End-of-Life Care in Anaesthesia

Quick Answer

Exam Essentials - ANZCA Professional Skills

End-of-life care in anaesthesia involves complex decisions about surgery in dying patients, organ donation pathways, and treatment limitation. ANZCA PG67(G) provides guidance on Goals of Care (GOC) framework: Curative/Restorative, Palliative, Terminal.

Organ Donation in Australia/New Zealand:

• Donation after Brain Death (DBD): Brain death determined by neurological criteria; organs perfused until retrieval
• Donation after Circulatory Death (DCD): Controlled withdrawal of life support; organs retrieved after circulatory arrest (5-minute stand-down in Australia, 5-10 minutes in NZ)
• Tissue donation: Eyes, heart valves, skin (longer retrieval window)
• Referral trigger: Any patient likely to die in ICU where death is imminent or life support withdrawal planned

Withholding vs. Withdrawing Treatment:

• Withholding: Not starting treatment that is not indicated
• Withdrawing: Ceasing treatment that is not beneficial or is burdensome
• Both ethically equivalent; neither constitutes euthanasia
• Must be in patient's best interests and align with goals of care

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Legal and Ethical Framework

ANZCA Guidelines

PG67(G) Guideline for End-of-Life Care (2022):

• Applies to all registered medical specialists and trainees
• Addresses surgery and interventional procedures in end-of-life patients
• Excludes futile surgery and voluntary assisted dying (separate scope)
• Provides framework for decision-making and treatment limitation

Key Principles:

1. Decision-making capacity: Assess capacity for all end-of-life decisions
2. Advance care directives: Must be valid and applicable to current situation
3. Goals of Care: Use GOC framework to guide treatment decisions
4. Multidisciplinary involvement: Engage palliative care, ethics, family
5. Documentation: Record rationale for all limitation decisions

Australian Legal Framework

Medical Treatment Decision-Making:

Victoria (Medical Treatment Planning and Decisions Act 2016):

• Instructional directives: Binding refusals of specific treatments
• Values directives: Non-binding statements of preferences
• Medical treatment decision makers: Substitute decision-makers appointed by patient

New South Wales (Common Law):

• No specific advance care directive legislation
• Common law directives recognized
• Person responsible hierarchy for decisions (spouse, carer, relative)

Queensland (Powers of Attorney Act 1998):

• Advance health directives for specific treatment decisions
• Statement of choices document (non-binding)
• Statutory health attorney system

Other Jurisdictions:

• All states/territories have guardianship and medical consent legislation
• Variations in recognition of common law vs. statutory directives
• Emergency provisions for treatment without consent (therapeutic privilege)

Voluntary Assisted Dying (VAD):

Note: VAD is outside scope of PG67(G). Anaesthetists may be involved in VAD in limited circumstances depending on jurisdiction and scope of practice.

New Zealand Legal Framework

Advance Directives:

• Recognized under common law
• Must be valid (capacity when made, clear, applicable)
• No specific statute (unlike Australian states)
• Welfare Guardian appointed under Protection of Personal and Property Rights Act 1988

End-of-Life Decisions:

• Withholding and withdrawing treatment legally permissible
• Must be in patient's best interests
• Substitute decision-makers apply substituted judgment standard
• Euthanasia and assisted suicide currently illegal (End of Life Choice Act 2019 not yet in force)

Code of Health and Disability Services Consumers' Rights 1996:

• Right to informed consent (Right 6)
• Right to make informed choice (Right 7)
• Right to support (Right 8)
• Right to compliance with advanced directives (implied)

Goals of Care Framework

Curative/Restorative Phase:

• Patient has indefinite (normal) life expectancy
• Care directed toward cure or prolonged remission
• Full escalation of care appropriate
• Surgery aims for cure or functional restoration

Palliative Phase:

• Living with progressive, incurable disease
• Death anticipated (timeframe variable: months to years)
• Care directed toward symptom control and quality of life
• Life prolongation secondary objective
• Surgery may be appropriate for symptom relief (e.g., fracture fixation, obstruction relief)

Terminal Phase:

• Actively dying
• Death expected within hours to days
• Care directed toward comfort, dignity, good death
• Non-beneficial interventions should be withheld/withdrawn
• Surgery rarely appropriate except for urgent symptom relief

Application to Anaesthesia:

• Preoperative assessment must include GOC determination
• Surgery in end-of-life patients requires clear goals alignment
• Anaesthetic risks weighed against expected benefits
• Postoperative care plans must align with GOC (e.g., ICU admission may not be appropriate for terminal phase)

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Organ Donation

DonateLife Australia

National Framework:

• Organ and Tissue Authority (OTA) coordinates national program
• DonateLife agencies in each state/territory
• Family-centered approach to donation conversations
• All health professionals must identify and refer potential donors

Referral Criteria:

• Any patient likely to die in ICU
• Imminent death expected
• Planned withdrawal of life-sustaining therapy
• Brain death suspected or confirmed
• Age generally <85 years for organ donation (tissue donation broader)

Referral Process:

• 24/7 DonateLife hotline in each jurisdiction
• Early referral allows assessment and family approach
• Donation specialist coordinates process
• Donation should not influence timing of end-of-life care

Donation Pathways

Donation after Brain Death (DBD):

Brain Death Determination:

• Clinical examination by two senior doctors (not donation team)
• Apnoea test performed
• Confirmatory tests if clinical examination equivocal:
  • Cerebral angiography (contrast or CT/MRA)
  • Nuclear medicine cerebral blood flow study
  • EEG (less commonly used)

Clinical Criteria (Australia):

• Deep coma (cause known, irreversible)
• Absent brainstem reflexes (pupillary, corneal, gag, cough, vestibulo-ocular)
• Apnoea (no respiratory effort despite PaCO2 >60 mmHg or >20 mmHg above baseline)
• Preconditions: No sedatives, normothermia, normotension, no severe electrolyte disturbance

Donation Process:

• Brain death declared; family informed
• Donation approach by trained donation specialist
• Consent obtained from senior available next of kin
• Organ perfusion maintained (cardiovascular, respiratory support)
• Organs allocated through national waitlist system
• Surgical retrieval in operating theatre

Donation after Circulatory Death (DCD):

Controlled DCD (most common):

• Planned withdrawal of life-sustaining therapy
• Family consent for withdrawal and for donation
• Patient moved to operating suite or nearby
• Life support withdrawn; death pronounced after circulatory arrest
• Stand-down period: 5 minutes (Australia), 5-10 minutes (NZ)
• Rapid organ retrieval (abdomen opened, aortic cannulation, organ perfusion)

Uncontrolled DCD (limited use):

• Unexpected cardiac arrest in patient with prior consent for donation
• Emergency preservation and transport if available
• Very limited application in Australia/NZ currently

Stand-Down Period:

• Ensures irreversibility of death
• Australia: 5 minutes of absent circulation (pulse, BP, ECG)
• New Zealand: 5-10 minutes depending on protocol
• Death pronounced by doctor not involved in retrieval

Organ Viability and Allocation

Organs for Transplantation:

• Heart, lungs, liver, kidneys, pancreas, small bowel
• Dual organ retrieval common
• Isolated heart or lung less common

Tissue for Transplantation:

• Corneas (most common)
• Heart valves
• Skin (burn patients)
• Bone and tendons
• Longer retrieval window (up to 24 hours after death)

Allocation System:

• National waitlist managed by Organ and Tissue Authority
• Blood group matching essential
• Tissue typing for compatibility
• Urgency status (e.g., liver allocation by MELD score)
• Geographical proximity considered

Anaesthetic Considerations in Donation

DBD Donor Management:

Cardiovascular Support:

• Brain death causes hemodynamic instability (catecholamine storm then loss of sympathetic tone)
• Maintain MAP >60-70 mmHg for organ perfusion
• Vasopressin often required for diabetes insipidus and vascular tone
• Inotropes (noradrenaline, adrenaline) as needed
• Target HR 60-120 bpm

Respiratory Management:

• Lung protective ventilation for potential lung donors
• Tidal volume 6-8 ml/kg, PEEP 5-10 cmH2O
• Regular suctioning, bronchoscopy if indicated
• Avoid fluid overload for lung protection

Fluid and Electrolyte:

• Diabetes insipidus common (treat with vasopressin/desmopressin)
• Target CVP 6-10 mmHg (balance organ perfusion vs. lung protection)
• Maintain glucose 4-10 mmol/L
• Correct electrolyte abnormalities

Temperature:

• Active warming to maintain normothermia (>35°C)
• Cold dissection if local retrieval technique used

DCD Considerations:

• Withdrawal of support usually in ICU or theatre
• Comfort medications prioritized (analgesia, sedation)
• Rapid transition from comfort care to organ retrieval if death occurs within timeframe
• 5-10 minute stand-down before surgical intervention

Indigenous Health and Organ Donation

Aboriginal and Torres Strait Islander Considerations:

Cultural Complexities: Organ donation discussions with Aboriginal and Torres Strait Islander families require extreme cultural sensitivity. The concept of brain death may conflict with cultural understandings of life and death. Some Aboriginal communities believe that the spirit remains until burial, while others may view the body as sacred after death.

Family Decision-Making: Decisions about organ donation are rarely individual in Aboriginal communities. Extended family, Elders, and community members may all have legitimate roles in the decision-making process. Healthcare providers must allow time for this collective deliberation, even when medical timeframes are pressing.

Sorry Business Impact: During Sorry Business, decision-making capacity may be culturally constrained. Cultural protocols may prevent certain individuals from participating in decisions or may require specific consultation processes. Rushing donation decisions during this period may cause significant cultural harm.

Organ Donation Attitudes: Research by the Organ and Tissue Authority (2023) indicates that Aboriginal and Torres Strait Islander peoples have lower rates of organ donation consent compared to non-Indigenous Australians. Contributing factors include:

• Historical mistrust of medical institutions
• Lack of culturally appropriate information and education
• Fear that organs may be used for experimentation
• Concerns about impact on cultural burial practices
• Lack of Aboriginal donor recipients (representation matters)

Best Practice Approach:

• Early involvement of Aboriginal Health Workers and DonateLife Indigenous liaison officers
• Culturally appropriate information materials
• Extended timeframes for family decision-making
• Respect for cultural authority structures
• Acknowledgment that donation may not align with cultural beliefs
• Non-judgmental acceptance of decisions

Māori Health Considerations:

Whānau Decision-Making: Whānau must be given time and space to make decisions about organ donation. The concept of whanaungatanga means that individual decisions affect the collective. Karakia and cultural rituals may be required before and after death.

Tapu and Noa: The deceased body is tapu (sacred). Handling of the body for organ retrieval must respect these concepts. Rapid return of the body to whānau is often culturally important. Some Māori may prefer that the body remain intact for return to ancestral lands (urupā).

Organ Donation Education: The Organ and Tissue Authority works with Māori health providers to improve understanding of organ donation. Representation of Māori on transplant waitlists and as donors remains an area of health equity focus.

Cultural Support: Involvement of kaumatua, Māori Health Workers, and cultural advisors is essential in donation discussions. Tikanga (customary protocols) must be observed throughout the process.

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Withholding and Withdrawing Treatment

Ethical Principles

Distinction Between Acts and Omissions:

• Withholding treatment = not starting non-beneficial treatment (omission)
• Withdrawing treatment = stopping non-beneficial treatment (omission)
• Both ethically equivalent; neither is euthanasia
• Intention is to stop burdensome/ineffective treatment, not to kill

Double Effect:

• Action with good intention may have foreseen but unintended bad effect
• Example: Morphine for symptom relief may hasten death as side effect
• Permissible if proportionate (benefit outweighs harm)
• Contrast with euthanasia (intention is to cause death)

Best Interests Standard:

• Decisions must be in patient's best interests
• Substituted judgment: What would patient want?
• Objective test: What would reasonable person want?
• Consider clinical factors, patient's values, quality of life

Clinical Scenarios

Withholding Life-Sustaining Treatment:

When Appropriate:

• Treatment would not achieve patient's goals
• Burdens outweigh benefits
• Patient (with capacity) refuses
• Valid advance directive refuses
• Futility (treatment cannot achieve physiological goal)

Examples in Anaesthesia:

• Not offering surgery when prognosis is terminal and surgery non-beneficial
• Not intubating patient with advanced dementia and pneumonia
• Not initiating CPR when clearly futile
• Not transferring to ICU when terminal phase and ICU care non-beneficial

Withdrawing Life-Sustaining Treatment:

When Appropriate:

• Treatment not achieving desired benefit
• Burdens have become excessive
• Patient's condition has changed
• New information about prognosis or outcomes

Examples in Perioperative Context:

• Withdrawal of mechanical ventilation when brain death confirmed
• Withdrawal of inotropes when multi-organ failure irreversible
• Withdrawal of dialysis when no longer beneficial
• Transition from active treatment to comfort care

Practical Considerations:

• Ensure adequate sedation and analgesia
• Remove unnecessary monitoring and lines (unless cause discomfort)
• Allow family presence
• Provide privacy and dignity
• Support family through process
• Document decision-making and process

Legal Protections

Good Samaritan and Protection Provisions:

• Decisions made in good faith and patient's best interests are protected
• No duty to provide non-beneficial treatment
• Document decision-making thoroughly
• Seek second opinions if uncertainty
• Ethics consultation helpful for complex cases

Advance Care Directives:

• Valid directives must be respected
• Cannot provide treatment refused in valid directive
• Emergency exception if validity/applicability uncertain
• Seek legal advice if genuine uncertainty

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Palliative Care in Perioperative Medicine

Role of Anaesthetists

Perioperative Palliative Care: Anaesthetists increasingly provide palliative care in perioperative settings:

• Surgery for symptom relief (palliative procedures)
• Pain management in palliative patients
• Coordination with palliative care teams
• End-of-life care in perioperative period

Palliative Procedures:

Appropriate Palliative Surgery:

• Fracture fixation for pain relief and mobility
• Debulking surgery for symptom control
• Stenting or bypass for obstruction
• Wound debridement
• Spinal cord compression decompression

Risk-Benefit Assessment:

• Burden of surgery vs. expected symptom relief
• Recovery trajectory and time remaining
• Patient goals and values
• Alternative non-surgical options

Anaesthetic Considerations:

• Minimally invasive techniques when possible
• Regional anaesthesia may reduce systemic impact
• Avoid long-acting agents that impair cognition
• Consider home discharge vs. facility care postoperatively
• Advance care planning should be current

Pain Management in Palliative Care

Principles:

• Pain is multidimensional (physical, psychological, spiritual, social)
• WHO analgesic ladder applies
• Regular scheduled dosing better than PRN
• Prevent side effects (constipation, nausea)
• Adjuvant analgesics (antidepressants, anticonvulsants)

Anaesthetic Interventions:

• Regional techniques for localized pain
• Neuraxial analgesia for cancer pain
• Nerve blocks for specific pain syndromes
• IV ketamine infusions for refractory pain
• Spinal cord stimulators (limited palliative use)

Perioperative Considerations:

• Preoperative optimization of analgesia
• Multimodal approach
• Regional techniques to reduce opioid requirements
• Postoperative transition to palliative care team

Integration with Palliative Care Teams

Collaborative Model:

• Early referral to palliative care (not just end-of-life)
• Joint decision-making about surgery appropriateness
• Shared care for symptom management
• Clear handover and communication

Communication:

• Goals of care alignment
• Prognostic understanding
• Patient and family expectations
• Postoperative care planning

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Practical Tools and Pathways

Brain Death Checklist

Preconditions (all must be met):

• Coma cause known and irreversible
• No sedative drugs (or adequate washout period)
• Normothermia (core temperature ≥36°C)
• Normotension (MAP ≥60 mmHg)
• No severe electrolyte, acid-base, or metabolic disturbance

Clinical Examination (performed by two senior doctors):

• Pupillary reflex absent (fixed, mid-position)
• Corneal reflex absent
• Oculocephalic (doll's eyes) reflex absent (if safe to test)
• Vestibulo-ocular reflex absent (caloric test)
• Gag reflex absent
• Cough reflex absent (tracheal suctioning)
• Motor response to painful stimuli absent (supraorbital, nail bed)

Apnoea Test:

• Pre-oxygenate (FiO2 1.0 for 10 minutes)
• Disconnect ventilator
• Deliver O2 via catheter to carina
• Observe for respiratory movements for 10 minutes
• Check ABG: PaCO2 ≥60 mmHg or ≥20 mmHg above baseline
• Reconnect ventilator immediately

Confirmatory Tests (if clinical test equivocal or cannot be performed):

• Cerebral angiography (four vessel): no intracranial flow
• CTA/MRA: no intracranial flow at circle of Willis or above
• Nuclear medicine blood flow study: no isotope uptake in brain parenchyma

Documentation:

• Two independent examiners (not donation team)
• Date and time of determination
• Specific findings documented
• Brain death declared

DCD Checklist

Eligibility Assessment:

• Imminent death expected with planned withdrawal of life support
• Age generally <65-70 years (varies by program)
• No exclusion criteria (malignancy, infection, etc.)
• Organs potentially suitable

Family Discussion:

• End-of-life care discussion first
• Separate donation discussion by specialist
• Consent for withdrawal and for donation
• Cultural/religious needs identified

Planning:

• Theatre or ICU location determined
• Surgical team briefed
• Perfusion team ready
• Timing agreed (does not compromise end-of-life care)

Withdrawal Process:

• Comfort medications prioritized
• Family present if they wish
• Extubation or cessation of support
• Death pronouncement after circulatory arrest

Stand-Down:

• 5 minutes (Australia) or 5-10 minutes (NZ) observation
• Absent pulse, BP, ECG
• Death pronounced by doctor not involved in retrieval

Organ Retrieval:

• Rapid laparotomy
• Aortic cannulation and perfusion
• Organ cooling and preservation
• Completion of retrieval

Treatment Limitation Order Template

LIMITATIONS ON MEDICAL TREATMENT

Patient: [Name, DOB, UR]
Date: [Date]
Author: [Name, designation]

GOALS OF CARE: ☐ Curative  ☐ Palliative  ☐ Terminal

DECISION-MAKING CAPACITY:
☐ Patient has capacity and has participated in decision
☐ Patient lacks capacity: Decision made by [SDM name/relationship]
☐ Valid advance care directive applies: [Reference]

LIMITATIONS:
☐ No CPR - rationale: _________________________________
☐ No intubation/ventilation - rationale: _______________
☐ No ICU admission - rationale: _______________________
☐ No vasopressors/inotropes - rationale: _______________
☐ No dialysis - rationale: ____________________________
☐ Other: _____________________________________________

TREATMENTS TO BE PROVIDED:
☐ Full active treatment within above limits
☐ Active treatment except specified limitations
☐ Comfort-focused care only

SYMPTOM MANAGEMENT PLAN:
- Analgesia: __________________________________________
- Sedation if needed: __________________________________
- Respiratory secretions: ______________________________
- Other: _____________________________________________

REVIEW:
☐ Reversible? Review if: ______________________________
☐ Not reversible unless condition changes significantly

SIGNATURES:
Doctor: ________________ Date/Time: ________________
Patient/SDM: ___________ Date/Time: ________________
Witness: _______________ Date/Time: ________________

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ANZCA Exam Focus

Common SAQ Topics

Question 1: End-of-Life Surgery Decision-Making (20 marks)

An 82-year-old man with metastatic pancreatic cancer presents with obstructive jaundice and is offered biliary bypass surgery. He has decision-making capacity but limited understanding of his prognosis. His family wants "everything done."

Discuss your approach to the anaesthetic preoperative assessment and decision-making.

Model Answer Framework:

Assessment of Decision-Making Capacity (5 marks):

• Apply four-element test (understand, retain, weigh, communicate)
• Ensure no reversible factors impairing capacity
• Document assessment specifically
• May need repeated assessments

Goals of Care Determination (5 marks):

• Patient in palliative phase (incurable progressive disease)
• Clarify goals of proposed surgery: palliative (symptom relief), not curative
• Assess whether patient understands prognosis and goals
• Discuss expected outcomes and recovery trajectory

Risk-Benefit Analysis (5 marks):

• High surgical risk in advanced malignancy
• Limited life expectancy (months)
• Recovery time vs. time remaining
• Alternative options: stenting, hospice care
• Burden of surgery vs. benefit

Family Dynamics (3 marks):

• Family's wishes important but patient's autonomy paramount
• Family may need education about prognosis and realistic outcomes
• Consider family meeting with surgeon, oncologist, palliative care
• Cultural considerations in decision-making

Documentation (2 marks):

• Capacity assessment
• Discussion of goals, risks, alternatives
• Patient's expressed wishes
• Plan and rationale

Question 2: Organ Donation (20 marks)

A 35-year-old man has suffered traumatic brain injury and meets clinical criteria for brain death. His family is considering organ donation. Describe the organ donation process including anaesthetic considerations for donor management.

Model Answer Framework:

Brain Death Determination (4 marks):

• Clinical examination by two senior doctors
• Preconditions: normothermia, no sedatives, no severe metabolic disturbance
• Absent brainstem reflexes (pupillary, corneal, gag, vestibulo-ocular)
• Apnoea test: PaCO2 >60 mmHg or >20 mmHg above baseline
• Confirmatory imaging if clinical test equivocal

Donation Pathway (4 marks):

• Referral to DonateLife agency
• Family approach by trained donation specialist
• Consent from senior available next of kin
• Organ allocation through national system
• Surgical retrieval in operating theatre

Donor Management - Cardiovascular (4 marks):

• Brain death causes hemodynamic instability
• Target MAP >60-70 mmHg for organ perfusion
• Vasopressin for diabetes insipidus and vascular tone
• Inotropes as needed; avoid excessive fluid

Donor Management - Respiratory (4 marks):

• Lung protective ventilation if lungs suitable
• Tidal volume 6-8 ml/kg, PEEP 5-10 cmH2O
• Regular suctioning, bronchoscopy
• Balance fluid status for lung protection

Additional Considerations (4 marks):

• Hormonal resuscitation (thyroid hormone, corticosteroids, vasopressin)
• Temperature maintenance (>35°C)
• Glucose management (4-10 mmol/L)
• Tissue donation (corneas, heart valves) if organs not suitable

Question 3: Withholding/Withdrawing Treatment (20 marks)

A 78-year-old woman with advanced dementia and aspiration pneumonia is not responding to antibiotics. Her advance directive states "no heroic measures" and "comfort only at end of life." Her daughter wants everything done including ICU admission and mechanical ventilation.

Discuss the ethical and legal issues and your approach to this situation.

Model Answer Framework:

Advance Directive Validity (5 marks):

• Made with capacity (when composed)
• Clear and specific language
• Applicable to current situation (end-stage dementia, terminal)
• Legally binding if valid
• "Heroic measures" and "comfort only" interpreted in context

Substitute Decision-Making (5 marks):

• Daughter is likely substitute decision-maker
• However, valid advance directive takes precedence
• SDM must follow patient's expressed wishes
• If no directive, apply best interests or substituted judgment
• Family disagreement common but patient autonomy paramount

Ethical Analysis (5 marks):

• Withholding/withdrawing treatment ethically equivalent
• Not euthanasia (intention is comfort, not to kill)
• Double effect: symptom relief may hasten death but permissible
• Quality of life considerations
• Burden vs. benefit analysis

Approach (3 marks):

• Family meeting with clear explanation of directive
• Honest prognosis discussion
• Focus on comfort care aligned with patient's wishes
• Offer second opinion if family uncertain
• Support family through grief

Documentation (2 marks):

• Directive reviewed and deemed valid
• Family discussion documented
• Decision to honor directive
• Comfort care plan initiated

Viva Scenarios

Scenario 1: Advance Directive Conflict

A 78-year-old woman is brought to theatre for emergency surgery following hip fracture. She has an advance directive refusing "heroic measures" and "life support." She does not have capacity currently. Her daughter insists on full treatment including ICU admission if needed.

Examiner Questions:

1. "How do you assess the validity of the advance directive?"
2. "What is your role in resolving this conflict?"
3. "How would you approach the family discussion?"

Key Points:

• Validity: capacity when made, clear language, applicable to situation
• "Heroic measures" is vague; does it apply to routine postoperative care?
• Emergency surgery for hip fracture is standard care, not heroic
• ICU admission may or may not be "life support"
• Family discussion: explore understanding of directive, current situation, patient's values
• Ethics consultation if unresolved
• Document thoroughly

Scenario 2: DCD Donation

You are the anaesthetist covering ICU. A patient with end-stage motor neurone disease is having life support withdrawn. The family has consented to organ donation after circulatory death. Describe the process and your role.

Examiner Questions:

1. "What is the process for controlled DCD?"
2. "What are the time limitations and constraints?"
3. "What medications would you administer?"

Key Points:

• Controlled DCD process: withdrawal in ICU or theatre, death after circulatory arrest
• Stand-down period: 5 minutes (Australia) of absent circulation
• Time constraints: organs must be retrieved rapidly (usually within 30-60 minutes of withdrawal)
• Medications: comfort-focused (opioids, benzodiazepines), not paralytics
• If death doesn't occur within timeframe, patient returns to ward for end-of-life care
• Family support throughout process

Scenario 3: Brain Death Determination

You are asked to assist with brain death determination in a patient who has suffered catastrophic intracranial hemorrhage. Describe the process including any confirmatory tests that may be required.

Examiner Questions:

1. "What are the prerequisites for brain death determination?"
2. "Describe the clinical examination findings required."
3. "When would you use confirmatory tests?"

Key Points:

• Preconditions: known irreversible cause, no sedation, normothermia, normotension
• Brainstem reflexes all absent
• Apnoea test with PaCO2 >60 mmHg
• Two independent examiners
• Confirmatory tests: equivocal clinical exam, facial trauma preventing exam, severe sleep apnoea
• Cerebral angiography or nuclear medicine flow studies

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Extended Case Studies

Case 1: Surgery in End-of-Life Patient

Scenario: A 68-year-old man with metastatic lung cancer is scheduled for emergency laparotomy for small bowel obstruction. He has been receiving palliative chemotherapy. The surgeon believes surgery may relieve obstruction but acknowledges high risk and uncertain benefit.

Issues:

• Palliative phase, limited life expectancy
• Emergency surgery with unclear benefit
• High perioperative risk
• Goals of care alignment

Approach:

1. Goals of Care Clarification:

   • Current phase: Palliative (incurable disease, symptom-focused)
   • Surgery goal: Palliative (symptom relief), not curative
   • Is surgery likely to achieve symptom relief?
   • What is expected survival with and without surgery?

2. Multidisciplinary Discussion:

   • Include surgeon, oncologist, palliative care
   • Discuss alternative: conservative management, venting gastrostomy
   • Prognostic estimate: days to weeks without surgery, weeks to months with successful palliation
   • Quality of life considerations

3. Family Meeting:

   • Clear explanation of goals (palliative, not curative)
   • Honest discussion of risks and uncertain benefits
   • Expected outcomes and recovery trajectory
   • Alternative options
   • Patient's values and preferences (if known)

4. Decision and Plan:

   • If surgery proceeds: minimally invasive if possible, clear limits on escalation (no CPR if terminal)
   • If conservative: hospice referral, symptom management
   • Document decision-making thoroughly

Case 2: Brain Death and Donation

Scenario: A 25-year-old woman has suffered catastrophic intracranial hemorrhage. Clinical examination confirms brain death. Her parents are devastated but mention she "always wanted to donate." However, they are hesitant and have cultural concerns.

Issues:

• Brain death confirmed
• Donation possible
• Family emotional distress
• Cultural considerations
• Time-sensitive decisions

Approach:

1. Brain Death Confirmation:

   • Formal examination documented
   • Two clinicians confirm
   • Family informed sensitively
   • Time for initial grief

2. Donation Approach:

   • DonateLife specialist leads approach (not primary team)
   • Timing: when family ready, but before organ viability compromised
   • Cultural liaison if needed
   • Explore cultural concerns
   • Emphasize donation aligns with patient's wishes

3. Decision Support:

   • Give family time and space
   • Answer questions honestly
   • No pressure or coercion
   • Respect decision if they decline
   • Document discussion

4. If Donation Proceeds:

   • Family present until support withdrawn (if they wish)
   • Honour cultural rituals if possible
   • Keep family informed throughout process
   • Support after donation
   • Follow-up and gratitude

Case 3: Conflicting Family Views on Treatment Limitation

Scenario: An 85-year-old man with severe Alzheimer's disease is admitted with aspiration pneumonia. He has a valid advance directive stating "no life support" and "comfort only." One daughter wants to honor the directive; another daughter wants "everything done including a feeding tube and ICU."

Issues:

• Valid advance directive exists
• Family conflict about interpretation
• Unclear who is substitute decision-maker
• Pressure from one family member
• Legal and ethical obligations

Approach:

1. Validate Directive:

   • Review document for validity
   • Confirm made with capacity
   • Clear and specific language
   • Applicable to current situation

2. Family Meeting:

   • Both daughters present
   • Explain legal status of directive
   • Primary obligation is to patient's expressed wishes
   • SDM must follow directive, not personal preferences
   • Explore concerns of daughter wanting aggressive care
   • Offer support and counseling

3. Clarify Roles:

   • Determine legal substitute decision-maker hierarchy
   • If conflict persists, consider guardianship tribunal
   • Ethics consultation helpful

4. Implement Care:

   • Comfort-focused care per directive
   • Treat aspiration pneumonia with antibiotics if appropriate
   • No feeding tube, ICU, or ventilation
   • Hospice/palliative care referral

5. Documentation:

   • Directive validity and contents
   • Family discussion
   • Decision to honor directive
   • Plan of care

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References

1. ANZCA. PG67(G) Guideline for the Care of Patients at the End-of-Life Who Are Considered for Surgery or Interventional Procedures. Melbourne: ANZCA; 2022.
2. ANZCA. PS02(G) Position Statement on Consent and Capacity. Melbourne: ANZCA; 2024.
3. Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. Melbourne: MBA; 2022.
4. Medical Council of New Zealand. Good Medical Practice. Wellington: MCNZ; 2020.
5. Organ and Tissue Authority. Best Practice Guideline for Offering Organ and Tissue Donation in Australia. Canberra: OTA; 2021.
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