So looking at the descriptions for the talks allocated today there’s a lot of overlap. I’d been asked to talk about palliative care in ICU and legal aspects of death. but I don’t want you to have to listen to the same talk over and over again, and there’s a lot of the legal aspects that either have been covered or will be covered.

Ali’s talk on organ donation, treatment withdrawal, consent and assent Is so clearly about the legalities of death

Alisons talk on treatment escalation plans and end of life care also clearly has overlap with palliative care. Sarah’s talk on bereavement support also overlaps with what we might think of as palliative care.

So I’m going to try and focus this talk in, into hopefully stuff that prevents too much repetition for you.

I’m going to talk briefly on the WHY of palliative care in ICU, why our cohort of patients have a particular need of it. This will cover general stats on ICU and hospital outcomes, symptom burden of ICU patients.

I’m going to talk a bit on the how of palliative care in ICU. In that I’m going to look at a systematic review of ICU palliative care studies published fairly recently, on how other units have tried to introduce palliative care in ICU.

I’m going to talk about some specifics on the legalities of treatment withdrawal in ICU, with a focus on the ideas of double effect, the right to life and the right to death.

I’m not going to talk about communication about death and the importance of it. I’m not going to talk about defitions of death. I’m not going to talk about ICU follow up for bereaved families. I’m not going to talk about the specifics of symptom control. If anyone want’s to talk or email about those things I’m happy to.

Why / How / Law

Why

Survival¹

All Hospital Inpatients (Medical And Surgical):
- Last Year of Life: ~33%

Survival¹

Patients Admitted To Intensive Care
- Hospital Mortality: ~20%
- One Year Mortality: ~36%

Survival²

Surgical Patients Admitted To ICU
- Hospital Mortality: ~16%
- One Year Mortality: ~24%

Survival²

High Risk Surgical Patients Admitted To ICU
- Hospital Mortality: ~22%
- One Year Mortality: ~33%
- Four Year Mortality: ~51%
Majority of Cohort: General, Vascular, Orthopaedics

Symptoms In ICU³

70% Of Patients Report Discomfort and Pain In ICU:
- Hallucinations
- Noise/No Rest
- Pain
- Thirst
- Unable to Talk
- Shortness of Breath
- Fear

Morbidity⁴

Survived ICU and Hospital (Medical and Surgical):
- Require Assistance with ADLs at 6 Months: ~ 25%
- Lost Work at 12 Months: ~ 28%
- Need Help With Mobility at 6 Months: ~58%
- Moderate/Severe Depression at 12 Months: ~46%
- Moderate/Extreme Pain at 12 Months: ~70%

How

Studies

58 vs 1

“aimed to maintain and improve the quality of life of all patients and their families during any stage of life-threatening illness”

How - Methods

Communication
Ethics
Education
Palliative Care Team
Anticipatory Care Planning

How - Who

Consultative
Integrative
Mixed

Outcomes

💀 / 💣 / 💵

Clinical

💊

Laws

Doctrine of Double Effect

R v Cox (1999)
R v Adams (1957)
R v Moor (2000)

Can you give someone medicines, knowing they will shorten their life?

Answer is it depends on why you gave them.

Can’t legally be with the intent of shortening life.

These are three cases that highlight this.

1991 Nigel Cox was a rheumatologist, who was looking after a woman named Lillian Boyes. She had worsening rheumatoid arthritis, and reportedly asked him repeatedly to end her life. He injected her with potassium chloride, deliberately with the aim of ending her life. He was arrested for attempted murder, convicted of it, and given a 12 month suspended sentence. The GMC didn’t take any further action, and he returned to work.

So cant treat with sole aim of ending life.

John Adams was a GP, tried in the 1950s for the murder of the wealthy Mrs Edith Morrell, shed been dead for several years at that point, in looking after her before her death he prescribed ever increasing doses of morphine and heroin. When she died her son gave Adams her Rolls-Royce, and a chest of silver cutlery. This is after Adams had billed her estate over the equivalent of £40K. The reason I mention his case is he went to the courts saying that he never intended to shorten life, although he was aware his medicines could do so.

If the first purpose of medicine, the restoration of health, can no longer be achieved, there is still much for a doctor to do, and he is entitled to do all that is proper and necessary to relieve pain and suffering, even if the measures he takes may incidentally shorten life

Doctrine of Double Effect

R v Cox (1999)
R v Adams (1957)
R v Moor (2000)

Doctrine of Double Effect

Actus Rea vs Mens Rea

Acts/Omissions

Airedale NHS Trust V Bland

a doctor has no right to proceed [with treatment] in the face of objection [from the patient] even if it is plain to all, including the patient that adverse consequences and even death will or may ensue

DNACPR

Tracey v Cambridge NHS Foundation Trust

Janet Tracey had terminal lung cancer with life expectency less than 1 year and was admitted to hospital with a cspine injury following a road traffic accident

This is a key piece of UK health law, and it’s an ICU case.

Tracey had a DNACPR put in place on 27 feb by a consultant in anaesthetics and ICU. They didn’t tell the family. They told the court that they did tell Tracey, and she was able to nod agreement to it. Resulted in health team withdrawing the DNAR on 5 days later when family did find out (after return from holida) and were horrified. So the surgeons withdrew it, after discussing with her and family.

She then got worse later and there was a sit down chat with family after she’d lost capacity, at that point a DNACPR was put in place. She died a few days after that. Courst of appeal found this breached her Article 8 Rights (rightt to private and family life - autonomy quality of life), by not coulting her

Judge criticiesd the consultants use of phrases like “slip away”, and not explaining CPR to Tracey properly. The judge also didn’t believe that the consultant had discussed with Tracey about the first case (no documentation)

They say when patients are clear they do not want to be involved in conversations abotu DNACPR, then you need to discuss with family, and you need to tell family and them that you have made the decision

First, a belief that it would cause distress to the patient to discuss the issue is unlikely to be sufficient, without more, to make it inappropriate to involve her. The distress must be likely to cause the patient a degree of harm.

Where the clinician’s decision is that attempting CPR is futile, there is an obligation to tell the patient that this is the decision. The patient may then be able to seek a second opinion

Why / How / Law

callum.taylor4@nhs.scot

Sources

        1. Care at the End of Life | Faculty of Intensive Care Medicine https://www.ficm.ac.uk/standardssafetyguidelinescriticalfutures/care-at-the-end-of-life
        2. Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study https://doi.org/10.1093/bja/aew396
        3. Pain in patients in critical condition and its environment.Revista Médica del Hospital General de México. 2018
        4. An exploration of social and economic outcome and associated health-related quality of life after critical illness in general intensive care unit survivors: a 12-month follow-up study https://doi.org/10.1186/cc12745

Palliative Care and Legal Aspects

Why / How / Law

Why

Survival1

Survival1

Survival2

Survival2

Symptoms In ICU3

Morbidity4

How

Studies

58 vs 1

How - Methods

How - Who

Outcomes

💀 / 💣 / 💵

Clinical

💊

Laws

Doctrine of Double Effect

Doctrine of Double Effect

Doctrine of Double Effect

Acts/Omissions

Airedale NHS Trust V Bland

DNACPR

Tracey v Cambridge NHS Foundation Trust

Why / How / Law

Sources

Survival¹

Survival¹

Survival²

Survival²

Symptoms In ICU³

Morbidity⁴