An elderly man presented to hospital with an acute abdomen. He was fit and well, with a background of well-controlled hypertension and chronic back pain. He had previously had admissions with a recurrent gastric volvulus, each time it had resolved spontaneously.

A CT scan was performed and revealed a gastric volvulus which was decompressed endoscopically. He was transferred to the high dependency ward post-procedure for observation as it was deemed high risk for recurrence and therefore likely that he would need surgery to correct it. Overnight he required increasing amounts of fluid and analgesia and suddenly deteriorated with a tachycardia, rising lactate and peritonitic abdomen. He was taken for an emergency laparotomy and had a gastrectomy. A feeding jejunostomy was inserted during the procedure.

The post-operative course involved a period of septic shock and multi-organ failure. He remained intubated, on a noradrenaline infusion and was receiving CVVH for renal failure. On the third post-operative day, despite a 24 hour sedation hold, he was showing no sign of any neurological recovery and was not eye-opening or obeying commands. It was at this point that his wife presented the team with an advance directive.

The advance directive was presented at a point in the care whereby the patient was already receiving high levels of support for his cardiovascular system (noradrenaline 0.3mcg/kg/min), respiratory system, renal system (CVVH) and gastrointestinal system (jejunostomy feed). It was discussed and a plan was made to, for the current time, continue management, but it was explained that the outlook was bleak.

His renal function worsened over the next few days (urea 27, creatinine 400) and despite a long sedation hold, he was still unable to obey commands. However,care was continued as both the cardiovascular and respiratory support was decreasing, with the noradrenaline having been weaned by day 6. He was extubated by day, but remained mildly confused and agitated. The following day, he became more tachycardic, tachypneoic and hypotensive. He deteriorated significantly to the extent where he became peri-arrest and was re-intubated. A CT confirmed an intra-abdominal/mediastinal catastrophe.

He once again developed severe septic shock with multi-organ dysfunction. His antiobiotics were restarted (meropenum) and an anti-fungal (fluconazole) introduced. NJ feed was commenced. He improved to the point of extubation on day 11, but again deteriorated. At this point, a decision involving his wife was made to palliate him. He died later that day

What are the implications of advance directives on the ICU?

Emma Fitzgerald

The use of advance directives is becoming increasingly common in recent years and can pose ethical dilemmas for physicians when faced with them, especially if it is unclear or should it be presented during the course of a critical care stay, as with this particular patient. It appears that over the last few decades, limitation of life support prior to death is the predominant practice seen when patients die in the intensive care unit [1].

The SUPPORT study [2] revealed short-comings in communication between patients and relatives and consequently meant that patients who died in these ICUs did so with pain and discomfort whilst being given treatments and investigations that they had asked not to be given. There was no improvement seen when the clinicians were given information on patient prognosis and preferences.

Since then there have been some advances in legal and professional guidance and that have resulted in a considerable interest in advance directives. It was hoped that these will enable doctors to know what patients would actually have wanted, should they have been in a position to consider the issues calmly and to express themselves without distraction caused by such extremes of pain [3].

People who understand the implications of their choices can state in advance how they wish to be treated if they later suffer loss of mental capacity. An “Advance Decision” is a general term that covers a range of options and could include a written document, an oral statement or even a note of a discussion with the patient in their hospital notes. An “Advance Directive”, or living will, is a clear written instruction (signed and witnessed) refusing a medical procedure or intervention. It must be made voluntarily by a competent and informed adult, specify the treatment refused and the circumstances in which the refusal is to apply (they must clearly indicate that it is to apply even if life is at risk and death will predictably result) and be consistent with the behaviour of the person making it. It usually applies to a refusal of treatments.

The level of capacity required to request or refuse treatment in advance is the same level that would be required for making the decision contemporaneously. It may be demonstrated by patients who lack insight into other aspects of their life as long as they understand the implications of the specific choice before them. However, even clear and specific advance refusals cannot override other legislation [4].

Health professionals are generally bound to comply when the refusal specifically addresses the situation which has arisen. The GMC supports the use of such documents, their guidance states that “….doctors must respect any valid advance refusal of treatment – one made when the patient was competent – which is clearly applicable in the circumstances and where there is no reason to believe the patient has changed his/her mind….” [5]

This patient made his AD in order to prevent unnecessary and futile procedures that may prolong the actual moment of his death. He had made the AD 4 years prior to his death. It was suitably dated, signed and witnessed. The specific nature of the clinical problems that this patient encountered were not listed in his AD, but one could assume that the statement “similar gravity” could mean that this was the situation that he would want to avoid. It was unlikely that should he be re-intubated for a third period of severe sepsis and multi-organ failure, that his chances of any meaningful recovery were very small.

The issues surrounding his feeding were contentious. Our patient appeared to have no concerns when he was extubated, about his jejunostomy tube that had been sited for feeding during his gastrectomy (note the AD referred only to oral feeding, but did not specifically refuse any other kind). He had also not raised any concerns about this prior to his surgery. His wife who had witnessed the AD did not have any concerns over this either.

Legal standing of advance directives is highly variable. They do have significant ethical validity and as such warrant respect. They should indicate to the physicians caring for the patient what their wishes would have likely been if they were able to discuss their treatment options

Some problems associated with the use of AD usually stem from them being non-specific and also that physicians cannot always be sure that the decisions were made in a rational and informed manner. This AD referred to a very non-specific “condition of comparable gravity” which was open to interpretation but does allow some idea of the patient’s general wishes.

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Lessons Learnt:

Unfortunately, the AD was not made available to us until the patient was sedated. This is a terrible shame, because had there been an opportunity to discuss it with the patient, the specific nature of this surgical problem could have been clarified with him. A learning point would be to specifically ask if the patient has any thoughts regarding their care as a matter of routine. The AD should be presented  and discussed at the time of hospital admission, but its existence did help in considering the wishes of this patient when circumstances occurred in which the risks and benefits of treatment were similar in magnitude.

A limited period of organ was given in an attempt to reverse any treatable pathology, but the sentiments from the AD were considered when he deteriorated for a third time and end-of life care was instead instigated.

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References:

1. Prendergast T. A National Survey of End-of-life Care for Critically Ill Patients. Am. J. Respir. Crit. Care Med., Volume 158, Number 4, October 1998, 1163-1167
2. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 1995 Nov 22-29;274(20):1591-8.
3. Flew A at al. Advance directives are the solution to Dr Campbell’s problem for voluntary euthanasia. Journal of Medical Ethics 1999;25:245-246
4. Advance decisions and proxy decision-making in medical treatment and research. Guidance from the BMA’s Medical Ethics Department. June 2007
5. Withholding and withdrawing Life-prolonging Treatments: Good Practice in Decision-making, GMC, August 2002