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.