Death, dying and other ethical dilemmas Anand Chatoorgoon University of Phoenix

Death, dying and other ethical dilemmas are issues that all Intensive Care Units (ICUs) throughout the world have to face and address. In the Current Opinion in Critical Care, Vol 16, No 6, December 2010, p. 640, Dixon-Woods and Bosk, writing on the topic of “Death, dying and other ethical dilemmas” under the journal’s section of ‘Ethical, legal and organizational issues in the ICU’, have stated that “Recent ethnographic work suggests that ethical dilemmas associated with end-of-life care in ICU clearly persist, even if clinicians are now more open about patients’ chances of surviving. An Australian study identified how decisions and actions made outside the ICU—such as proceeding with surgical procedures with very poor prognosis or admitting moribund patients who had sustained severe respiratory or cardiac arrest—led to a higher than expected rate of non-booked admissions. Staff believed these to be the result of futile interventions by staff outside the ICU that then resulted in ICU staff having to manage the patient and family through the dying process. ICU staff believed that this practice was detrimental to families by offering false hope of recovery, and that they were left to ‘clear up the unfinished work of medical staff’. Other studies have also documented the problems faced by staff confronted by patients whose potential for recovery is, at best, marginal, or when patients’ ‘significant others’ seek to influence ICU priorities and distribution of resources. Tensions exist between the critical care clinician’s view of the ICU as a place for caring for patients who can be salvaged, and an external view of the ICU as a place appropriate to send desperately ill, dying patients. Patients admitted to ICU despite ICU staff’s belief that they are not candidates for intensive care lead to role conflicts and other dilemmas for staff. The conflict is embedded in whom ICUs serve, the relative ease with which non-ICU clinicians can ‘turf’ their most critical patients to ICUs, the tensions ICU clinicians experience when delivering what they believe to be futile care, and the despair that family and clinicians share when having to abandon hope.” This administrative ethics paper takes a look at the issues contained in the article of the aforementioned journal, Current Opinion in Critical Care, Vol 16, No 6, December 2010, and applies these issues to the situations faced by ICUs today and in particular, the ICU healthcare personnel at the 6-bedded ICU at the San-Fernando General Hospital (SFGH), a general multi-disciplinary 680-bedded hospital situated in the south of the island of Trinidad and which serves a catchment area of 600,000 people. Trinidad and Tobago is a twin-island republic in the West Indies, south of the archipelago with a population of 1.2 million people. The SFGH also has a 4-bedded HDU (high-dependency unit). Brainstem death The future plan for brain-dead patients whose hearts have been resuscitated by doctors in the Emergency Department (ED) of the SFGH following a cardiac and or respiratory arrest at home, poses an ethical dilemma for the healthcare personnel at the SFGH. Should these patients be admitted to the ICU which has only six beds to serve a population of 600,000? Shouldn’t these ICU beds be kept for patients with potentially reversible and salvageable pathology? Emergency physicians at the SFGH defend their decision to resuscitate such patients on the grounds that they cannot predict with any certainty which patients have reversible brain function and which do not. The present practice at the SFGH to provide ventilator support for these patients in the ED instead of the ICU while tests of brainstem function are being carried out, is frequently met with severe criticisms from relatives and loved ones who claim that the best is not being, and cannot be, done for such patients in the ED as opposed to the ICU. And to a certain extent, this is true bearing in mind the chronic shortage of doctors and nurses in the ED. Frequently therefore, here in Trinidad, the ICU personnel have no choice but to transfer such patients to the ICU for monitoring and cardio-respiratory support. Passive Euthanasia “While active euthanasia is illegal, passive euthanasia, or allowing a patient to die naturally, is legal everywhere. Passive euthanasia includes withdrawing basic needs such as hydration and nutritional feeding” (Fremgen, 2009, p. 304). The Ministry of Health, an arm of the Government of Trinidad and Tobago, has issued a written protocol/policy for the discontinuation of life-support from patients on whom the diagnosis of brainstem death is confirmed but, for such discontinuation, written consent is required from the relatives. “The person should be pronounced dead, and there is no need for the permission of the surrogates to cease treatment, although there are still questions about consent for donation” (Garett, Baillie, McGeehan and Garett, 2010, p. 253). But intensivists here in Trinidad face an ethical dilemma because forty-five percent of the population consists of people of East Indian descent who, because of their religious and cultural background, do not readily agree to the discontinuation of ventilator support from their loved ones who have been pronounced brain-dead. For similar reasons, they do not readily agree to the donation of organs while the heart is still beating, a situation that has stymied the development of transplant programs here in Trinidad and Tobago. The Surrogate’s Obligation “Patient-physician relationship is at the heart of patient management. The trend over the recent years has been towards promoting patients’ autonomy. This model falls apart, however, when the patient loses decision-making capacity. Surrogacy is one means of preserving patient autonomy. Several European countries have recently developed laws defining the physician’s role, as well as patients’ and surrogates’ rights” (Lautrette, Peigne, Watts, Souweine and Azoulay, 2008, p. 714). “Each of the principles (the best interests principle and the rational choice principle) entails problems. The best interests principle asks the surrogate to do what is nearly impossible—to judge what is best for another. Furthermore, it does not address the fact that the interests of the patient and the interests of the surrogate may be in conflict. The rational choice principle assumes that we know what the patient would have chosen when competent and after having considered every relevant factor. This is a very broad assumption. We doubt that anyone can know what a person would have done in all circumstances” (Garett, Baillie, McGeehan and Garett, 2010, p. 72). When surrogates refuse to give permission for their brain-dead loved ones to be disconnected from the ventilator, intensivists at the SFGH in Trinidad, well aware of the limitations and constraints of the situation that exists at the SFGH, choose the ethical route and not only discontinue all drug and intravenous fluid therapy but also reduce the settings on, and oxygen therapy going to, the ventilator to as low as is possible, so as to satisfy the family that the patient has not been disconnected from the ventilator. A do-not-resuscitate order (DNR) is not only written, but is also verbally communicated to the nurses by the doctors in the event of a cardiac arrest.

The Cost Factor “Critical care medicine is expensive and its high cost has been a concern for many years.” (Halpern, 2009, p. 591). Canada’s health care system, including its delivery of hospital-based critical care services, is changing due to fiscal pressures. “Critical care services should be delivered to those who can benefit from them. Limiting therapy in patients with a poor prognosis may help redirect resources” (Leasa and Sibald, 1997, p. 320). Trinidad and Tobago, like the rest of the world, is currently facing an economic recession and so the Government of the day has to be very prudent in its fiscal spending. The Ministry of Health which is responsible for providing the financial resources for running the health system in the twin-island republic simply does not have the money required for the provision of quality healthcare at this time. ICUs are expensive and as such all attempts must be made by all stakeholders involved in the ICU to ensure that monies spent in this area of the hospital are spent wisely, ethically, effectively and efficiently.

Conclusion This administrative ethics paper took a look at various challenges faced by healthcare personnel in ICUs today as they deal with death, dying and other ethical dilemmas. Particular reference was made to the ICU at the San Fernando General Hospital, Trinidad, West Indies.

References
Dixon-Woods, M., Bosk, C., (2010). Learning through observation: the role of ethnography in improving critical care, Current Opinion in Critical Care, 16: 639-642
Fremgen, Bonnie, F. (2009) Medical Law and Ethics 3rd Edition, Pearson/Prentice Hall
Garrett, T. M., Baillie, H. W., McGeehan, J. F., and Garrett, R. M. (2010) Health Care Ethics, Principles and Problems, 5th Edition, Prentice Hall.
Halpern, N. A. (2009). Can the costs of critical care be controlled? Current Opinion in Critical Care, 15:591-596
Lautrette, A., Peigne, V., Watts, J., Souweine, B., Azoulay, E., (2008). Surrogate decision makers for incompetent ICU patients, Current Opinion in Critical Care, 14:714-719
Leasa, D. J., Sibbald, W. S., (1997). The rationing of critical care services within Canada, Current Opinion in Critical Care, 3:317-321