Escalation versus NonEscalation of Therapy
Shaun O’Keeffe
Galway University Hospitals
Ireland
‘Escalation’
The phenomenon of something getting more
intense step by step, for example a quarrel, or,
notably, hostilities between states.
‘War on cancer’
‘He fought bravely to the end’
‘Pyrrhic victory’
Enough or Too Much?
Fail to provide
adequate care
Burdensome
treatment and
undignified death
Escalation Dilemmas/Disagreements
• Substantive difference of values regarding
the meaning of life, death, disability, family
obligations, etc.
or/and
• Miscommunication or misunderstanding
between involved parties
Risk of Undertreatment?
• Ideas based upon life expectancy
– 70y woman: median life expectancy 18 years
– 10% of 90yo will reach 100y
• Ageism
• Exclusion of older adults from clinical trials
• Assumption that older adult may not want
’aggressive’ treatment
• Overestimation of risks and underestimation of
benefits of treatment
“Very good, Larry! Just one more step and
you'll have the entire aisle blocked!"
Judging QOL of Others?
• Healthcare professionals and relatives
consistently and significantly underestimate QOL
in people with disabilities (eg Ouslander et al, Arch Intern Med
1989, Uhlmann et al Arch Intern Med 1991).
• Relatives and professionals underestimate QoL of
dementia patients (Sprangers & Aronson, 1992)
• Pts likely to underestimate QOL of their older,
more disabled and cognitively impaired selves
O’Keeffe et al Eur J Med 1993; Cotter et al Age Ageing 2008
Use of Early Invasive Strategy for MI by Age
Older adults may gain greater absolute benefits with an early invasive strategy
compared with younger adults because of their higher risk for adverse outcomes
with conservative management (often despite increased procedural risks).
Age Group
(n)
≤55 y
(716)
56-65 y
(614)
66-75 y
(612)
≥75 y
(278)
0
Odds of DEATH or MI
0.5
Invasive Better
1
1.5
2.0
Conservative Better
Source: (TACTICS TIMI 18) Bach AIM 2004; 141:186-195; J Am Coll Cardiol 2007;50:658-752
Hospital MI Mortality by Number of Recommended Therapies
Benefits of adjunctive therapy (antiplatelet, beta-blockers, ACE inhibitors and
statins) are as great, if not greater, in older adults as in younger adults.
% In-hospital Mortality
30
Age <75
Age 75-89
Age 90 +
25
20
15
10
5
0
0
1
2
3
4
5
Number of Recommended Therapies *
(1) Acute Aspirin, (2) Acute Beta-blockers, (3) Acute Heparin, (4) GP IIb/IIIa inhibitors
(2) with PCI, (5) Cardiac Catheterization <48 hours
Risk of Overtreatment?
‘ The Good Death’ - common themes:
•
•
•
•
•
•
•
Feeling at home, or being at home
Comfort, no pain
Sense of completion (tasks accomplished)
Saying goodbyes
Life review
Love
Make it quick
Steinhauser et al, Ann Intern Med 2000
SUPPORT study (JAMA 1995)
• 4300 adults with life-threatening diagnoses;
6-month mortality rate was 47%.
– 47% of doctors knew when their pts wanted to
avoid CPR;
– 46% of DNR orders written within 2 days of death
– 38% of pts who died spent 10+ days in ICU
– Family reported moderate to severe pain at least
half the time for 50% of conscious patients who
died in the hospital
Algorithm Medicine
• ‘I’ve started, so I’ll
finish’
• Each decision node
as opportunity to
reflect on decision
• Current vs advance
directives
CPR: All or nothing?
• Current protocols imply CPR is all or nothing
(Colquhoun et al, ABC of Resuscitation. BMJ 1999)
• Arrest variables strongly predict failure to survive
– Asystole or EMD
– Unwitnessed arrest
– Resuscitation duration > 5 minutes
• Limited CPR (e.g. witnessed arrest and v fib only):
– Acceptable to patients and doctors; may reduce risk of
prolonged death (Everhart & Pearlman, Chest 1990; O’Keeffe, Age Ageing
2001)
– Lack of clarity for staff. A ‘cop-out’
(Berger Crit Care 2004)
Pitfalls in Communication: Physician
• Physician’s communication styles can worsen misunderstanding
– Use of medical language when need to discuss values, QOL
– Jargon: “usually” “most of the time” “cannot rule out” “futile”
– Semantics: “everything done” “vegetable”
• Multiple voices of heath care team
• Goals not clarified: what parties believe will be achieved by
treatment or intervention
• Decision-making reduced to power struggle between patient and
clinician
• Failure to ask patient (early enough)!
Goold SD et al. Conflicts regarding decisions to limit treatment. JAMA 2000.
Futility - ‘an ethical trump card’?
• No obligation to offer or to discuss futile treatment
BUT
• What does futile mean?
• Futile for whom?
Many clinicians view futility the way one
judge viewed pornography.
They may not be able to define it, but
they know it when they see it!
• Are we good at predicting outcomes?
– Quantitative thresholds for futility are arbitrary
– Often involves probability: Chance of success rarely zero
– ‘Will he come off the ventilator this time?’
’He’s one tough cookie. I’ve never seen anyone
bounce back from an autopsy before’.
• Physicians’ futility judgements rely more on values
and biases than on evidence (Curtis, JAMA 1995)
– Race, age, social class and cause of illness all influence
“Because of your age, I’m going to
recommend doing nothing.”
Pitfalls in Communication: Patient
• Very difficult to hold discussion with acutely ill patients
‘To hold vulnerable patients .. in the glare of autonomy, carefully explaining
their bleak prognosis and insisting lawyer-like on a decision .. seems barbaric
to many’ (Finucane JAGS 1999)
• Bad news poorly processed and not remembered well
• Denial—may lead to focus on trivial but controllable
matters
• Fear of abandonment “withdrawing care”, “Stopping care.”
• Don’t understand medical situation
Overestimation of Benefits
• TV major source of public information (Miller, Arch Int Med
1992)
‘’’I’m afraid there is really very little I can do’
• CPR on US medical television shows (Diem et al
NEJM 1996)
– 67% survival to discharge
• Prognosis of 24h+ coma in soap operas (Cassaret
BMJ 2005)
– Fifty seven (89%) patients recovered fully
– On the day they regained consciousness, 86% had no
cognitive deficit or residual disability
Pitfalls in Communication: Family
• Low agreement between surrogate and patient preferences
(e.g. Ouslander et al, Arch Intern Med 1989)
• Disagreement / ‘Daughter from California syndrome’
• Older people want to be consulted themselves
• Guilt of family members
– Asked to sign patient’s death warrant
– Physicians ask that they take responsibility for medical
decisions
• Intrinsic family issues
• Conflict of interest
Some suggestions….
• Communicate early with patients and their nominees about
values, goals of treatment
• Framing: not “nothing I can do” but “we’ll do everything possible
to ensure comfort and dignity”
• Ask the right questions! Of people with consistent end of life
preferences in SUPPORT (critically ill) and HELP (elderly)
– 80% want doctor / family to make final decision
– Only 20% want their own preferences adhered to ‘ no matter
what’
(Lynn, JAGS 2000)
• Educate and guide: not “do you want ventilation, etc”
‘I do not want to be in the position of a shopper
at the Casbah. … A physician who merely
spreads an array of vendibles in front of his
patient and then says "Go ahead, choose, it's
your life" is guilty of shirking his duty...’
Franz Ingelfinger, NEJM 1980