A 75-year-old woman is admitted to the intensive care unit due to worsening shortness of breath. Medical history is significant for systolic heart failure with a left ventricular ejection fraction of 10% on recent echocardiogram. Evaluation reveals acute hypoxic respiratory failure due to cardiogenic pulmonary edema. The patient also has a history of three-vessel coronary artery disease, diabetes mellitus, and chronic kidney disease. Her heart disease is not amenable to any intervention or surgery due to her poor functional status, and she has been treated with maximal medical therapy as tolerated. She was hospitalized a month ago due to an exacerbation of congestive heart failure and was discharged to a nursing facility after responding to treatment. The patient has limited mobility and requires assistance for activities of daily living. In the intensive care unit, her symptoms slowly improve with noninvasive positive-pressure ventilation, ionotropic therapy, and intravenous diuretic treatment, but her kidney function gradually deteriorates. The critical care physician and nephrologist recommend that all treatments be stopped and that the patient receive comfort care only. The patient's son agrees and says, "The time has come to let go." The patient, however, wants "everything to be done" and even to receive cardiorespiratory resuscitation if required. Which of the following is the most appropriate course of action?

Question

A 75-year-old woman is admitted to the intensive care unit due to worsening shortness of breath.  Medical history is significant for systolic heart failure with a left ventricular ejection fraction of 10% on recent echocardiogram.  Evaluation reveals acute hypoxic respiratory failure due to cardiogenic pulmonary edema.  The patient also has a history of three-vessel coronary artery disease, diabetes mellitus, and chronic kidney disease.  Her heart disease is not amenable to any intervention or surgery due to her poor functional status, and she has been treated with maximal medical therapy as tolerated.  She was hospitalized a month ago due to an exacerbation of congestive heart failure and was discharged to a nursing facility after responding to treatment.  The patient has limited mobility and requires assistance for activities of daily living.  In the intensive care unit, her symptoms slowly improve with noninvasive positive-pressure ventilation, ionotropic therapy, and intravenous diuretic treatment, but her kidney function gradually deteriorates.  The critical care physician and nephrologist recommend that all treatments be stopped and that the patient receive comfort care only.  The patient's son agrees and says, "The time has come to let go."  The patient, however, wants "everything to be done" and even to receive cardiorespiratory resuscitation if required.  Which of the following is the most appropriate course of action?

Quizplus · Accepted Answer

Explanation: Issues regarding withdrawal of care can become complex, especially when there is disagreement among physicians and patients about the appropriate treatment course. This patient has an extremely poor prognosis and what many would consider a poor quality of life. However, poor prognosis is not the same as medical futility, which has been defined as treatment that can have no beneficial physiologic effect. This patient has recently responded to aggressive treatment that resulted in prolonging her life. She is alert and possesses adequate decision-making capacity. Although the physician may not agree that this is the best course, her wishes to continue aggressive treatment should be honored based on the ethical principle of autonomy. Physicians are not ethically obligated to provide treatment that is futile (eg, dialysis in an unconscious patient expected to die from end-stage cancer in a few days). A high degree of certainty is required for the application of the concept of medical futility. This can be difficult to ascertain in cases of end-stage kidney disease or heart failure, such as in this patient, as there is a chance that these conditions may improve with treatment, albeit only minimally or briefly. The issues of cost-effectiveness and allocation of resources should not be considered in the determination of futility. (Choice A) The patient is awake and alert and has the capacity to make her own end-of-life decisions. It would be inappropriate to ask the son to make decisions for her. (Choice C) Although prognosis is poor, aggressive treatment and intensive monitoring have resulted in temporary improvement, and it cannot be determined with a high degree of certainty that further treatment is medically futile. It would be inappropriate to treat the patient with comfort-care measures only when she has specifically stated that she wants all treatments to be performed. (Choice D) This patient still has adequate decision-making capacity and is making a rational decision. She has firmly stated her wishes to continue all treatments; she does not wish to begin hospice care. (Choice E) It would be inappropriate to transfer the patient to another hospital. The patient's wishes should be upheld by the current treatment team. Educational objective: Patients have a right to make their own end-of-life decisions even if the treating physician does not agree. With the exception of requests for treatments that are clearly medically futile, a patient's autonomy in end-of-life decisions must be upheld. References: Challenges in end-of-life decisions in the intensive care unit: an ethical perspective. (http://www.ncbi.nlm.nih.gov/pubmed/23299401) Perspective: medical futility: a contemporary review. (http://www.ncbi.nlm.nih.gov/pubmed/28001142)

A 75-Year-Old Woman Is Admitted to the Intensive Care Unit