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NCS Currents Sept 2016

NCS Ethics Committee Opines on Multiple Critical Care Society’s Position Statement on Medical Futility By Michael Rubin, MD, MA The NCS endeavors to be a catalyst of academic discourse regarding the critically ill neurological patient. Additionally, we want to project our expertise outwards and serve as a voice to the greater medical community on how to best manage our patient population. Just as certain pathologies are relevant to multiple critical care disciplines (i.e., acute respiratory failure, sepsis, and acute renal insufficiency), the ethical practice of medicine is a daily concern to our society as well as other critical care societies. In 2015, a consortium of five critical care societies – American Thoracic Society (ATS), American Association of Critical Care Nurses (AACN), American College of Chest Physicians (ACCP), European Society of Intensive Care Medicine (ESICM), and the Society of Critical Care Medicine (SCCM) – published a policy statement in the American Journal of Respiratory Critical Care Medicine (Am J Respir Crit Care Med 2015;191:1318-1330) titled “Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units.” This publication was intended to create a consensus definition of medical futility and suggest an appropriate way that requests for such therapy ought to be managed. The NCS Ethics Committee issued a letter to the editor, “Neurocritical Care Society Views on Potentially Inappropriate Treatments in Intensive Care Units,” that was published earlier this year (Am J Respir Crit Care Med 2016; 193:466-467) and included the results of a survey of NCS members regarding medical futility cases, as well as our review of the position statement. The most significant finding of the position paper was the delineation of “futility” to mean the physiologic sense of the term – the ability to achieve the biological goal of an intervention. Other treatments are classified as “potentially inappropriate” and a formal set of procedures was recommended on how to manage these challenging cases. In our letter to the editor, we supported the position paper and, more importantly, indicated that questions about medical futility in our patient population are most often not related to physiologic futility but to cognitive recovery and quality of life. It is not multi-organ failure with impending death that causes the most moral distress in the Neuro ICU, it is the continued support of patients that we fear may never wake up. The authors of the position paper responded and acknowledged the growing recognition of palliative care needs in the Neuro ICU as well as the importance of our own “devastating brain injury guidelines” emphasis on accurate prognosis and careful family guidance in shared medical decision making. While many of our needs are in common with other critical care environments, our ethical concerns are specialized, just as is our approach to medical care. We encourage NCS members to read both the position statement and our response to it. During this coming year, the NCS Ethics Committee will be supporting the Ethics, Law, and Humanities Committee – a joint committee of the American Academy of Neurology, American Neurologic Association, and Child Neurology Society – in a summit on Death by Neurologic Criteria. We also intend to further develop recognition of palliative care needs in the Neuro ICU. The NCS Ethics Committee will continue to expand our role as the voice of our membership on the national stage regarding the ethical care of the critically ill. Michael Rubin, MD, MA is chair of the NCS Ethics Committee and a member of the Currents Editorial Board. He co-authored the NCS letter to the editor with Jordan Bonomo, MD. 16


NCS Currents Sept 2016
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