In this episode, Zack and Joe talk with Dr. Cyrus Olsen, Oxford graduate and expert in bioethics about how to decide when to “Stop the Train”.
“in regards to ECMO : There's now a space, a hopeful space, to allow patients & family the time to make better decisions.” – Cy Olsen PhD
— ED ECMO Project (@edecmo) November 22, 2014
WARNING: This is going to get waaaaay touchy-feely and waaaaay outside of Joe's comfort zone (Zack, on the other hand, is feeling right at home here). With that in mind…
“How young is too young…” to withhold resuscitation?
- How old is too old…or better yet…how young is too young? aside from routine resuscitation: drugs, chest compressions, shocks, is there an age that is too old for ECMO? We currently use a soft cutoff of 75 yoa. Lets take all of the variables out of the equation and just assume a person has ZERO medical problems and is on ZERO medications. They ambulate on their own, live independently, and they believe they have a good quality of life. In this scenario, is there any age that is too old for ECMO? This should be our starting point and then move down (in age) from there. The 95 year old is easy. The 40 year old is easy. All the rest are tough and that's where we will get criticism for “doing too much.”
- Concrete resuscitation cutoff vs. a graded response? Whatever we decide is the cutoff (age, quality of life, comorbidities), should we use the exact same set of criteria for even initiating CPR as we do for ECMO? Should they be the same? In other words, should we have the same set of criteria for both or should there be a graded response to the dying patient (over 75 I do CPR and intubate but don't do ECMO but under 75 I go full-court-press and possible ECMO)?
- Only Reverse the Reversible. Somehow we need to identify inevitable death and allow that to happen. Greg Henry always says, “Despite all the advances of modern medicine, the death remains the same: one per person.” But when we can't be sure that death is inevitable, does everyone deserve a shot? In other words, should we be making that decision on the front end (ED) when little information is known to us, or should that be sorted out on the back end…in the ICU? Is there a way to tell a resuscitationist that its ok to err on the side of over-resuscitation, so long as your intent to is to reverse the reversable? Peter Safar's quote, “Death is not the enemy, but occasionally need help with timing.” exemplifies this.
- Define “Quality of Life”. How do we determine “Quality of Life”? Who decides this in the heat of the moment? The doctor or the family?
- What is the real goal of resuscitation? Should we only resuscitate people who were previously healthy and have a chance of 100% recovery? It seems we've come to a place where the knee-jerk reaction by ED doctors is to do full CPR on everyone and then see what happens. So how do we determine when and where to stop?
- MD paternalism vs. patient automony = “The Tyranny of Choice.”
The Episode Play-by-Play:
Dr. Olsen talks about the first concept: The “3 Senses of Dignity” from Daniel Sulmasy MD, PhD, a spokesman for the President's Council on Biotheics
- Intrinsic Dignity = your value for just being human
- Attributed Dignity = your “market value” to society
- Inflorescent Dignity = your “flourishing”; or your quality of life
The Life Matrix and the Functional Threshold:
“We cannot predict the neurologic outcome of patients that are in cardiac arrest” – Zack Shinar MD
Bottom line: As a resuscitationist in the Emergency Department you MUST err on the side of aggressive curative care, unless there is compelling evidence to do otherwise. You are on ethical solid-ground to approach resuscitation in this fashion. But…you will fuck this up. And that's ok if your heart is in the right place. And once you realize that your patient does not belong in the AGGRESSIVE CURATIVE arm, you begin AGGRESSIVE PALLIATIVE care. In either case, you care is MAXIMALLY AGGRESSIVE.
Dr. Olsen is a graduate of the University of Oxford and is now an Associate Professor at The University of Scranton, in Pennsylvania where he specializes in Ethics and Theologic Studies. He has published extensively in the arena of medical ethics and sits on the IRB (Institutional Review Board) for both human and animal studies at his institution. A graduate of the Comparative History of Ideas Program at The University of Washington, and Systematic Theology from The University of Oxford, his research and teaching address many aspects of human studies and bioethics.
Medical Journal Articles on the Ethics of Resuscitation Discussed in this Episode
1. Emcrit Podcast 25: End of Life and Palliative Care in the ED – Scott Weingart from the Emcrit Podcast