Geriatric Critical Care: No Meaningful Advance Directive

[Geri_Gal]

I'm an IM R3 with an interest in geriatrics and critical care and have cared for too many 87-94 year-old patients at the end of their lives in the MICU -- on a ventilator, tubes in every orifice, restrained to a bed, sedated into oblivion -- because the patients lacked a meaningful advance directive and had little remaining family that knew the pt well enough to feel confident in making the decision to let the patient die as a natural course of their disease process. The medical intensivist culture in my institution is conservative and tends to follow past code status discussions to make recommendations about aggressive ICU care, so if the patient was noted to be "full code" during their hospitalization for pneumonia one year ago, they will often not recommend withdrawal of care...even if the patient is an 89 year-old person with multiple comorbidities in multi-organ system failure nearing hemodialysis.

Is my institution simply very conservative? I admire the surgical mindset; surgeons will refuse to operate on a patient if the risks of harm are greater than the benefit...or if the benefit is marginal or nonexistant. I have never seen a patient with multiple medical comorbidities over the age of 85 y/o survive severe sepsis with multi-organ dysfunction in the MICU to live outside of the hospital.

Now that hysteria over "death panels" has removed the end-of-life provision [simply reimbursing physicians for talking to their patients about advance directives and end of life wishes] from the health care reform legislation,

http://newoldage.blogs.nytimes.com/...life-provisions-from-health-care-legislation/

I imagine that this scenario will be revisited time and time again.

What is your experience with this group of patients? Do we simply need more data? Does anyone think that physicians have a role in advocating for futility of care for the very old patient with marginal baseline functional status who develops sepsis with a high APACHE or SOFA score?

Thank you for your consideration of this topic.

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[RTrain]

Absolutely, I think we are obligated as compassionate providers of end-of-life care to advocate for the comfort and dignity of our patients at the time surrounding their inevitable death. I think the directive of informed consent and autonomy of patients has been misapplied in the case of palliative care/comfort measures only for elderly or medically fragile patients.

We have the tendency to present the options for resuscitation or aggressive care as if they were a buffet table for families, who are overwhelmed at having to choose "chest compressions or no?," "intubation or no?," "dialysis or no?," "pressors or no?" with no guidance from physicians they trust, because we fear being seen as paternalistic and directive. I try never to leave them to this horrible task. I first talk entirely in generalities about their goals of care - if they want their loved one to be comfortable as nature takes its course, or it they want some life-sustaining measures undertaken but nothing invasive, or if they feel that their loved one would want their life to be prolonged no matter what physical cost it might entail, including the possibility of prolonged suffering. Only after we discuss basic beliefs and goals do I start talking about resuscitation.

And I don't think we should be so tentative about sharing our opinion about what direction the patient's care should take in that situation. It's very likely that this is the only time the family has been in the position of making end-of-life decisions for a loved one and they don't know what to expect, but we see the scenario all the time. I think by avoiding providing guidance to them, we are adding to their anguish and anxiety, even though it is with the noble goal of preserving their autonomy.

[/$0.02]

 

[Hernandez]

It sounds like it is your institution. and it definitely is highly physician dependent on top of that. I've seen a doc get a DNR on a 40 y/o that I had a hard time backing because we really had no clue wtf was going on, and I've got another attending that does not have the balls to tell the family that there's nothing else we can do and instead lets them push them into performing procedures and ordering consults that aren't going to do a make a damn bit of difference in their prognosis or outcomes.

 

[souljah1]

Absolutely, I think we are obligated as compassionate providers of end-of-life care to advocate for the comfort and dignity of our patients at the time surrounding their inevitable death. I think the directive of informed consent and autonomy of patients has been misapplied in the case of palliative care/comfort measures only for elderly or medically fragile patients.

We have the tendency to present the options for resuscitation or aggressive care as if they were a buffet table for families, who are overwhelmed at having to choose "chest compressions or no?," "intubation or no?," "dialysis or no?," "pressors or no?" with no guidance from physicians they trust, because we fear being seen as paternalistic and directive. I try never to leave them to this horrible task. I first talk entirely in generalities about their goals of care - if they want their loved one to be comfortable as nature takes its course, or it they want some life-sustaining measures undertaken but nothing invasive, or if they feel that their loved one would want their life to be prolonged no matter what physical cost it might entail, including the possibility of prolonged suffering. Only after we discuss basic beliefs and goals do I start talking about resuscitation.

And I don't think we should be so tentative about sharing our opinion about what direction the patient's care should take in that situation. It's very likely that this is the only time the family has been in the position of making end-of-life decisions for a loved one and they don't know what to expect, but we see the scenario all the time. I think by avoiding providing guidance to them, we are adding to their anguish and anxiety, even though it is with the noble goal of preserving their autonomy.

[/$0.02]

This is called hitting the nail on the head.