Thursday, January 22, 2009
Imagine a nurse in the ICU raises concerns about possible euthanasia by staff in the ICU. You might think it may first go to the ethics committee, the hospital board, and likely the legal department. Then imagine if the Feds (Office of Inspector General) get involved and conduct a complete investigation into the allegations of hastened death. Really. Just imagine it happening to you.
Makes answering, "Hey honey, how was your day?" seem impossible.
Now imagine someone in your department says, "You know what we should do? We should publish our experience of being investigated by the OIG in a major medical journal!" Would you not want to throw a drink in that guy's face?
Well thank goodness someone did think that was a good idea, because Chest published an important article regarding ICU & Palliative Care ethics this month from the group at VA Palo Alto. They are to be highly commended for shedding some light on this very difficult subject.
The paper discusses four cases of alleged euthanasia in detail as well as the investigation and the changes made by the ICU staff to improve communication and standardization of comfort care orders.
Briefly here are the four cases (there are many more details in the original article):
Man in his late 50's with metastatic lung cancer to the brain, with hemorrhage into his brain, and respiratory failure requiring a ventilator. Family and clinicians agreed to comfort care as the primary goal and the vent was discontinued and the ET tube left in place. Over two days, he received increasing doses of morphine eventually getting 30mg/hr. Another nurse felt this to be excessive and she titrated down to under 10mg/hr. He was extubated 3 days after the vent was stopped and died that morning.
Patient in his mid 60's with metastatic lung cancer on a ventilator with pneumonia and ARDS. Goals were changed to comfort care. Vasopressors were stopped and 100% oxygen per vent was decreased to 21%. He was continued on fentanyl (1oomcg/hr) and midazolam (2mg/hr) without titration. He died minutes later.
Another man in his mid-60's with metastatic lung cancer with pneumonia and sepsis, renal failure and eventually requiring a ventilator. After 1 week goals were changed to comfort care. His oxygen concentration on the vent was decreased from 100% to 21% and vasopressors were stopped. The ventilator, fentanyl and midazolam were all continued and he died two hours later.
Man in his mid-50's with metastatic colon cancer with neutropenia, respiratory failure and sepsis. Placed on a ventilator, vasopressors and antibiotics. He required paralyzation and sedation (fentanyl 200mcg/hr & versed 6mg/hr). After 36 hours family requested comfort care, the paralytic, pressors, and ventilation were stopped. No titration of the fentanyl and versed. He died within minutes.
Of particular note the last three deaths happened on the same day, which brings to mind the impact of death acuity. So many deaths in such a short time can be very shocking to staff and in other situations unusual grouping of deaths in medical settings has been a tip off for identifying health care professionals who are killing patients.
Another significant issue was the concern that the deaths were hastened to possibly open up ICU beds for other patients. This allegation was not supported by the OIG's investigation.
The results of the OIG inspection are online and basically found no substantial evidence for intentionally hastened death but did find there was significant variations with the interpretation of appropriate end of life management in the ICU, and recommended the establishment of new guidelines.
The ICU department developed an ICU comfort care QI project, comfort care guidelines, a physician template note for comfort care, and a comfort care order set. The VA Palo Alto ICU group responded in a constructive fashion to potentially severe allegations and demonstrated a willingness to share with the health care community a very difficult situation. This transparency is leading to better care for patients there and with the publication may improve the care for other patients dying in ICU's.
W. G. Kuschner, D. A. Gruenewald, N. Clum, A. Beal, S. C. Ezeji-Okoye (2009). Implementation of ICU Palliative Care Guidelines and Procedures: A Quality Improvement Initiative Following an Investigation of Alleged Euthanasia Chest, 135 (1), 26-32 DOI: 10.1378/chest.08-1685