Doctorin' with Double Effect Part II: The Devil is in the Details

In a prior post, Doctorin' with Double Effect, (a double entendre with Doctrine of Double Effect) I attempted to tease out ethical issues related to the withdrawal of life support and specifically the provision of oxygen in dying patients.  The simplest case is that of a moribund patient who is completely dependent upon life support measures such as mechanical ventilation and vasopressors.  In such a patient, withdrawal of these measures often allows a quick death to ensue.  Provision of oxygen in such a patient will not avert death, but will prolong it, so I think that while oxygen is often reflexly applied to such patients, I can say with some confidence that it should not be.  While it is mostly benign, it generally does not provide comfort and it prolongs the dying process so it is on the net futile or harmful.  I struggle to reconcile my strong pragmatic intuition about this with ethical principles such as the DDE, although I think it is consistent with the notion that I can take away something that restores a natural state to abrogate its associated discomforts or in deference to patient autonomy and a wish to have a "natural death."

But there is a very large grey area.  What about patients in whom death is not imminent?  Consider a patient who has been on the ventilator for a week with dementia and aspiration pneumonia, and who has developed weakness.  He is alert, but not oriented.  When he is extubated, it is expected that he will develop retained secretions, atelectasis, and over several days, obtundation and oxygenation and ventilation failure.  But over several days.  Should oxygen be administered in the hope that he will rally?  Does its deprivation deprive him of a chance of survival that is disproportionate to the removal of the endotracheal tube and the mechanical ventilator in terms of net costs and benefits?

Or, consider the patient who is demented and is admitted with pneumonia from aspiration and who is DNR/DNI and is given supplemental oxygen.  Does escalation of oxygen therapy to a non-rebreather mask from nasal cannula fly in the face of his DNR order?  Does the administration of peripheral vasopressors for hypotension have the same result?  Does DNR/DNI mean Do Not Respond/Do Not Intervene?

Accidental Survival from Beneficent Neglect: When "There's Nothing More We Can Do" Becomes Your Salvation

"There's nothing more we can do", according to this NYT article, is a terrible thing for a physician to say to a patient or his family member, even if the intention is much needed candor.

Yet sometimes, a physician's resignation or a patient's refusal becomes the patient's salvation.  There is something to be learned about the futility of many of our treatments and our arrogant ignorance of our impotence in many situations.  Several examples, I hope, will cause physicians to reflect on many of our practices.

A study showing that cancer patients choosing palliative care outlived those choosing aggressive care should have caused a lot of introspection about the possibility that many things we do harm rather than help patients.  How are we to know?  In the ICU, we have several unique opportunities to observe the futility or downright harm of many things we do.

A young woman came to the ICU with mental status changes, an EEG was ordered, and a diagnosis of "non-convulsive status epilepticus" (NCSE) was made.  She was intubated and heavily sedated and treated with every manner of anticonvulsant and CNS depressants and coma-inducing agents.  The EEG continued to show, according to the report, NCSE two weeks later.  The family was told that "there's nothing more we can do" and a decision was made to stop all therapy and withdraw care and prepare to send her to hospice.  This was done, but over the next 24 hours, she awakened and was alert and oriented. She walked out of the hospital later that week.