Yvette Ollada
Letter of Intent
Methods
October 30, 2018
(1496 Words)
RE: INVESTIGATING MORAL DISTRESS AND WITHDRAWING LIFE SUSTAINING TREATMENT
Summary
Can implementing timers on ventilators reduce moral distress?
Ethical Context
Though many clinical ethicists seem settled that there is no moral difference between withdrawing and withholding treatments, many clinicians struggle with having to withdraw a treatment once it has been started because they sense a moral distinction between withdrawing and withholding therapies.
The claim that there is no moral difference between withdrawing and withholding treatments is asserted through the Equivalence Thesis:
“1) If it would have been morally permissible to have withheld a therapy (that has in fact already been started), then it is now morally permissible to withdraw that therapy. and 2) If, in the future, it would be morally permissible to withdraw a therapy (that has not yet been started), then it is now morally permissible to withhold the therapy.”
However, Solomon et al. found that only 34 percent of clinicians surveyed believed “there is no ethical difference between forgoing (not starting) a life support measure and stopping it once it has been started,” which means that only a minority of clinicians concede the “settled” nature of the Equivalence Thesis.
In the “Withholding and withdrawing life-sustaining treatments” chapter of Palliative Care and Ethics: Common Ground and Cutting Edges, Robert Troug concedes, “the fact remains that many clinicians are much more uncomfortable with withdrawing therapy than they are withholding it.” He brings up the case of Eve, a two-year-old girl with holoprosencephaly who gets intubated and days before the care team was planning to extubate her, her parents request that she be extubated immediately. Eve’s ICU care team was “nearly universally opposed, insisting that her favorable trajectory and likely recovery made withdrawal of ventilation at this point unethical.” The “universally” distraught care team highlights the real-life conflicts that arise around withdrawing life sustaining treatment.
The implications in the clinical setting can have negative outcomes for both patients and practitioners. Clinicians and care teams may not wish to comply with patient or surrogate decisions; may do so under duress; may ask to recuse themselves from the team, burdening the remaining members of the team; or may comply and feel lingering or residual negative moral culpability.
Specific Aims or Research Questions
Timers on mechanical ventilators arose out of the Jewish tradition that holds the belief that there is a difference between withdrawing and withholding life-sustaining treatment. Ravitsky explains that, “According to Jewish religious law, even if the outcome is ethically desirable, the procedure leading to it may still be forbidden,” whereas it is morally permissible to withhold treatment. “The difficulty of accepting withdrawal is not based on a belief that the life of a suffering dying patient should be prolonged at all costs but on a cultural approach that is ethically opposed to human intervention to terminate life.” They make the distinction between allowing a person to die and causing a person to die. It isn’t that death is viewed negatively, it is that act of causing death is morally wrong. Therefore, terminating continuous treatment is seen as ethically prohibited not because it leads to death, but because it is an intervention that causes death.
Timers installed on ventilators convert a traditionally continuous treatment into discrete, independent treatments with distinct beginnings and endings. This allows the patient or patient surrogate to decide to withhold treatment once the timer runs out. By setting up this system that creates multiple concrete beginnings and endings of treatments, the clinician is not put in the position to have to withdraw life-sustaining treatment.
Converting continuous mechanical ventilation to discrete mechanical ventilation treatments may seem arbitrary when the outcome of both not starting a discrete mechanical ventilation treatment and withdrawing continuous treatment is the same (and the result is death), but the logic behind the solutions lies in the action, or lack thereof, that brings about the death, not the outcome of death itself. As Ravitsky explains it, Jewish tradition does not follow the consequentialists’ moral determination. He says, “the termination of continuous treatment is perceived as ethically prohibited not because it leads to an ethically wrong outcome but because it uses an ethically questionable procedure to achieve that outcome,” and draws a parallel to using tainted evidence to achieve a justified conviction.
This proposal seeks to investigate whether implementing a system that uses timers on ventilators to fragment treatment options creating “discrete treatments” can reduce moral distress in clinical care teams.
Methods
This study will seek approval from by the hospital site Institutional Review Board. The study will run for 24 months. Surrogate decision-makers of patients entering the hospital site intensive care unit will be asked if they are willing to participate in the study, then after signing informed consent to be included in the study, will randomly be assigned using computer-generated randomization to a “ventilator with timers” group (intervention group) or “standard ventilators” group (control group). Patients in the ventilators with timers group will have the ventilators set on 48-hour timers and the surrogate decision-maker will be asked each cycle if they would like the timer reset for another 48 hours and the care team will adhere to the directions of the surrogate in each 48-hour cycle. The care team will advise surrogates on treatment status and still conduct the proper standard of care, but will not be allowed to remove the ventilation, only to allow the timer to run out or be restarted with permission from the surrogate. For patients in the control group, normal standard of care will be offered and ventilation treatment will be administered according to the normal standard of care. Once the patients in both groups are officially declared deceased or are discharged from treatment, the care team will be individually surveyed by the research team about their moral distress regarding each patient within one week after the conclusion of patient treatment. The survey instrument will ask questions about whether the clinician agreed with the surrogate’s decisions, whether they wanted to comply or not with the surrogate’s decisions, whether they did comply with the surrogate’s decisions and on a scale of 1-10 how much moral distress they had after complying with or not complying with the surrogate’s decisions. After the survey data is completed in the 24-month period, data will be analyzed to compare moral distress of the care team members to see if there is a difference in moral distress between the normal standard care with ventilators and ventilators with timers.
Innovation
Considering the moral objections, religious and otherwise, that many clinicians have to withdrawing life-sustaining treatment, putting timers on mechanical ventilators could offer a practical solution to alleviate the moral conflict. By using timers on ventilators or setting up systems that fragment treatment options or utilize discrete treatments, rather than defaulting to continuous ones that may need to be withdrawn, inevitable problems can be avoided.
Psychologically, timers on ventilators could allow clinicians to act in a beneficent way by intervening to provide life-sustaining treatment, rather than in a way they could perceive as harmful. When a clinician takes action in the case of withdrawing mechanical ventilation, the action taken leads to death; whereas, in the case of resetting a timer, the action taken leads to extension of life.
Whether or not one views withdrawing or withholding therapy as ethically the same or ethically different, the fact remains that patient care can become hindered from real-life implications that result from clinicians’ sentiments on withdrawing treatment. Timers on ventilators alleviate the inevitable circumstances that care teams will run into of having team members conflicted about withdrawing treatment and lead to less than optimal patient care. For those clinicians who take ethical issue with withdrawing treatment, timers on ventilators could offer a resolution to their moral distress by allowing them to withhold discrete treatment, rather than withdrawing treatment.
Anticipated Products
If this research finds that timers on ventilators can be used to avoid clinician moral distress, the goal would be to publish this research in a major medical journal. It would be helpful for hospital head administrators and clinical care quality improvement administrators who manage clinicians who face moral distress and have difficulty withdrawing treatment once it has been started. It could potentially offer a simple solution to alleviate that moral distress. It would also be of interest to clinicians who face this type of moral distress around withdrawing mechanical ventilation.
This research could also be used to investigate further research on surrogate moral distress in making the difficult decision to withdraw mechanical ventilation treatment.