Tracheostomy Exchange in the Setting of Do‐Not‐Intubate Order

An elderly gentleman with a history of a supraglottic mass causing stridor was urgently admitted for awake tracheostomy placement, laryngoscopy with biopsies, and expedited oncologic evaluation. His inpatient stay involved tracheostomy management, further oncologic workup for laryngeal squamous cell carcinoma, and pain management. Initially, he opted for full code/full care. However, in further discussions, he expressed the desire for prioritization of pain management and avoidance of a medically or artificially prolonged disease course. He firmly chose to be do-not-resuscitate/do-not-intubate (DNR/DNI) but was open to pain-relieving and dyspnea-relieving treatments. The option of receiving positive pressure through his stoma in place of intubation was not discussed within the goals of care conversation. He was transitioned on Postoperative Day 5 to an uncuffed tracheostomy tube for improved voicing. On Postoperative Day 10, the patient's work of breathing increased, and his mental state changed abruptly. The medical team suspected hypoxia, potentially from aspiration, COPD exacerbation, or polypharmaceutical narcosis. They urgently decided to switch to a cuffed tracheostomy tube to offer positive pressure ventilation. The question arose as to whether this change conflicted with the patient's current DNI directive. Due to his mental status change, the patient was unable to communicate and his family, unacquainted with the nuances of cuffed and uncuffed tracheostomies, did not feel they could make an informed decision regarding the change. This manuscript was deemed exempt by the Stanford Institutional Review Board. In this scenario, the medical team is asked to make an acute choice for a patient without input from him or his family. In situations where a team or individual is asked to make decisions for treatment for an incapacitated person, and there are no better mechanisms (ie, health care proxies), it is common to utilize ethical methods such as the “Substituted Judgement,” “Best Interests” and consequentialist frameworks to aid in decision-making.1, 2 Substituted Judgement uses knowledge of a patient's values or goals to guide decision making. When these values are unknown or unclear, “Best Interests” guides the team to the decision that maximizes the potential benefits of the situation for the individual.3 Consequentialist frameworks emphasize the goals and interests of the individual in question and evaluate actions based on the outcome of the situation. The decision-maker is tasked with the difficult job of carefully balancing the benefits and burdens of each potential outcome to maximize the well-being of the individual within their context and the current situation. The question becomes how to best advocate for this patient and his goals without the guidance of previous conversations or explicit wishes surrounding this issue. To do this, it is helpful to consider what we know about the patient's preferences based on the patterns of his health care decisions. We know, for instance, that the patient recently put into place an advanced directive declaring his wish to be DNR/DNI. We also know that this patient has plans for future cancer symptom treatment and ongoing therapies targeting his comorbidities and chronic diseases. We know that he has been receiving treatments in the hospital and plans to continue them upon discharge. We know that he recently consented to and underwent the placement of a tracheostomy tube for the treatment of airway obstruction and the preservation of his airway. We know that literature shows that when asked, many patients with existing DNR/DNI orders would still desire intervention in acute clinical scenarios.4 We know that this event likely represents an acute setback and potentially not a chronic change in his health status. We also know that not placing a cuffed tracheostomy tube to allow for adequate ventilation will likely result in this patient's demise. However, we do not know the patient's wishes regarding trans-tracheostomal intubation and ventilation as this was not discussed previously. We also do not know if initiating this therapy would cause moral injury by disrespecting his right to dictate care. Our question, therefore, becomes, how do we amalgamate all these data points into a decision that acts in an attempt to best substitute his decisions? How do we weigh his recent decisions to proceed with procedures and interventions, as well as planning for future care, with his decision to designate himself as DNR/DNI? How do we do this while considering the potential consequences of each of these decisions? How do we interpret his DNI order in the setting of trans-tracheostomal positive pressure ventilation? Applying substituted judgment and consequentialist frameworks to our scenario requires acknowledging the multiple unique attributes of the context, namely the acute nature of the event, the unknown but likely limited expected need for positive pressure therapy, the variability in interpretations of long- and short-term care goals and preferences for patients in similar situations, and the high potential stakes of the situation. It also requires, however, that within this decision schema, we keep the welfare of the individual at the forefront of our decision and prioritize the different variables accordingly. In this situation, failure to provide a cuffed tracheostomy and positive pressure ventilation could potentially result in this patient's acute deterioration or demise. This significant possibility for a negative outcome must, therefore, be weighed strongly against concerns of his DNI order representing broadly his preference for both chronic and acute care situations. Therefore, unless there is confidence among his care team and the patient's family members that the patient would not desire any initiation of positive pressure ventilation by any modality in conjunction with all of his ongoing treatments, the principles of substituted judgment and consequentialism would necessitate the changing of the tracheostomy tube and the administration of positive pressure ventilation in this short term period because it represents the highest possible benefit for the patient and the greatest potential good through avoidance of potential devastating harm. A DNI order allows patients to specify care preferences and guide providers and proxies in decision-making processes when they become incapacitated. This patient had a DNI placed not more than a week before this incident and within this hospital admission. A DNI order reflects a patient's desire not to receive procedures such as intubation and not to receive treatments such as mechanical ventilation. These orders were placed by the patient's direction after multiple multidisciplinary conversations between the patient and providers about preferences for receiving care and, therefore, should be respected as such. In the context of the above case, exchanging the tracheostomy tube for a cuffed tracheostomy tube and initiating positive pressure ventilation could be considered to directly conflict with the DNI order. While explicit understandings of the term vary, a DNI order is often created when a patient wishes to refuse mechanical ventilation and endotracheal intubation, even if they were deemed necessary components of life-sustaining care.5 While it is true that the presence of the existing tracheostomy tube in this patient negates the need for endotracheal intubation, the intention of the order is the same and in lieu of previous delineation by the patient should stand as such. The placement of a cuffed tracheostomy tube could represent a procedure akin to transoral intubation, and the outcome, the initiation of positive pressure ventilation, would be the same. Advanced directive orders intend to provide patients with dignity, autonomy, and proactive planning and allow them to choose not to receive specific health care interventions such as invasive ventilation and cardiopulmonary resuscitation. These “DNR/DNI” signifiers are placed in the chart after a discussion of goals and care plans with the patient and their providers. Advanced directives allow individuals to ensure that their preferences and choices for receiving health care are preserved. While we may not always be privy to the intentions or the circumstances that the patients envisioned when they chose to enact these orders, that does not allow a health care team to subvert them. While in this situation, the presence of a tracheostomy does provide some irregularity to the more traditional “DNI” order, this does not change the intent. As medical practitioners, it is our duty to respect and protect the care decisions of our patients. One might argue that a “DNI” order represents the ultimate wish of a patient, one which they were willing to put into writing with the understanding that it would dictate care in the future without their conscious knowledge or opportunity to intervene. Therefore, it would follow that an advanced directive is one the most important decisions a person can make and one which it behooves a clinician to uphold. Respecting this decision, even when an individual is no longer able to express it, represents a deep respect for that person and their values. A person's ability to make moral choices based on their principles and values and to have those choices respected is commonly referred to as respect for autonomy.6 Much of the basis of respect for autonomy lies in deontological ethical theories, including Kantian ethics and rights-based ethics.7 Deontology argues that the justification for our actions must be conceptualized within the umbrellas of duty and obligation, in this case, our duty to uphold the individual's choices. To do this, deontology dictates that we must take those decisions at face value, independent of any potential outcomes or consequences resulting from those decisions. In this case, that would mean that although it is not unlikely failure to initiate positive pressure ventilation may result in the decline or even demise of the patient, his wishes, as expressed in his DNI order, must be respected. Therefore, respect for autonomy dictates that changing the tracheostomy tube would conflict with the DNI order and should not be performed. The ethics of making decisions around treatment and interventions in an acute airway case are frequently complex. Air hunger can be terrifying and may by itself impair autonomy. Respiratory failure can sometimes be reversible, and with it, capacity may be expected to be restored, allowing a second chance conversation. The presence of a tracheostomy tube can definitively change the terms and methods of resuscitation. In this case, the goals of care discussion made it clear that the tracheostomized patient declined transoral intubation but did not specify whether he would consent to trans-stomal intubation and ventilation. The omission of this discussion resulted in the dilemma experienced by the care providers and raised the ethical questions described above. The qualitative and patient-experience differences between orotracheal/sedated intubation, cuffed tracheostomy, and uncuffed tracheostomy with or without speech valves are significant and must be explored with patients. Clarification of DNI status to include or exclude trans-stomal ventilation for tracheostomized patients may not be routinely explored by providers across specialties (including otolaryngologists, oncologists, palliative care doctors, and intensive care unit physicians). Incorporating routine discussion of a patient's attitudes toward trans-stomal ventilation as part of goals of care conversations in tracheostomized patients may help clarify goals and prevent moral distress and injury in situations such as this one. Zoë Fullerton, conceptualization, methodology, drafting of manuscript; Monica Bodd, conceptualization, methodology, revision of manuscript; Susan McCammon, methodology, revision of manuscript, supervision; Brian Nuyen, conceptualization, methodology, supervision, revision of manuscript. All authors approved the final version of the manuscript for submission. None. None.