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PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY March 2013 | Archived Issues

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Risk of Potentially Fatal Heart Rhythms with Azithromycin (Zithromax or Zmax)

Pharmacy Focus

The U.S. Food and Drug Administration has strengthened a previous warning regarding a small but significant increased risk of fatal arrhythmias associated with azithromycin (marketed as Zithromax® or Zmax®). Also, the FDA is evaluating unpublished findings by a group of academic researchers that suggest an increased risk of pancreatitis and pre-cancerous cellular changes in patients with type 2 diabetes treated with a class of drugs called incretin mimetics.

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Symposium Offers Perspectives on End-of-Life Care

The specialists who make up Cedars-Sinai's Surgical Critical Care team recently presented a multidisciplinary symposium on end-of-life care. The following is a summary by each speaker.

Leo Gordon, MD, moderator

As the issues of healthcare and finance occupy a significant part of the medical dialogue, a focused view of end-of-life care has become necessary. To that end, the Department of Surgery convened an end-of-life care mini-symposium on Jan. 31. This symposium examined end-of-life care from the different clinical perspectives encountered by the practicing physician.

A lead-off presentation by Eric Ley, MD, director of the Intensive Care Unit, examined the survivability percentages of the ICU population. The efficacy of interventions was discussed as a function of age and severity of illness. An in-depth economic evaluation of ICU care was presented by Glenn Braunstein, MD. Data generated from hospitals similar to our medical center was analyzed for end-of-life care. The important aspect of planning and preparation with an advanced directive was stressed.

Following this analysis, the ethical aspects of end-of-life care were analyzed by Stuart Finder, MD, director of the Center for Healthcare Ethics. The evolution of healthcare ethics as a critical element in the management of end-of-life care was discussed. Rabbi Jason Weiner, BCC, discussed the role of the Chaplaincy Division in managing the challenging religious and cultural aspects of care. Insights were provided by discussing varying views of these emotionally charged clinical situations from family perspective. Robin McCaffery, JD, of the Legal Affairs Department ended the symposium with an outline of the legal implications of end-of-life care. The legal obligations of the physician as well as the legal limitations of delivering care in these situations were discussed. The symposium concluded with a question-and-answer session based on the issues discussed.

Eric Ley, MD, director, Intensive Care Unit

Negotiating end-of-life care in the surgical critical care population requires an understanding of mortality and an ability to communicate its likelihood. What is the mortality rate in the Surgical Intensive Care Unit? In a recent study of mortality in SICU patients, in-hospital mortality was 11 percent, one-year mortality 25 percent, and 10-year mortality 51 percent (Timmers TK et al).

With regard to cardiopulmonary resuscitation, a 2012 study noted in-hospital mortality after SICU CPR was 84.3 percent (Gershengorn HB et al) and 20 years prior mortality after CPR was 87.3 percent (Smith DL et al). In terminal patients, mortality after CPR is especially high, approaching 100 percent. Guiding patients and family members through end-of-life care requires involvement with social work, palliative care, religious services and ethics such that there is an understanding of Do Not Attempt Resuscitation orders, as well as withdrawal of care, dying-patient protocol and terminal extubation.

Glenn Braunstein, MD, vice president, Clinical Innovation

It is estimated that the United States spends at least a quarter of all Medicare dollars on patients during the last year of their lives, with a large portion of those sums being expended in their final month. Many of the costs go for futile, life-sustaining treatments, such as mechanical ventilation, dialysis, feeding tubes and cardiopulmonary resuscitation, which do not prolong meaningful life, and may inflict unnecessary suffering on the individual and their families.

Patients with cancer too often receive useless chemotherapy during the last two weeks of life, and too many patients with chronic terminal illnesses spend many of their remaining days in intensive care units in hospitals, do not receive appropriate palliative care, comfort care measures or hospice referral – and often when these are provided, they are provided very late in the course of the disease.

National data also show that there is great variation as to the services provided to the terminally ill and that some of this variation relates to the number of doctors and hospital beds in a community, the physician practice patterns, the physician's acceptance that a patient's death is not a failure, the expectations of the patient, the patient's race and ethnicity, financial issues, access to hospice or palliative care services and whether the physician has discussed goals of care and end-of-life issues with the patient.

Certainly the data at Cedars-Sinai Medical Center support the published data, and in order to improve the care that we deliver to patients with chronic terminal illnesses, a multidisciplinary committee has been meeting for over two years under the auspices of Cedars-Sinai Medicine and has developed criteria for where these patients should be admitted. The committee has created and is distributing an Advance Healthcare Directive booklet for patients, is creating a video to help patients understand the importance of having advanced directives, and has developed a training program for house staff on how to have these difficult end-of-life conversations with patients. This latter program uses actors to play the patient roles, and the sessions are videotaped for immediate feedback.

Stuart Finder, PhD, director, Center for Healthcare Ethics

Talking directly and explicitly with patients about their end-of-life preferences is, in many ways, the most practically challenging ethical issue associated with end-of-life care. There are many reasons for this. One is that clinical contexts are infused with many values, some reflective of individual beliefs and commitments, others grounded in professional and institutional norms, and yet others shaped by broader social, cultural, political and economic frameworks and perspectives.

But none has absolute primacy. Clinical contexts are also infused with many forms of uncertainty, and oftentimes we lack long-term relationships with our patients and their families; they are, so to speak, strangers. Trust is thus often not based on demonstrated trustworthiness, but is a "forced trust,' based simply on one's acting in a role – be it patient, doctor, nurse, and so on. And finally, as care providers, we are responsible for making judgments about what, in the face of all input – patients' goals and values, medical indications, best practice evidence and accepted standards of practice, etc. – makes medical "sense" – and yet must do so keeping at bay our own personal values. To talk about another's end of life is daunting, which is why the many end-of-life-related policies at CSMC aim both to provide guidance and to ensure that we make decisions with consistency even as we always tailor each decision based on the particularity of patients' situations.

Rabbi Jason Weiner, BCC, manager, Spiritual Care Department

Involvement of a professional spiritual care provider is essential both before and after death. Even when curative medical treatment is deemed inappropriate, patient care continues until the very end. It is at this point, when some of the medical team begins to step back, that spiritual care becomes increasingly essential. As Rabbi Levi Meier, PhD, used to say, "Even when a cure is not possible, healing is always possible." This healing can be emotional, spiritual, or relational and can involve finding a sense of wholeness despite (or because of) terminal illness, and it can involve repairing strained relationships (whether with family, friends, or God), or thinking about one's legacy and writing an ethical will.

In this way, an incurable patient who is given appropriate care, space and guidance can literally heal into death. The role a chaplain plays for a patient, their family or our staff is often healing in and of itself, as a chaplain's focus is frequently to be that person who sits and provides a compassionate presence for as long as it takes for them to articulate their fears, hopes or even anger at God, without trying to fix anything. Spiritual care providers can also play a crucial role in end-of-life decision making, as death is more than just a medical or scientific issue; death is a process, and the point at which a human being no longer retains the status of a living entity is a complex religious, philosophical, and moral issue. Once a patient has died, the chaplain remains crucial in providing a nonanxious presence comforting the bereaved family and often assisting with specific prayers or rituals essential to the patient and/or their loved ones.

Robin McCaffery, JD, Legal Affairs Department

End-of-life care also triggers a number of specific and occasionally complex legal issues. Cedars-Sinai has developed policies which address end-of-life issues. These can be found on the Center for Healthcare Ethics Intranet site. These policies have taken into account relevant California law, as well as Cedars-Sinai standards of practice, and so are an excellent source of guidance. As a very broad summary: Laws relating to end-of-life care, such as those applicable to the withdrawal or withholding of life-sustaining care or medically inappropriate care, include provisions that not only protect patients, but protect physicians from liability when they follow the patient's healthcare decisions.