City-Wide Palliative/Ethics Grand Rounds

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City-Wide Palliative/Ethics Grand Rounds

• Next Session 11/19/07
• Barry Smith
• SUNY Distinguished Professor
• Julian Park Professor
• The Future of Biomedical Informatics

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Jack P. Freer, MD

• UB
• Professor of Clinical Medicine
• Palliative Medicine Course Coordinator
• Kaleida Health
• Ethics Committee Chair
• Palliative Care Consultation (Gates)

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CME Disclosure

• No commercial support
• No unapproved or off-label uses

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Breathlessness

• Jack P. Freer, MD
• Professor of Clinical Medicine
• University at Buffalo

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Learning Objectives

• Understand pathophysiology of dyspnea
• Be familiar with basic modalities of treatment
• Be capable of sound ethical reasoning in
  intubation/ventilation decisions
• Be able to guide coherent decisions based upon
  good medicine and good ethics

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Dyspnea

• Pathophysiology
• Treatment
• Decision Making/Ethical Issues

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Dyspnea shortness of breath, breathlessness

• Rapid breathing
• Incomplete exhalation
• Shallow breathing
• Increased work/effort
• Feeling of suffocation
• Air hunger
• Chest tightness
• Heavy breathing

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Dyspnea shortness of breath, breathlessness

• Rapid breathing
• Incomplete exhalation
• Shallow breathing
• Increased work/effort
• Feeling of suffocation
• Air hunger
• Chest tightness
• Heavy breathing

• COPD, pulm vasc dis
• Asthma,
• Asthma, Neuro-musc, Chest wall
• COPD, Interstitial, Asthma, N-m, Cw
• COPD, CHF
• COPD, CHF, Pregnancy
• Asthma
• Asthma
• Manning HL, Schwartzstein RM Pathophysiology of
  Dyspnea. NEJM (1995), 3331547-1553

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Dyspnea

• Cancer (dyspnea common)
• Obvious cause (lung mets, effusion etc)
• Co-morbid conditions (COPD/CHF)
• No evidence of 1. or 2. (?cachexia)
• Non-malignant (COPD, CHF)

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Dyspnea in Cancer

• Cancer related causes
• Treatment related causes
• General medical condition causes

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Cancer Related Causes

• Airway obstruction by tumor
• Lung parenchyma replacement
• Pleuro-pericardial effusion
• Lymphangitic carcinomatosis
• SVC syndrome
• Ascites

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Treatment Related Causes

• Pneumonectomy
• Radiation fibrosis
• Chemotherapy
• Cardiac toxicity
• Pulmonary toxicity

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General Medical Conditions(both related and
unrelated to cancer)

• COPD
• CHF
• Asthma
• Infection
• Anemia

• Pneumothorax
• Pulmonary embolus Pulmonary hypertension
• Psychosocial/Spiritual

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Mechanism of Dyspnea

• Mechanical Receptors
• Lung
• Chest wall
• Upper airway

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Mechanism of Dyspnea

• Sense of Respiratory Effort
• Effort major factor in breathlessness
• Simultaneous motor cortex signals
• Efferent to respiratory muscles
• Signal to sensory cortex

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Manning HL, Schwartzstein RM Pathophysiology of
Dyspnea. NEJM (1995), 3331547-1553
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Mechanism of Dyspnea

• Sense of Respiratory Effort
• Effort major factor in breathlessness
• Simultaneous motor cortex signals
• Efferent to respiratory muscles
• Signal to sensory cortex
• Mismatch enhances sense of effort
• Probably similar signals from brainstem

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Mechanism of Dyspnea

• Chemical Receptors
• Hypercapnia
• Hypoxia

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Mechanism of Dyspnea

• Hypercapnia
• Early studies in normal subjects suggested CO2
  not a factor
• Probably mediated by pH

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Mechanism of Dyspnea

• Hypoxia
• Some evidence of effect
• Still
• Some patient hypoxicnot SOB
• Some patients SOBnot hypoxic
• Some hypoxic/SOB pts show little improvement with
  O2 therapy

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Treatment of Dyspnea

• Treat underlying causes
• Oxygen
• Nebulized bronchodilators
• Opioids
• Benzodiazepines
• Nebulized opioids used by some but no solid
  evidence of efficacy
• Fans across face

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Decision Making/Ethical Issues

• Opioids and hastening death
• Withdraw vs. Withhold
• DNI

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Resistance to Opioids for Dyspnea

• Hasten death kill patient
• Response
• Tolerance to respiratory depression
• Slowing respirations may improve oxygenation

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Resistance to Opioids for Dyspnea

• However, failing to intubate and ventilate a
  patient in severe respiratory failure will result
  in death (with or without opioids).
• Opioids may hasten that death
• Double effect

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Withhold LST vs. Withdraw

• Logical/clinical difference?
• Therapeutic trials
• Duty to start or stop independent of whether the
  treatment is already in place
• Legal difference? NO
• Religious difference
• Psychological difference

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Withhold vs. Withdraw Ventilator

• Quality of life (prior to vent decision)
• Reversibility

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Withhold vs. Withdraw Ventilator

• Trialwithdraw later
• Acceptable quality of life
• Reversible condition

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Withhold vs. Withdraw Ventilator

• Trialwithdraw later
• Acceptable quality of life
• Reversible condition
• Clear timetable, endpoints to gauge success of
  the trial

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Withhold vs. Withdraw Ventilator

• Trialwithdraw later
• Acceptable quality of life
• Reversible condition
• Clear timetable, endpoints to gauge success of
  the trial
• Legally appointed agent to act on behalf of the
  patient

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Withhold vs. Withdraw Ventilator

• Die without intubation/ventilation (DNI)
• Poor quality of life
• Irreversible process

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Withhold vs. Withdraw Ventilator

• Die without intubation/ventilation (DNI)
• Poor quality of life
• Irreversible process
• Prior reversible process, tough wean

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Withhold vs. Withdraw Ventilator

• Die without intubation/ventilation (DNI)
• Poor quality of life
• Irreversible process
• Prior reversible process, tough wean
• Crystal clear informed consent NO need for last
  minute clarification.

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Withhold vs. Withdraw Ventilator

• Die without intubation/ventilation (DNI)
• Poor quality of life
• Irreversible process
• Prior reversible process, tough wean
• Crystal clear informed consent NO need for last
  minute clarification.
• Scrupulous symptom management

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Withhold vs. Withdraw Ventilator

• Trial / Withdraw
• Good QoL
• Reversible
• ________________
• Clear Endpoints
• Timeframe
• Outcomes
• Proxy

• Withhold
• Poor QoL
• Irreversible
• ________________
• Clear Consent
• No last minute clarifications
• Symptom Treatment

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Dying Without Intubation

• Decision making
• Broad planning based on goals of treatment
• Positive treatment directed toward ALL goals
• Reversibility/Quality of life
• Treat respiratory failure symptomatically
• No intubation/ventilation

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Dying Without Intubation

• Documentation
• Document rationale in detail
• Document informed consent discussion
• Detailed symptomatic plan
• Communication
• Clear discussions with nurses, family
• Explain what to expect
• Avoid focus on not

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Dying Without Intubation

• What if the patient changes his mind?

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Dying Without Intubation

• Failure to document the informed consent
  discussion can lead to last minute
  clarification about decision (and patient
  changing mind about intubation).

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Dying Without Intubation

• Failure to provide adequate symptom relief can
  lead to suffering (and patient changing mind
  about intubation).

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Respiratory Death without Intubation/Ventilation

• can be the most appropriate and ethically
  defensible option.
• can be part of a comprehensive palliative plan
  based on the patients goals of care.
• can NOT be summarized in 3 letters.

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Editorial