Comprensión de textos orales Estrategias de comprensión:

Triage in the context of resuscitation refers to the process of sorting critically ill patients in terms of expected outcome and possible treatment regimens, i.e., “appropriate” care. At Pittsburgh's Presbyterian-University Hospital, critical care triage is facilitated in the following manner. At least two physicians classify and periodically reclassify each ICU patient into one of four categories (Table 5.1).

Table 5.1. Recommended Critical Care Triage

1. Total support (All ICU patients fall into this category at the time of ICU admission.) 2. Full support, short of CPR

3. “Letting die” (Extraordinary measures are withdrawn) 4. Brain death certification (All measures are withdrawn)

Persistent Vegetative State

“Letting die” should be carried out according to medical, legal, and ethical customs of the community. These determine the degree of care appropriate in hopeless, moribund patients.

The socioeconomic tragedy of severely brain-damaged survivors is obvious because such cases may impose an unbearable financial and emotional burden on the family. The decision to discontinue extraordinary means of life support is a medical one. It should be made by an experienced physician, who is thoroughly familiar with the entire case, in consultation with experienced specialists and should consider the patient's previously expressed wishes, the family's attitude, and the quality of life expected at best. Although one should not ask relatives to make the decision to let the patient die, their agreement with the physician's decision should be sought. Although brain death certification calls for withdrawal of all life support measures, “letting die” (passive euthanasia, not active euthanasia) calls for discontinuance of

extraordinary measures only (Table 5.1). Extraordinary measures may be defined differently in different countries, depending on priorities and available resources, which are finite. In most industrialized countries, extraordinary measures include mechanical ventilation, blood administration, dysrhythmia control, and life-supporting drugs and may or may not include IV fluids and alimentation, whereas airway care is usually considered “ordinary” care. In an irreversible vegetative state, antibiotics

and artificial feeding and hydration (intravenously or by gastric tube) may be justifiably withheld. In the terminal state of a hopeless case, dignity and esthetic “comfort” for the patient (if aware) and surroundings and honoring the patient's wishes (previously expressed if presently unconscious) must receive priority over prolonging “life.” Recent trends, including public perceptions of “miracle” CPR from television and other media (mostly unfounded) have been influential. Various organizations have met to develop consensus standards for decision making including the Society of Critical Care Medicine and others. These issues are not easily resolved and various critical facts (e.g., ultimate prognosis, patient's wishes, etc.) may not be known.

Euthanasia and Economic Conflicts of Interest

Some critical care nurses are also engaging in euthanasia practices despite the prohibitions. Recent court decisions have also challenged the standard policy.

Concurrently, a counter movement has grown that fears erroneous judgments or medical decisions based on societal and economic need. For the first time in history, public shareholders in for-profit health care companies are demanding return on investment. Simultaneously, such businesses are seeking cost-cutting where

possible. The critically ill are indeed costly for such organizations. These financial-medical care conflicts are not subject to easy resolution since there are conflicting loyalties and duties. The so-called “slow code” can arise in this setting and represents unethical behavior.

However, once irreversibility of coma is determined by a combination of clinical judgment, the patient's history, and laboratory data, letting the patient die from natural causes in a dignified setting is ethical and feasible; prolonged expensive intensive care in the clearly hopeless case is inappropriate, undignified, socioeconomically counterproductive, and unethical.

* Portions of this chapter appeared in: Schwartz GR, Cayten CG, Mangelsen MA, et al, eds. Principles and practice of emergency medicine. 3d ed. Philadelphia: Lea & Febiger, 1992 and were authored by Dr. Peter Safar.

Suggested Readings

Asch D: The role of critical care nurses in euthanasia and assisted suicide. N Engl J Med 1996;334:1374. Baier K: The ethics of passive euthanasia. Crit Care Med 1976;4:317.

Back AL, Wallace JI, Starks HE, Pearlman RA: Physicians-assisted suicide and euthanasia in Washington State: patient requests and physician responsibility. JAMA 1996;275:919. Bartlett ET: Differences between death and dying. J Med Ethics 1995;21:270.

Barber J, Becker D, Behrman R, et al: Guidelines for the determination of death. Report of the Medical Consultants on the Diagnosis of Death to the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. JAMA 1981;246:2184.

Beecher H: Harvard Medical School Ad Hoc Committee to examine the definition of brain death: a definition of irreversible coma. JAMA 1968;205:337. Bone RC, Rackow EC: Ethical and moral guidelines for the initiation, continuation and withdrawal of intensive care. Chest 1990;97:949–958.

Compassion in Dying v. Washington State. 1996 Court of Appeals 9th District.

Darr K: Ethics in Health Services Management. 2d ed. Baltimore, Health Professions Press, 1991.

Diem SJ, Lantos JD, Tulsky JA: Cardiopulmonary resuscitation on television: miracles and misinformation. N Engl J Med 1996;334:1578. Emanuel EJ: Euthanasia. Arch Int Med 1994;154:1890.

Evans A, Brody B: The do not resuscitate order in teaching hospitals. JAMA 1985;253:2236.

Fleming C, Mallepalli I, Brensilver JM, et al: How and when to obtain consent for DNR orders. J Crit Illness 1995;10:679. Gazelle G: The slow code: should anyone rush to its defense. N Engl J Med 1998;338:467–469.

Grenvik A, Powner DJ, Snyder JV, et al: Cessation of therapy in terminal illness and brain death. Crit Care Med 1978;6:284.

Grenvik A, Hardesty R, Griffith B, et al: Multiple organ procurement in interhospital transfer of heartbeating cadavers. Transplant Proc 1984; 16:251. Iserson KV: Ethics in emergency medicine. Baltimore: Williams & Wilkins, 1988.

Iserson KV: Withholding and withdrawing medical treatment: an emergency medicine perspective. Ann Emerg Med 1996;28:51. Karnik AM, Khan MB: Ethical issues in ventilated patients. Resident and Staff Physician 1997;43:11–25.

Levy DE, Bates D, Caronna JJ, et al: Prognosis in non-traumatic coma. Ann Intern Med 1981;94:293.

Luce JM: Withholding and withdrawal of life support from critically ill patients. West J Med 1997; 167:411–416.

Mullie A, Lust P, Penninckx J, et al: Monitoring of cerebrospinal fluid enzyme levels in post-ischemic encephalopathy after cardiac arrest. Crit Care Med 1981;9:399. Safar P, Bircher NG: Cardiopulmonary cerebral resuscitation. An introduction to resuscitation medicine. 3d ed. Stavanger, Norway: Laerdal A; London: WB Saunders, 1988. Scanlon C: Euthanasia and nursing practice—right questions, wrong answer. N Engl J Med 1996;334:1401.

Thomas JE: Indicators of humanhood and the care of aging chronically ill patients. Clin Geriatric Med 1986;2:3. Thomasma DC: Quality of life judgements, treatment decisions and medical ethics. Clin Geriatric Med 1986;2:17.

Wachter R, Lua JM, Hearst N, et al: Decisions about resuscitation: inequities among patients with different diseases but similar prognosis. Ann Intern Med 1989;6:525. Wanzer SH: The physician's responsibility toward hopelessly ill patients. N Engl J Med 1989;320:844.

CHAPTER 6 PAIN MANAGEMENT

Principles and Practice of Emergency Medicine

CHAPTER 6 PAIN MANAGEMENT

James R. Ungar, Daniel Brandes, Bruce M. Reinoehl, George R. Schwartz, Al Ritter

Capsule