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Casebook on Ethical Decision-Making in End-of-Life Care
of Older Adults (只備英文本)
Decisions about feeding tubes in advanced dementia
-by Dr. Jacqueline Yuen, Clinical Lecturer, Department of Medicine and Therapeutics, CUHK
Introduction
In Hong Kong, tube feeding in advanced dementia patients is highly prevalent, particularly amongst those living in residential care homes for the elderly (RCHEs).1,2 However, feeding tubes are most frequently placed during an acute hospitalization where decisions are made with healthcare providers who are unfamiliar with the patients.3 Clinicians commonly rely on the swallowing assessment that a patient is high aspiration risk to justify feeding tube placement. This can be problematic if the decision neglects to consider other factors that are important to the best interests of the patient. Compounding the problem is the fact that many clinicians have inaccurate expectation of benefits from tube feeding that is not supported by evidence.4-7 Given that tube feeding carries significant risks and can negatively impact a patient’s quality of life,8 healthcare providers have an important responsibility to help families make informed decisions that support their loved one’s values and best interests. This article provides a step-by-step approach to guide clinicians on the decision-making process about feeding tube placement in advanced dementia patients.
Step 1: Investigate the etiology of the feeding problem
Eating difficulties in dementia patients can be due to many causes. The first step is to thoroughly evaluate whether the underlying cause is reversible. For example, poor appetite can be due to depression, dental problems, untreated pain, dry mouth, constipation, and medication side effects. All of these can be reversed with proper treatment.9 For problems that are manifestations of dementia such as apraxia resulting in inability to use utensils or refusal to open the mouth, conservative strategies such as providing finger food, cueing, altering the environment, and stimulation with different food temperatures, textures, and flavors can be tried.8 In Hong Kong, specialized dementia feeding programs in certain public hospitals have been successful in overcoming eating difficulties in some dementia patients through conservative feeding strategies.
Step 2: Determine the patient’s overall prognosis
Healthcare providers and family often don’t recognize that dementia is a terminal illness. Average life expectancy after initial diagnosis is 4 to 9 years.10,11 Difficulty swallowing leading to recurrent aspiration pneumonia is common in patients in the advanced stage and may be a sign that the patient is near the end of life.12 Recognizing the patient’s stage in the disease trajectory is important to determine the prognosis and the likelihood of benefit from tube feeding. Prognostication tools such as the Functional Assessment Staging Tool (FAST) can help clinicians make this determination.13 Consultation with a geriatrics specialist may be helpful in some cases.
Step 3: Weigh risks and benefits of tube feeding and alternatives based on evidence
If a reversible cause cannot be identified and conservative strategies have been exhausted, clinicians should then determine how the evidence for tube feeding applies to the patient at hand. Contrary to a common misconception amongst healthcare providers that tube feeding can improve survival, this has not been shown in studies for patients with advanced dementia.14-18 This is consistent with the findings of a local study of elderly RCHE residents with advanced dementia where 1-year mortality was high at 34% and enteral feeding was a risk factor for mortality.2
In advanced dementia patients, tube feeding has not been shown to prevent aspiration pneumonia. Aspiration of oral secretions and regurgitated stomach contents can still occur.19,20 Tube feeding may even increase aspiration events since it decreases the lower esophageal sphincter pressure, making gastroesophageal reflux more common.21 Furthermore, tube feeding has not been shown to improve functional and nutritional status in advanced dementia patients.8,14,22 Tube feeding carries other significant risks include bleeding, mucosal erosion, vomiting, diarrhea, and tube blockage and dislodgement requiring repeated re-insertions.8 In Hong Kong, nasogastric tubes are more commonly used than percutaneous endoscopic gastrostomy tubes but are more uncomfortable.3 Physical restraints may be used to prevent patients from pulling out the tube. This not only worsens agitation in a demented patient, but also limits mobility leading to increased rates of pressure sores.15,23
An alternative strategy for feeding problems in advanced dementia is careful hand feeding (CHF).24 In CHF, a trained carer feeds the patient orally using feeding techniques and closely observes the patient for choking and pocketing of food. Although CHF cannot prevent aspiration events, it is no worse than tube feeding for the outcomes of aspiration pneumonia, functional status and death.22,25 CHF may be preferable when considering the patient’s quality of life. Unlike tube feeding, CHF allows patients to enjoy the pleasure of eating and socialization during meal times. Given these risks and benefits, the American Geriatrics Society recommends CHF over feeding tubes for eating difficulties in older adults with advanced dementia.26
Step 4: Individualize decision through a shared decision-making process with family
Clinicians should involve the family in shared decision-making when considering the option of tube feeding and its alternatives. The decision should prioritize any preferences of the patient if known, such as documented in an advance directive. If the patient’s preferences are not known, then the decision should be based on the patient’s best interests. Besides having a firm grasp of the clinical facts and evidence, clinicians should consider other factors including psychological, cultural, economic and institutional factors that may come into play.27
Families often experience distress when seeing a loved one without adequate nutrition, as providing nourishment is commonly seen as a way to nurture and comfort one who is ill.28 It may take time for families to accept the fact that their loved one is near the end of life and that placing a feeding tube is not going to “fix” the problem. Furthermore, families may hold certain cultural or religious beliefs that influence their perspectives. Clinicians should take on a respectful attitude when listening to their concerns, provide support, and try to find common ground when disagreements arise. A common concern raised by families in the local culture is the fear that their loved one will “starve to death.”27 Clinicians should respond empathically by acknowledging the families’ distress in seeing their loved one’s deterioration and reassure them that their loved one is not experiencing hunger at this advanced stage of illness. The patient is dying because the disease process is causing the body to shut down and not because inadequate nutrition is provided. It should be emphasized that CHF can promote comfort for their loved ones when they are near the end of life.3
It is also important to understand other team members’ and carers’ concerns in the decision process. Practical issues such as the availability of trained staff or caregivers to dedicate time for CHF in the hospital and when patients return to their place of residence are important to consider. As are potential concerns from healthcare staff about legal liability if a patient subsequently aspirates after being hand fed. Institutions need to have strong policy support for CHF and a culture that promotes end-of-life care in order for this practice to be successfully implemented.27
Step 5: Comply with institutional policies on artificial nutrition and hydration (ANH) in terminally ill patients
When the healthcare team and family jointly decide that tube feeding is not in the best interest of a patient, clinicians should follow their institutional policies on withholding tube feeding. In Hong Kong public hospitals, clinicians should refer to the Hospital Authority’s Guidelines on Life-Sustaining Treatment in the Terminally Ill.3 For patients whose death is imminent (death is expected within a few hours or days), it is acceptable to withdraw or withhold ANH without a valid advanced directive. For patients whose death is not imminent, the decision requires consensus with the family and within the healthcare team. The team must include two doctors, one of whom is a specialist in a relevant field (e.g. geriatrics or palliative care). In the case where the patient is unable to swallow and thus CHF cannot be offered as an alternative, the team must also seek advice from the cluster clinical ethics committee. Two exceptions to this requirement are 1) patients who have previously expressed a clear wish to refuse tube feeding verbally to family members or in an advanced directive and 2) patients who are actively and persistently resisting tube feeding, such as repeatedly pulling out their nasogastric tube (HA Guidelines 2015).3
Conclusion
The decision about tube feeding for advanced dementia patients should be made in accordance to the ethical principles of patient autonomy and benevolence. Still, it should be a shared decision that ensures accurate communication about the patient’s prognosis, risks and benefits of tube feeding versus alternatives, and respects the family’s and healthcare team’s perspectives. Ideally, patients diagnosed in the early stages of dementia would have a chance to express their preferences about tube feeding and other preferences for future medical care while mentally sound. The advance care planning process can continue with the family after the patient loses capacity whenever signs of disease progression appear. In this manner, families will have more time to come to terms with the expected trajectory of their loved ones’ illness and avoid the need to make decisions during a “crisis” when the patient is hospitalized. Through earlier conversations, families can also make better decisions that honor their loved ones’ wishes and provide them with dignified care at the end of life.
References
- Luk JK, Chan FH, Pau MM, Yu C. Outreach geriatrics service to private old age homes in Hong Kong West Cluster. J Hong Kong Geriatr Soc 2002;11:5-11.
- Luk JK, Chan WK, Ng WC, et al. Mortality and health services utilization among older people with advanced cognitive impairment living in residential care homes. Hong Kong Med J 2013;19:518-24.
- HA guidelines on life-sustaining treatment in the terminally ill 2015. Hong Kong: Hospital Authority; 2015.
- Shega JW, Hougham GW, Stocking CB, Cox-Hayley D, Sachs GA. Barriers to limiting the practice of feeding tube placement in advanced dementia. J Palliat Med 2003;6:885-
- Carey TS, Hanson LC, Garrett JM et al. Expectations and outcomes of gastric feeding tubes. Am J Med 2006;119:527.
- Hanson LC, Garrett JM, Lewis C et al. Physicians’ expectations of benefit from tube feeding. J Palliat Med 2008;11:1130–1134.
- Brett AS, Rosenberg JC. The adequacy of informed consent for placement of gastrostomy tubes. Arch Intern Med 2001;161:745–748.
- Finucane TE, Christmas C, Travis K. Tube feeding in patients with advanced dementia: a review of the evidence. JAMA 1999;282:1365-70.
- Roberson RG and Montagnini M. Geriatric failure to thrive. American Family Physician 2004;70:343-350.
- Larson EB, Shadlen MF, Wang L et al. Survival after initial diagnosis of Alzheimer disease. Ann Intern Med 2004;140:501–509.
- Boustani M, Peterson CB, Hanson LC et al. Screening for dementia syndrome: A review of the evidence. Ann Intern Med, 2003;138:927–937.
- Mitchell SL, Teno JM, Kiely DK et al. The clinical course of advanced dementia. N Eng J Med 2009;361:1529-1538.
- The National Hospice Organization. Medical guidelines for determining prognosis in selected non-cancer diseases. Hosp J 1996;11:47-63.
- Sampson EL, Candy B, Jones L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev 2009:CD007209.
- Kuo S, Rhodes RL, Mitchell SL et al. Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc 2009;10:264–270.
- Meier DE, Ahronheim JC, Morris J et al. High short-term mortality in hospitalized patients with advanced dementia: A lack of benefit of tube feeding. Arch Intern Med 2001;161:594–599.
- Sanders DS, Carter MJ, D’Silva J et al. Survival analysis in percutaneous endoscopic gastrostomy feeding: A worse outcome in patients with dementia. Am J Gastroenterol 2000;95:1472–1475.
- Teno JM, Gozalo PL, Mitchell SL et al. Does feeding tube insertion and its timing improve survival? J Am Geriatr Soc 2012;60:1918–1921.
- Finucane TE, Bynum JP. Use of tube feeding to prevent aspiration pneumonia. Lancet 1996;348:1421–1424.
- Vergis EN, Brennen C, Wagener M, Muder RR. Pneumonia in long-term care: a prospective case-control study of risk factors and impact on survival. Arch Intern Med 2001;161:2378-81.
- Gomes GF, Pisani JC, Macedo ED, Campos AC. The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Curr Opin Clin Nutr Metab Care 2003;6:327-33.
- Garrow D, Pride P, Moran W et al. Feeding alternatives in patients with dementia: examining the evidence. Clin Gastroentol Hepatol 2007;5:1372-1378.
- Teno JM, Mitchell SL, Kuo SK, et al. Decision-making and outcome of feeding tube insertion: a five-state study. J Am Geriatr Soc 2011;59:881-6.
- Hanson LC, Ersek M, Gilliam R et al. Oral feeding options for people with dementia: A systematic review. J Am Geriatr Soc 2011;59:463–472.
- Hanson LC. 2013. Tube feeding versus assisted oral feeding for persons with dementia: using evidence to support decision-making. Ann Long Term Care 21(1):36-39.
- American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. J Am Geriatr Soc 2014;62:1590-3.
- Luk JK, Chan FH, Hui E et al. The feeding paradox in advanced dementia: a local perspective. Hong Kong Med J 2017;23:306-310.
- Lopez RP, Amella EJ. Time travel: The lived experience of providing feeding assistance to a family member with dementia. Res Gerontol Nurs 2011;4:127–134.
Case: Mrs Wong
ICU triage for patient with advanced cancer
Mrs. Wong is a 65-year-old retired teacher. She lives with her husband and they have no children. She is an active person who enjoys going on hikes with her husband. About two months ago, Mrs. Wong presented to the hospital with respiratory failure and was emergently intubated and admitted to the ICU. She was found to have tracheal and right bronchial obstruction by a mediastinal mass. The cardiothoracic surgical (CTS) team placed a tracheal stent and performed a mediastinoscopy with mediastinal lymph node biopsy. Although her respiratory status initially improved after stenting, her course was complicated by stent migration causing lung collapse. The CTS team brought her back to the OT and the stent was successfully replaced. Still, for a couple of weeks, her condition remained difficult to manage as she developed ventilator-associated pneumonia and had frequent episodes of desaturation due to mucous plugging.
Eventually, her condition improved and she was successfully weaned from the ventilator. That day, the biopsy results came back. Unfortunately, it confirmed advanced stage of an undifferentiated carcinoma with evidence of left adrenal metastasis on CT scan. An oncologist was consulted about treatment options and indicated that the patient is not a candidate for chemotherapy or radiation due to her tenuous respiratory status.
Dr. Tong, the ICU physician taking care of Mrs. Wong, broke the news with the patient and her husband. He explained the overall poor prognosis and the high likelihood that the respiratory failure could recur as this cancer is unresectable. This was shocking news to Mrs. Wong and her husband. Nevertheless, they were able to accept this news.
Furthermore, to plan for future medical decisions that may arise, Dr. Tong explained that if Mrs. Wong’s cancer causes blockage of her airway again leading to respiratory failure, she will likely require intubation but the chance that she will be able come off the ventilator would be very low. Given that the harm would likely outweigh the benefits of this treatment, Dr. Tong made the recommendation that the patient not be re-intubated again in the future.
Hearing this, Mrs. Wong nods in agreement. “I would not want to be hooked up to a breathing machine again if I cannot come off. This is not the state that I want to be at the end of my life,” she said with her husband sitting beside her and holding her hand.
A couple days after this conversation, Mrs. Wong was transferred to the medical ward to continue her antibiotics course. A week later, she suddenly developed respiratory distress and then had a cardiac arrest. She was resuscitated in less than one minute with return of spontaneous circulation and breathing but remained unconscious. The CTS team performed a bronchoscopy and found that her respiratory failure was due to stent migration of a poorly-fitted stent. They had purchased a tailor-made stent for her and planned to take her to the OT for stent replacement. Meanwhile, the CTS team requested that the patient be admitted to the ICU since the patient needed to be intubated for the procedure and will likely need ventilator care afterwards.
The case medical officer consulted Dr. Tong on the question of ICU admission. He conveyed that the husband is sobbing at the patient’s bedside and is pleading with the doctors to “do everything to save my wife.” When considering this question, Dr. Tong thought of the following. Although he and the patient had previously agreed on the plan for no re-intubation, Dr. Tong felt that plan was made without knowledge of the availability of a new stent. According to the CTS team, the stent replacement, if successful, may possibly allow the patient to come off the ventilator again and live for several weeks or perhaps a couple of months.
On the other hand, Dr. Tong also knew that the stent replacement does not guarantee that the patient can come off the ventilator. Even if she does, it is only a temporary measure. The underlying cancer is not reversible. Furthermore, there are only a couple of remaining ICU beds in the hospital. If he admitted Mrs. Wong to a bed, it may leave another critically ill patient with a better prognosis after ICU care without a bed when needed. Dr. Tong was unsure whether or not to admit Mrs. Wong to the ICU.
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Themes: ICU triage, advance care planning, goals of care, life-sustaining treatment
- Dr. Derrick Au Kit Sing, Director, CUHK Centre for Bioethics
We often think of ethical decision-making as making the ‘right’ decision but in real bedside scenarios there will be dilemmas where it is unclear if a single ‘right’ decision exists. The decision would have been straightforward in this case if the intervention were clearly medically futile. In this case, even though the underlying malignant condition is beyond active interventions, the CTS team considered that the tailor-made stent replacement “may possibly allow the patient to come off the ventilator” and the patient may live for several weeks or a couple of months if successfully weaned. Note that the patient had been through this once – with a stent (not tailor-made) successfully placed before, she was successfully weaned from the ventilator after a couple of weeks.
The decision would also have been straightforward had the patient expressed that she would never wish to be intubated again after that experience. But in this case, what she said was that she would not want to be hooked up to the machine at the end of her life. This left us with significant uncertainty: Did she mean “refusing intubation till the very end”, or did she mean that at this end stage of her life, with a few weeks or a couple of months to go, she already wished no more intubation – even if there was hope of extubation?
One may say that it is impossible to foresee and exhaust all possible scenarios to obtain the patient’s advance instructions. That is why advance care planning should not be limited to treatment preferences for particular situations. When time and circumstances permit, it should also seek to clarify the rationale behind the patient’s decisions. If the patient’s values and views (particularly on burdensome treatments) can be understood, it will be helpful in handling unforeseen scenarios.
The husband sobbingly pleaded to ‘do everything to save my wife’. He was unlikely to literally mean ‘doing everything’ – for instance, would he wish her to undergo aggressive chemotherapy beyond this critical stage? It may be appropriate at this juncture to emotionally support him and then invite him to consider: “What do you think she would have wanted if she were able to express her wish at this juncture?”
The underlying concept here is “substituted judgement”. A loved one, often a family member, is asked to make a difficult decision regarding withholding a life-sustaining treatment. A distinction needs to be made – though sometimes difficult – between what the patient would have wanted and what the loved one wishes. The patient’s voice should take priority over the loved one’s own view. In this case it is not clear if such distinction has been made.
There is an underlying issue of scarcity of ICU beds. Any patient admitted to ICU and occupying an ICU bed for a prolonged period may potentially affect the chance of admission for a subsequent patient. Admission criteria to ICU are often based on severity, prognosis, and reversibility of the critical condition. When two patients present at the same moment competing for the only remaining bed, it may be reasonable to consider their relative likelihood to benefit. In this case there are still a few beds vacant and it can be problematic to exclude a patient solely based on the worry that a future patient may lose out.
From the point-of-view of the ICU team, a pragmatic approach is tempting – based on experience of how soon the few remaining vacant beds will last, and whether this patient is likely to occupy a bed for a prolonged period, the team may consider this patient to have “low net benefit” compared to another prospective patient. But the point in this case is that it is not clear if the tailor-made stent procedure has “low net benefit”. It would be helpful for the ICU team to seek more clarification from the CTS team on the specific point that the stent “may possibly allow the patient to come off the ventilator”. It makes some difference if that possibility is remote – in which case it will be more like a medically futile intervention. If there is a good chance that the stent will serve the useful purpose, the decision of this last round of intervention may be better justified.
個案：黃女士
晚期癌症病人的深切治療部分流問題
黃女士是65歲退休教師，與丈夫同住，沒有子女。黃女士生性好動，喜歡與丈夫一同行山。黃女士大約兩個月前因呼吸功能衰竭而入院，需要緊急插喉，並入住深切治療部。診斷發現黃女士患有縱隔腫瘤，及阻塞氣管與右支氣管。胸腔外科手術團隊植入氣管支架，使用縱膈腔鏡進行淋巴結活體組織切片。黃女士呼吸系統植入支架後狀況一度好轉，卻出現支架移位導致肺塌陷，影響治療。黃女士送返手術室，胸腔外科手術團隊成功重置支架。不過，黃女士及後感染呼吸器相關肺炎，黏液梗塞亦導致血氧飽和濃度不時降低，手術後數星期情況依然難以控制。
黃女士後來情況好轉，毋須繼續使用呼吸機。停用呼吸機當日，團隊收到切片分析結果。報告確認黃女士不幸患上晚期肺癌，電腦斷層掃描顯示癌細胞可能已經散播到左腎上腺。團隊詢問腫瘤科醫生治療意見，腫瘤科醫生認為病人呼吸系統情況欠佳，不適合進行化療和放射性治療。
負責照顧黃女士的深切治療部唐醫生告知病人和病人丈夫消息。唐醫生解釋，整體治癒機會不高，而且由於癌腫瘤無法切除，導致呼吸系統極有可能再度衰竭。黃女士與丈夫聽了消息後相當震驚，但都能接受現實。
另外，為了準備應對可能出現的醫學抉擇，唐醫生解釋，黃女士的腫瘤如果再次阻塞呼吸道，引致呼吸系統衰竭，黃女士很可能需要插喉。不過，黃女士能夠再次移除呼吸機的機會很微。由於治療的壞處很可能大於好處，唐醫生建議黃女士未來不要再插喉。
黃女士聽罷點頭同意：「如果要一直接駁呼吸機，我希望不要再接駁了。我不希望自己生命結束的時候仍要接駁呼吸機。」黃女士的丈夫坐在一旁，握著黃女士的手。
對話過後數天，黃女士轉到病房繼續接受抗生素治療。一星期後，黃女士突然出現呼吸困難，導致心跳停頓。黃女士一分鐘內接受搶救後，恢復自發性血液循環與呼吸，不過依然昏迷。胸腔外科手術團隊進行支氣管鏡檢查，發現黃女士的支架不合身造成移位，導致呼吸功能衰竭。團隊為黃女士訂製支架，計劃為她做手術重置支架。同時，胸腔外科手術團隊認為病人需要於手術過程中插喉，手術後亦可能需要呼吸機，所以要求病人轉移深切治療部。
主診醫生諮詢唐醫生意見，並告訴唐醫生，黃女士的丈夫於床邊抽泣，請求醫生「用盡一切辦法救我的妻子」。雖然唐醫生先前與病人同意不再插喉，討論時卻不知道有新支架。胸腔外科手術團隊表示，支架重置手術若然成功，病人有機會重新拔除呼吸機，多活數星期甚至數個月。
另一方面，唐醫生亦清楚支架重置無法保證病人能夠停止使用呼吸機。即使黃女士毋須使用，亦只屬短暫措施。黃女士本身的癌症無法治癒。再者，醫院空置的深切治療病床不多。如果轉移黃女士到深切治療部，其他危殆但治癒機會較高的病人有需要時就無法使用。唐醫生不知道應否轉移黃女士到深切治療部。
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主題： 深切治療部分流、預設照顧計劃、護理目標、維持生命治療
香港中文大學生命倫理學中心總監區結成醫生撰寫
我們經常覺得倫理抉擇是要作「正確」的選擇，但真實臨床情況常常出現兩難情況，並不清楚是否存在單一「正確」的選擇。如果個案中的治療顯然無效，抉擇過程便簡單直接。雖然個案中的根本病況無法治癒，但是胸腔外科手術團隊認為病人重置訂製支架「有機會重新拔除呼吸機」。如果成功拔除呼吸機，病人可能多活數星期至數個月。留意病人已經曾經成功植入（非訂製）的支架，亦曾經成功拔除呼吸機數星期。
如果病人經歷過先前的情況，表明希望以後不再插喉，抉擇過程就變得簡單直接。不過，黃女士說的是臨終前不希望接駁呼吸機。我們無法肯定黃女士意思：究竟是「最後一刻不想插喉」，還是生命最後的數星期至數個月，即使有機會移除呼吸機，也不希望插喉？
有人可能會說團隊無法預見所有可能情況，再逐一排除，取得病人的預設指示。正因如此，預設照顧計劃不能只應對個別情況的治療取向。如果時間情況許可，應該釐清病人決定背後的原因。了解病人的價值觀與看法，特別是不舒適治療方面的意見，有助應對無法預見的情況。
丈夫一邊哭，一邊請求醫生「用盡一切辦法救我的妻子」。丈夫的實際意思大概不是真的「用盡一切辦法」──例如丈夫願意讓黃女士在這危急情況下接受進取的化療嗎？這個時候應該安慰病人的丈夫，再請他思考一下：「如果黃女士此刻能夠表達自己意願，你覺得她會想怎樣做？」
案例的主要概念是要替人作判斷，需要病人親友，通常是家人，作出困難的抉擇，決定是否進行維持生命治療。我們需要清楚分開病人意願和病人親友的意願。不過，兩種意願有時候難以分辨。病人自己的意願應該較親友意願重要。我們不清楚個案中有沒有分開兩種意願。
個案亦出現深切治療部病床不足的問題。任何病人入住深切治療部長期佔用病床，都可能影響其他病人入住的機會。入住深切治療部的准則一般考慮病情嚴重程度、痊癒機會和嚴重情況改善的機會。如果兩名病人同時到達，就需要考慮病人獲益的機會率。個案中深切治療部仍有數張病床空置，單純因為未來其他病人可能無法使用而拒絕轉移此刻的病人，可能會造成問題。
直接務實的處理手法可能對深切治療部團隊相當吸引；團隊可能根據經驗判斷餘下病床大概何時住滿，同時判斷病人會否長期佔用病床，繼而認為病人帶來的「整體效益」比其他潛在病人低。然而，個案中訂製支架治療的「整體效益」不一定低。深切治療部團隊可以向胸腔外科手術團隊了解清楚，「病人有機會移除呼吸機」的詳情。如果機會極低，代表手術相當於無效治療，會影響抉擇推論過程。如果支架可能有效幫助病人，就能為入住深切治療部提供更有力的論據。
