if patients can be brought back from the “undiscovered country,” when is it ever OK for physicians to stop resuscitation efforts? Steven Laureys, MD, PhD, head of the Coma Science Group at Cyclotron Research Center and Department of Neurology at Liège University Hospital, says it’s a question of outcomes.
“For many patients, the decision is clear, and we decide to withdraw or withhold treatment and let them die because we know by clinical [experience] or through testing that there’s no chance for reasonable recovery,” Dr. Laureys says. “For still too many patients, we can’t make that decision, and we continue [resuscitation] and end up with artifacts of modern medicine — patients ending up vegetative, non-responsive or minimally conscious.”
Dr. Laureys adds that it’s still challenging to identify the subsection of patients in which resuscitation will result in positive outcomes. The idea of poor outcomes has been significantly reshaped.
“In the old days, it was death or persistent vegetative state,” Dr. Laureys says. “Now, there’s a shift toward patients who don’t recover independent living, and [we]’ve also put this as a bad outcome. That’s not an easy discussion for society to have — what is a life worth living?”
This consideration underscores the importance of do not resuscitate (DNR) orders.
“There are some people who say, ‘Yes, do everything under all circumstances, and do it as long as possible,’” Dr. Derse says. “Others say, at some point — especially for individuals who have expressed wishes to [be] neurologically intact and to live a full life and not have artificial means of resuscitation — it won’t lead to a good outcome. Obviously, for these individuals, the answer is not to do everything under all circumstances.”
Conducting conversations with patients during routine checkups helps avoids difficult situations in the intensive care unit (ICU), where best medical practices can conflict with the wishes of family members and the inferred wishes of the patient.
“There is no question this is an important conversation to have, but it’s more important for this discussion to occur with every adult,” Dr. Derse says. “Physicians should be the initiators of this conversation, even if family members and individuals aren’t.”
In the event a patient suffers severe cardiac arrest and must be sustained by ECMO, Dr. Derse emphasizes the importance of physician recommendation.
“There is no question that physicians want to offer any hope for family members they can,” says Dr. Derse. “Attempts at resuscitation are often done in part because physicians do respond to the feeling that families need hope and err on the side of treatment. That’s not the professional obligation for emergency physicians or intensivists. The professional obligation is to offer interventions that have a likelihood of benefit and actually have benefits to the patient that outweigh the risks. When that can’t be done, we shouldn’t offer or make recommendations to do intervention.”
As resuscitation science continues to evolve, bringing the dead back to life can no longer be relegated to myths and horror stories. Further understanding about the progression of cellular and molecular processes during death will continue to expand our knowledge about how we die, and current studies seek to assess what happens after we shuffle off this mortal coil.