Shoemaker, William C.

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The Linacre QuarterlyVolume 42 | Number 2 Article 8May 1975Problems in the Classification of Prognosis forPurposes of Disengagement of Therapy in theCritically Ill PatientWilliam C. ShoemakerFollow this and additional works at: http://epublications.marquette.edu/lnqRecommended CitationShoemaker, William C. (1975) "Problems in the Classification of Prognosis for Purposes of Disengagement of Therapy in theCritically Ill Patient," The Linacre Quarterly: Vol. 42: No. 2, Article 8.Available at: http://epublications.marquette.edu/lnq/vol42/iss2/8Problems in the Classification of Prognosis for Purposes of Disengagement of Therapy in the Critically III Patient William C. Shoemaker, MD. You can not find a medicine for life , when once a man is dead . - Ibycus, 550 B.C. The practicing physician whose patient is dying initially sees an operational and quantitative problem rather than a dilemma involving moral principles. From his point of view, the issue is, have I overlooked an obscure but correctible diagnostic possibility? Have I given the maximum ther-apy available in the optimal dose schedule? Could another consult-ant be of help? The attendants are acutely aware of the possibili-ties of errors, the time and effort that have already gone into the patient's care, as well as the pressing anxieties, false hopes and present recriminations. It is little wonder there is belated recogni-tion that the time for action has come and gone, that further ef-fort is futile, and that continued therapy, at best, will not save life, Dr. Shoemaker is Professor of Surgery at UCLA and Chief of the Acute Care Center, Harbor General Hospital , Torrance, Cali-fornia. May, 1975 but only prolong death. Often the last to recognize this situation is the patient's primary physician; the abrupt 180 degree change in direction is not as easy to appre-ciate in the real world as it is in the abstract. And once recognized it is not psychologically easy to deal with; the approach of "never give up under any circumstance" and other overstatements are well ingrained as the "party-line" In many institutions. Moral and ethical considera-tions in the hopeless case have been lucidly discussed by Cas-sem I and others2 . 4 and are pre-sented elsewhere in this journal in detail. In a real sense, these questions are in large measure definable; and where the issues are properly defined, eternal verities and logical thought may be applied. Unfortunately, how-ever, the application of these principles to a particular patient is obscured by essentially unan-swered or incompletely answered clinical and physiologic problems. The change from a salvageable to a totally hopeless, inevitably lethal condition is not heralded by a clearly definable event. There are no bridges burned, no 105 Rubicon crossed; the Stygian shore is not well marked and road maps are hard to come by. Irre-spective of the overwhelming ~umber of anecdotal instances that may be mustered, categori-cal statements about a given patient's chances are elusive; prognosis is usually given in terms of probabilities, not certainties. As there are few athesists in fox-holes, there are few absolutists on intensive care services. Opera-tionally the problem is more often quantitative rather than qualita-tive; that is, the question be-comes, "Is there one chance in lOa?" Or, alternatively, " Is there less than once chance in a mil-lion?" Assuming that these two rhetorical questions could be an-swered, one in the affirmative, the other in the negative by all par-ties concerned in the decision-making process, what about the patient whose chances are one in a thousand, or one in 10,000? The question then becomes, where do we draw the line and, secondly, how sure can we be that the prog-nosis is one in 1000 as opposed to one in 10,000, if this is to be con-sidered the dividing point. The question of the probability of death is not only a quantita-tive one, but in the critically ill patient, it is an estimation that changes with time. Our patients are not all as considerate as Charles III, who apologized to his physicians because he took so long to die. Obviously, more cer-tain measurements of the severity of illness are needed; that is, physiologic predictors of death 106 that can be used serially both as a measure of the effectiveness of therapy as well as the ineffec-tiveness of continued therapy. Until that day arrives - and it may not be too far off - we are left with the clinical guestimate, which though fallible, is never-theless an improvement over the indecisiveness that comes from having no estimate at all. Despite these obvious limita-tions, Tagge et al-' have developed an operational approach that vir-tually forces evaluation and fre-quent reviews at regular intervals so that decisions would be made as soon as concurrence was pos-sible and then translated into a systematic plan for the discon-tinuation of specific therapy in a concerted fashion . The principle advantage of the Tagge system of therapeutic disengagement is that it provides the mechanism by which all members of the thera-peutic team are confronted with the necessity of giving full and complete therapy with periodic reevaluations until t he time they agree not to initiate new therapy, to stop active theapy and finally to discontinue all life-support sys-tems. ' This prevents the not un-common situation where one physician continues to order full treatment while the others have abandoned their efforts. Cullen et a l(' have evolved a rating system of the intensity of therapy in the intensive care uni t. This system attempts to develop a semi-qualitative index of severi-ty of illness from the amount of time and effort expended on ther-Linacre Quarterly apy. This index also provides a useful mea n s for cost-benefit analysis. Our experience with the Tagge system over a two year period was entirely favorable. It provid-ed the mechanism for early con-scious decision to continue or to omit active therapy based on fre -quent reassessment, and it pro-vided communication between the primary physician, ICU staff, and patient's family regarding prog-nosis and advisability of continu-ing therapy. Of major import was the salutary effect on morale of nursing personnel who frequently had been called upon to render extraordinary care to patients with no reasonable hope for sur-vivallong after the private physi-cian had fled. While this system of categori-zation was clearly feasible and useful, critical review of its ac-curacy was hard to assess. As the system was new and evolving, we chose not to make the categoriza-tion part of the patient's chart; rather we noted the category on the cardex file. An exact account-ing of errors in categorization, therefore, is not possible. How-ever, of over 1000 admissions an-nually, approximately one-fifth were temporarily classified as Category II and then placed into Category I as they improved; these changes did not affect the intensity of therapy in any way , but did provide all personnel with the assurance that we were mind-ful of the overall problem. There were 115 to 130 patients, or 11 to 13 %, who died on the unit an -May, 1975 nually ; at least 75% of these pa-tients were kept in Category II as the possibilities of survival could not readily be ruled out and their demise was sufficiently rap-id that no one questioned the advisability of continuing ther-apy. There were three patients who were placed in Category IV; after due deliberation, the ven-tilator was turned off in two who had clearly evident brain death, and active therapy including transfusions withheld in the third patient. Two patients were placed in Category III for periods of 12 and 24 hours and subsequently redesignated Category II after unexpected spontaneous clinical improvement. The following are summaries of the salient features of these two cases. Case 1 A 73 year old man with an a 0 r tic aneurysm, hytertension and chronic renal disease under-went aneurysm resection and re-placement with a dacron graft. The patient was given nine pints of whole blood, two liters of Ring-er's-lactate and two liters of 5% glucose, but by the end of the operation his blood pressure had fallen from 180/ 90 to 110/ 50, and the heart rate increased to 130. He was cold, clammy, and oli-guric when he arrived in the ICU. He was resuscitated with an ad-ditional two units of whole blood plus 2000 ml of 5% albumin over the next 24 hours. The patient had a stormy postoperative course with fever, pneumonia, multiple PVC's and EKG changes, renal failure and coma. He was given 107 mechanical ventilation with high FlO, levels for over one week; his urine output was 200 to 350 rnl/ day; his BUN was 180 mgm/ lOO ml and creatinine 9 mgm/ 100 ml and rising, despite hemodialysis. On the fifth postoperative day he had a large upper gastrointestinal hemorrhage and was given five units of whole blood over the next two days with other supportive therapy. Discussions with the family and all consultants led to the unanimous decision that he had severe renal failure, respira-tory fa i I u r e , and unremitting hemorrhage and that there was nothing further that could or should be done as his prognosis was essentially nil. Accordingly, he was placed in Category III, maintained on mechanical ven-tilation with an FlO, of 70 % and slowly administered LV. fluids but no additional transfusions; no sedation was needed as he was semicomatose. Inexplicably , over the next 24 hours he spontane-ously stopped bleeding and im-proved in terms of his level of consciousness and activity. It was felt that this change was suffi-ciently striking that he was re-classified to Category II. The F~O, was gradually reduced as tolerated over the next week and he was "weaned" off the ventila-tor. His renal failure also im-proved and his BUN fell to the range of 40 to 50 mgm/ 100 ml over the next few weeks; these were approximately his preopera-tive levels. He was discharged from the ICU and eventually from the hospital. 108 Case 2 A 78 year old woman with a previously documented myocar-dial infarction entered the hospi-tal for multiple peripheral emboli, one which led to gangrene of the left lower leg. While in the X-ray department, she had a cardiac arrest. CPR was initiated, an en-dotracheal tube was inserted and she was transferred to the ICU. Despite mechanical ventilation for three days, FlO, values from .9 to .98 and other supportive measures she remained unrespon-sive. She was placed in Category III; the family, represented by her nephew who was a well re-spected physician in an affiliated hospital, requested that the ven-tilator and other supportive meas-ures be abandoned , as all agreed that her prognosis was hopeless . However, it was pointed out to the family that we would like to observe the patient for at least another 24 hour period before re-sorting to this. After the next 12 hour period, the patient spon-taneously improved in both her level of consciousness and respira-tory function. Active and ag-g res s i v e respiratory care was reinstituted. After three days the patient was able to tolerate room air and was subsequently weaned off the ventilator. She subse-quently made an uneventful re-covery was discharged from the ICU and later, from the hospital. Three months later she celebrat-ed her 50th wedding anniversary, surrounded by her grandchildren, and then went on a vacation to Mexico. Six months after dis-Linacre Quarterly charge she died suddenly at home, presumably of another myo-cardial infarction. It was generally appreciated by all concerned that there had been sufficient deliberation, en-couragement for input from all relevant sources, and appropriate exercise of critical judgement. All things considered, these two er-rors in categorization were ac-ceptable to the medical communi-ty as well as the patients and their families. Moreover the er-rors did not appear to produce any permanent harm, as both pa-tients eventually recovered and left the hospital. These two cases remind us that, despite the track records of suc-cess, medical 0 pin ion is still shrouded by uncertainties and judgematic errors which, like the poor, are always with us. A sys-tem of step-wise categories which relates therapy to prognosis after due deliberation by all involved parties provides, on the one hand , a reasonable guard against uni-lateral precipitous action and, on the other hand, undue prolonga-tion of futile efforts. Moreover, t his system may cont inue to pro-vide the mechanism for joint de-cision-making even as medical science gains more precise meth-ods for assessing the severity of illness, prognosis and cost-effec-tiveness estimates of va rio u s types of therapy in life-threaten-ing conditions. REFERENCES 1. Cassem. N. H ., "Confronting the Decision to Let D eath Come." Critical Care Medicin e, 2:113 (1974). 2. B eeche r . H. K .. "Ethical Prob-lems Created by the Hopelessly III Patient." N ew England Journal of 1\1 edicine 278: 1425 (1968). 3. Moore. F . D .. "Medica l R espon-s ibility for the Prolongation of Life ." J AM A 206:384 (1968) . 4. Ramsey , Paul. The Patient As a Person (New Haven : Yale Univers ity Press). 1970. 5. Tagge. G. F .. Adler, D .. Bryan-Brown, C. W. , and S hoemaker. W. C .. " R elationship of Therapy to Prognosis in Critica lly III Patients," Critical Care 1\1 edicill e 2:61 ( 1974). 6. Cullen. D. J.. Civetta. J . M. , Briggs. B. A.. and Ferrara. L. C .. "Therape uti c Inte rvention S co r i n g Systems: A Method for Quantitative Comparison of Patient Care." Critical Care Medicine 2:57 (1974). W e extend our condolencps to the family of Dr. W. B. J. Pem-berton, who died on February 17, 1975. Dr. Pemb prton was a physician of integrity and dedication, and served for several y ears as British correspondent for Linacl'e. We will miss his friendship. May he rest in peace. May, 1975 109 

Problems in the Classification of Prognosis for Purposes of Disengagement of Therapy in the Critically Ill Patient

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Problems in the Classification of Prognosis for Purposes of Disengagement of Therapy in the Critically Ill Patient

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