Thursday, 5 April 2007

End of Life Decisions

As physicians, how do we manage End of Life Decisions?

We are all taught to treat conditions to make people better and then as doctors, we will have tried our best at all costs.

However, although this kind of thinking is respectable and usually appropriate, in some cases it may be inappropriate for the patient or in fact, even inhumane.

Sometimes as doctors, by keeping patients tied to a bed, on a ventilator with TPN dripping into their neck when they have an End Stage/ Terminal disease and will not recover and when the patient has had a poor quality of life, this kind of therapy makes the doctors feel better for trying but certainly not always the patient who is receiving it.

In such cases, it may be more humane to treat symptoms and to withdraw unnecessary therapies which are not helping the patient and which may be prolonging their agony or discomfort.

I hear of many cases where family members wish for their relative to have active treatment such as antibiotics and feeding whilst at the same time, they do not want Cardiopulmonary Resuscitation (CPR). I think in some circumstances this is sometimes an appropriate way but it is of course, on a case by case basis.

However, for example, in the patient who has had a Cardiopulmonary Arrest (CPA) with extensive hypoxic-ischaemic brain damage and who is otherwise 'Brain Dead' in the sense of no higher cerebral functioning, should we be treating infections and maintaining fluids when the chances of restoring the patient to a functional and meaningful life are negligible?

This decision is not an easy one to make.

However, patients deserve to be treated humanely and not be exposed to procedures and therapies that are not going to be effectively life prolonging or improve their quality of life.

In such cases, it is sometimes better to complete antibiotic therapies, if justified, and then not to restart if further infection occurs. Fluids may prolong life by preventing renal failure, but in patients who are at the end of life and moribund, fluids are unlikely to be necessary either.

Sometimes, rather than giving intravenous fluids, subcutaneous fluids can be given, thereby avoiding the painful procedure of trying to find and puncture a vein which can be quite painful especially in oedematous patients with no visible blood vessels! Subcutaneous fluid with normal saline (no potassium) can maintain a level of hydration and nursing staff can resite the fluids easily.

Ventilated patients can sometimes be transferred to non-invasive ventilation or even mask and oxygen therapy in order to reduce the uncomfortable therapy that intubation and ventilation can represent.

Basically, change therapies that would be used to treat patients actively to ones that are more conservative but at the same time, more humane by being less invasive and uncomfortable.

When patients reach the End of Life stage, it is perhaps better to give symptomatic, palliative therapy than continuing active, invasive therapies that are clearly not working and inhumane to the patient.

Although families have a big input to what happens with their relative, they should understand through the physician's explanations, that therapies change dependent upon the patient's condition. Moreover, continuing some therapies is at the request of the family, but you as doctors have responsibility for overseeing the care of the patient, not the family.

Through effective and honest communication with the family and stating why treatments would be inappropriate, for example, due to poor prognosis and being inhumane, the family members might have a different perspective with regards to using palliative therapies rather than inappropriate active therapies.

Remember to always put your patients first and not subject them to inhumane treatment even if it makes you feel uncomfortable.

Although as doctors you can do many treatments, it does not always mean that it is appropriate to do so and it is not for us to feel good that we did something when the patient is then put through inhumane treatment.

Please consider.

Monday, 2 April 2007

How to spot acute liver failure

Acute liver failure is quite a rare occurrence whilst chronic liver disease is relatively more common.

The two conditions can sometimes be confused in the jaundiced patient and even missed entirely if a careful history and physical examination is not taken.

Patients with acute liver failure do not usually have a history of liver disease and in fact, they may have no unusual history at all.

Nevertheless, a careful history should be taken concerning the causes of liver failure e.g. viral hepatitis, drugs, alcohol etc...

So, how do you spot a patient with acute liver failure with no pathognomonic signs?

Well, conscious level is important.

Always score the Glasgow Coma Scale and aim to use a mini mental test scoring system of up to ten questions to see if the patient can remember immediate memory, short term memory and long term memories. These scores can be compared as the patient improves or worsens and can be used as a guide.

Always check for a Hepatic Flap (arms extended and hands extended at the wrists with all digits spread open)-- a typical intermittent flexion-extension motion can be seen.

Smell your patient's breath for Liver Breath (fetor hepaticus) and check the eyes for jaundice.

None of the above can delineate acute from chronic decompensated liver disease.

However, the absence of chronic signs e.g. spider naevae, gynaecomastia, palmar erythema, clubbing, Dupytreen's contracture, gross ascites and caput medussa are clues that the disorder may be acute.

Moreover, in acute liver failure, the liver can be enlarged and tender on palpation whereas chronic liver patients tend to have hard and non-tender livers which may be impalpable.

Both conditions have increased bleeding tendencies but acute failure is far more serious as worsening clotting is a sign of worsening acute liver dysfunction. Patients can develop profound metabolic acidaemia and hence, their symptoms may be confused as a respiratory condition through increased respiratory rate from a Kussmaul-type of reactive breathing.

Patients may also present with unconsciousness due to profound hypoglycaemia, something not so common in chronic failure, and this may be due to decreased storage capacity, reduced glycogenolysis and gluconeogenesis in the acutely failing liver. Simply treating with 50% dextrose is not enough as patients may soon become hypoglycaemic again, so an infusion is required.

Of course, liver results showing very high AST and ALT in the thousands is highly significant of an acute process rather than the smaller rise seen in cirrhotic livers.

I hope the above helps you to separate the two conditions, as treatment and prognosis are different especially as acute liver failure patients may require acute liver transplantation.