197 Locke Patient Preference Scenarios
197.1 Summary
- PGR – Value Concordant care in the ICU
- McFadden
- Twitter poll: from my twitter – do DNR orders (in the absence of other specified restrictions) ever applicable to patients with a pulse?
- Question 1 – is this a consistent preference?
- Clinical Momentum in the Intensive Care Unit
- Ethical Frameworks to make decisions
- Pitfalls of deontologicalism (actual reasoning behind commitments to individual patients, ethical normative frameworks)
- Actualism vs Possibilism
- How many times do we address “code status”
- Was this an error?
- the idea of preference-sensitive decisions
- Advance directives have been standardized for a good reason. Health care providers must be able to immediately understand and act on them without requiring a lawyer’s interpretation. Without the patient’s input or that of a knowledgeable surrogate, neither the patient’s reason for the nonstandard directive nor his or her present wishes concerning resuscitation can be independently known.
197.2 Slide outline
197.2.1 Slide 1
- PGR – Value Concordant care in the ICU ### Slide 2
- McFadden
- Choosing Wisely critical care: goal discordant care
- Discussed risks/benfits. Full code but does not want to undergo EGD due to the risk of intubation associated with the procedure.
- Discussion: if surviving is your priority, due the procedure now. If you prioritize not being intubated over surviving, ok to wait.
- https://twitter.com/vitaincerta/status/1334265070164070403 ### Slide 3
- Twitter poll: from my twitter – do DNR orders (in the absence of other specified restrictions) ever applicable to patients with a pulse?
- Follow-up: should every patient admitted admitted to the hospital have some variation on the discussion of “if your heart were to stop,…”
- What percentage of patients do you think have
- Is code status documentation: Goals of care theater? (pretending we are engaging with the question, when in fact we are not) ### Slide 4
- Question 1 – is this a consistent preference?
- Relevant in determination of whether the patient has capacity
- Gut reaction: no, either commit to maximizing chance of survival or maximizing chance of avoiding suffering.
- However say you place the value of the following outcomes as: death after intubation 0/100, death without intubation 5/100, surviving with intubation, 10/100, surviving without intervention 90/100
- Say ,further, I expect the chance of rebleed is 50%, and the chance of death with rebleed and out intubation is 75%. How would this play out? What is the expected value of the various decision-making strategies? ### Slide 5
- Clinical Momentum in the Intensive Care Unit
- A Latent Contributor to Unwanted Care
- DOI: 10.1513/AnnalsATS.201611-931OI ### Slide 6
- Ethical Frameworks to make decisions
- Consequentialist – take the course of action that produces the best outcomes
- Possibly involves disagreeing with a patient’s stated preference if it achieves their stated goals
- Non-consequentialists – behave in a way in which we encourage being the type of people we would want to take care of us
- E.g. deontologist – duty guided non-consequentialism
- Ignoring patient’s stated preferred course of action disregards patient autonomy – which we would not want to be that type of healthcare provider.
- https://plato.stanford.edu/entries/actualism-possibilism-ethics/ ### Slide 7
- Pitfalls of deontologicalism (actual reasoning behind commitments to individual patients, ethical normative frameworks)
- Pitfalls of consequentialism (beneficence to society, but justifies Machiavellian things)
- Appealing, but in this case would argue that I should push harder to commit to a course of action that produced stated goals, even if it puts them through situations they don’t want to do. We have generally agreed not to do this in medicine. ### Slide 8
- Actualism vs Possibilism
- You have 3 options: go to the pub, stay home and study, or stay home and watch TV. Utility of the actions are stay home and study > go to the pub > stay home and watch TV. You know, in practice, if you stay home and try to study you’ll probably watch TV. What should you do?
- Actualism: go to the pub
- Possibilism: stay home and study ### Slide 9
- How many times do we address “code status”
- https://twitter.com/drsamuelbrown/status/1359353395996368897?s12
- What do patient’s remember about the care team after? ### Slide 10
- Was this an error?
- Do you define an error based on outcomes, or based on decision-making?
- Meaning, if we played our hand well (statistically), but lost - is it still an error?
- Most would say no, but consider out of the 2x2 grid of options, which ones do we investigate? ### Slide 11
- the idea of preference-sensitive decisions
- https://www.nejm.org/doi/full/10.1056/NEJMc1713344
- https://www.uptodate.com/contents/ethical-issues-in-palliative-care?searchcough%20assist&topicRef5124&sourceseelink ### Slide 12
- Advance directives have been standardized for a good reason. Health care providers must be able to immediately understand and act on them without requiring a lawyer’s interpretation. Without the patient’s input or that of a knowledgeable surrogate, neither the patient’s reason for the nonstandard directive nor his or her present wishes concerning resuscitation can be independently known. ### Slide 13
- Lit review
- https://www.sciencedirect.com/science/article/abs/pii/S2213260019300876
- https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/jgs.16801
- https://jamanetwork.com/journals/jamanetworkopen/article-abstract/2735460
- https://pubmed.ncbi.nlm.nih.gov/7474243/
- https://www.bmj.com/content/340/bmj.c1345.long
- https://www.atsjournals.org/doi/abs/10.1164/ajrccm.155.1.9001282
- https://www.nejm.org/doi/full/10.1056/NEJMoa1802637 ### Slide 14
- https://pubmed.ncbi.nlm.nih.gov/28099054/
- https://pubmed.ncbi.nlm.nih.gov/33264125/
- https://pubmed.ncbi.nlm.nih.gov/31625037/
- https://pubmed.ncbi.nlm.nih.gov/21286839/ ### Slide 15
- How do you choose who to spend time on ?
- Can we predict who is at risk for mortality?
- If not: how often to patients change their mind?
197.3 Learning objectives
- PGR – Value Concordant care in the ICU
- McFadden
- Twitter poll: from my twitter – do DNR orders (in the absence of other specified restrictions) ever applicable to patients with a pulse?
- Question 1 – is this a consistent preference?
- Clinical Momentum in the Intensive Care Unit
197.4 Bottom line / summary
- PGR – Value Concordant care in the ICU
- McFadden
- Twitter poll: from my twitter – do DNR orders (in the absence of other specified restrictions) ever applicable to patients with a pulse?
- Question 1 – is this a consistent preference?
- Clinical Momentum in the Intensive Care Unit
197.5 Approach
- TODO: Outline the initial assessment or decision point.
- TODO: Outline the next diagnostic or management step.
- TODO: Outline follow-up or escalation criteria.
197.6 Red flags / when to escalate
- TODO: List red flags that require urgent escalation.
197.7 Common pitfalls
- TODO: Capture common errors or missed steps.
197.8 References
TODO: Add landmark references or guideline citations.