EDECMO 16: The End-of-Life Matrix & The Ethics of Advanced Resuscitation with Dr. Cyrus P. Olsen III, D.Phil.

What this episode covers

In this episode, Zack and Joe talk with Dr. Cyrus Olsen, Oxford graduate and expert in bioethics about how to decide when to "Stop the Train". "in regards to ECMO : There's now a space, a hopeful space, to allow patients & family the time to make better decisions." - Cy Olsen PhD — ED ECMO Project (@edecmo) November 22, 2014 WARNING: This is going to get waaaaay touchy-feely and waaaaay outside of Joe's comfort zone (Zack, on the other hand, is feeling right at home here). With that in mind... "How young is too young..." to withhold resuscitation? The Dilemmas: * How old is too old...or better yet...how young is too young? aside from routine resuscitation: drugs, chest compressions, shocks, is there an age that is too old for ECMO? We currently use a soft cutoff of 75 yoa. Lets take all of the variables out of the equation and just assume a person has ZERO medical problems and is on ZERO medications. They ambulate on their own, live independently, and they believe they have a good quality of life. In this scenario, is there any age that is too old for ECMO? This should be our starting point and then move down (in age) from there. The 95 year old is easy. The 40 year old is easy. All the rest are tough and that's where we will get criticism for "doing too much." * Concrete resuscitation cutoff vs. a graded response? Whatever we decide is the cutoff (age, quality of life, comorbidities), should we use the exact same set of criteria for even initiating CPR as we do for ECMO? Should they be the same? In other words, should we have the same set of criteria for both or should there be a graded response to the dying patient (over 75 I do CPR and intubate but don't do ECMO but under 75 I go full-court-press and possible ECMO)? * Only Reverse the Reversible. Somehow we need to identify inevitable death and allow that to happen. Greg Henry always says, "Despite all the advances of modern medicine, the death remains the same: one per person." But when we can't be sure that death is inevitable, does everyone deserve a shot? In other words, should we be making that decision on the front end (ED) when little information is known to us, or should that be sorted out on the back end...in the ICU? Is there a way to tell a resuscitationist that its ok to err on the side of over-resuscitation, so long as your intent to is to reverse the reversable? Peter Safar's quote, "Death is not the enemy, but occasionally need help with timing." exemplifies this. * Define "Quality of Life". How do we determine "Quality of Life"? Who decides this in the heat of the moment? The doctor or the family? * What is the real goal of resuscitation? Should we only resuscitate people who were previously healthy and have a chance of 100% recovery? It seems we've come to a place where the knee-jerk reaction by ED doctors is to do full CPR on everyone and then see what happens. So how do we determine when and where to stop? * MD paternalism vs. patient automony = "The Tyranny of Choice." The Episode Play-by-Play: Dr. Olsen talks about the first concept: The "3 Senses of Dignity" from Daniel Sulmasy MD, PhD, a spokesman for the President's Council on Biotheics Intrinsic Dignity = your value for just being human Attributed Dignity = your "market value" to society Inflorescent Dignity = your "flourishing"; or your quality of life Utstein Variables for CPR The Life Matrix and the Functional Threshold:

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