When Do You Decide Not to Take a STEMI Patient to the Cath Lab? Addressing an Ethical Dilemma

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Author(s): 

Morton J. Kern, MD, Clinical Editor; Chief Cardiology, Long Beach Veterans Administration Health Care System, Long Beach, California; Associate Chief Cardiology, Professor of Medicine, University of California Irvine, Orange, California

The ST-elevation myocardial infarction (STEMI) team was called in to the hospital for activation at 11:30pm on a Thursday night. I always try to get the electrocardiogram (ECG) sent to my smartphone while getting dressed and before driving in. The ECG showed acute inferior STEMI with anterior T-wave inversions (Figure 1). The ECG was not classic, but certainly was an inferior STEMI, obtained with the patient having “chest pain”. The cath lab team and I were en route to the emergency room (ER) when my fellow, Dr. Megha Agarwal, called me and said there might be some issues with consent. In the ER, I met the patient, a 60-year-old woman with a terminal illness, two weeks of atypical chest pain and shortness of breath. The chest pain was now associated with more severe shortness of breath which had been increasing over the last one week.  

The patient was also affected by a terminal neurodegenerative illness with likelihood of one-year survival at less than 50%. She understood the state of her illness and prognosis. She was bedridden and had in attendance her two caregivers, one of which had her health care power of attorney. Despite her underlying disease and STEMI, the patient was alert, conversant, intelligent and coherent. She was a heavy smoker for many years, continuing to the onset of her recent symptoms, but otherwise had no coronary artery disease risk factors. To further complicate matters, the chest x-ray showed a large, right lung pneumonic consolidation and infiltrate. Her white blood cell count was 24,000 with normal hemoglobin, platelets, and renal function. Troponins were elevated at 10 ng/mL. 

She was examined in bed, but at home was confined to a wheelchair and did not ambulate. Her blood pressure was 88/50, with a heart rate of 110 beats per minute and respirations at 22/minute. She had decreased breath sounds over the right lung with some rales in the left lung, a II/VI systolic murmur at apex, and diminished pulses in all extremities. She was afebrile. We concluded her pneumonia probably started 10 days earlier, but was now markedly worsened and associated with an inferior STEMI.  

What to do? To cath or not to cath?

The patient had no family, but her full-time caregivers were present. She had lived with her disease for many years, and did not want any maneuvers that would prolong her life, given the terrible prognosis of her underlying illness. She specifically had declined resuscitation measures should anything happen to her. With her acute STEMI (which may actually have been a couple of days old), and her pneumonia, do you proceed to the cath lab or tell her that medical therapy would be a good alternative to revascularization? This was one of the most difficult decisions that I have had to make in many years.  As the physician that would perform the angiogram and possible percutaneous coronary intervention, what was my obligation to proceed in the care of this particular patient?  The rest of the story continues in a moment.

When should you not take a STEMI patient to the cath lab?

There are some clear situations where you should not take the STEMI patient directly to the cath lab. These “no-go” conditions, a.k.a relative contraindications (Table 1), can make the decision to defer cath fairly straightforward.  Some of these include recent or active bleeding, fulminant infection, inability to understand procedure and give informed consent, severe anemia, hyperkalemia, severe hemodynamic or electrocardiographic instability, aortic dissection, central nervous system impairment or trauma. Of course, if the informed and competent patient declines the procedure, that’s the end of the discussion.  (I always remind our fellows that we work for the patient; he/she is our “boss” in the clinical setting.)


Table 1.  Contraindications to Cardiac Catheterization

  • Absolute contraindications
    Inadequate equipment or catheterization facility
  • Relative contraindications
    Acute gastrointestinal bleeding or anemia
    Anticoagulation (or known, uncontrolled bleeding diathesis)
    Electrolyte imbalance
    Infection and fever
    Medication intoxication (e.g., digitalis, phenothiazine)
    Pregnancy
    Recent cerebrovascular accident (<1 month)
    Renal failure
    Uncontrolled congestive heart failure, high blood pressure, arrhythmias
    Uncooperative patient
    Source: Kern MJ. The Cardiac Catheterization Handbook. 5th edition. Elsevier Saunders: Philadelphia, Pennsylvania; 2011: 4. 

Under all other circumstances and if the criteria for STEMI are met, we take the patient to the cath lab and proceed with PCI if the angiographic appearance of the infarct-related vessel makes PCI feasible.  Under rare circumstances, we may not be able to perform PCI or we may need to refer the patient to the cardiothoracic surgeon. In patients in cardiogenic shock with STEMI, we may also proceed to do PCI of the non-infarct-related vessels.  

What to do about informed consent?

No procedure can proceed without the patient’s consent unless there is overwhelming evidence that failure to treat would result in severe harm or death. In the circumstance where the patient cannot give consent and there is no one known that has the legal authority to speak for the patient (family, surrogate or designated individual with credentials), emergency lifesaving procedure consent can be obtained and signed by two physicians familiar with the critical issue and who both agree that the procedure is needed.  

What would you tell a STEMI PCI patient with terminal illness and limited long-term prognosis about what is the best approach, especially if she is unsure of her own mind? What do we do with the patient who presents with a STEMI, but who has metastatic cancer, end-stage neurodegenerative disease, end-stage Alzheimer’s disease, or any of a number of pre-terminal co-morbid conditions which have a very limited life expectancy? What should we tell the patient and their family? 

There are no pat answers. Each discussion with the patient and their family must be individualized. I can only tell you what I do and what I tell my fellows in these circumstances. First, after reviewing all the information, especially old ECGs and records, if available, I speak with the patient. I ask for the patient’s family to be present to share in the discussion, but I address the patient directly. I explain to the patient what I know is happening now, and what I understand has happened to him/her in the past that complicates the STEMI treatment. Then I ask the patient what they understand to be happening and what they think might be best for them. Then I listen and wait, actively listening without being distracted or having someone distract the patient.  

What will STEMI PCI accomplish?

At this point, we should ask ourselves, what will the PCI in this setting for this patient accomplish? We may not know exactly what benefit might accrue, but we certainly know what the potential for harm may be. At this point in the process, the patient often asks a couple questions. Will this hurt? Will I live longer? Will I die sooner if I don’t have the procedure? Will I need a breathing tube or life support? Will I be a “vegetable” if something happens? What would you do if you were me?

These are the hardest questions with the least certain answers. If I can answer any of the questions with certainty, then of course I do. If I can’t, then I tell the patient that I do not know the answers and can only provide my best educated guess. The ultimate decision is always the patient’s. While the family has great influence at this point in a person’s life, I still want to hear directly from the patient whether they would like to proceed or not. If I cannot get a commitment from the patient that they want the procedure, then we defer, readdressing the issues and timing of cath later as clinically indicated. 

What did we do?

We spent about an hour talking to the patient about her options and wishes. She vacillated between wanting to do nothing and do everything. She was terribly conflicted, as was I. I understood that we might have little to offer, but that she might benefit by knowing whether opening the right coronary artery would add some quality time to her life. I suggested that we could do the angiogram and see if there was something that might help and only do revascularization if it could be done safely with low risk, so that we would not be put in the difficult situation of unwanted intubation and resuscitation during the PCI. 

She and her caregivers understood what I had explained and agreed to proceed. I knew that this was a difficult decision for her and prayed that I could get the procedure done safely and get her out of the lab alive. Consent for cath was signed. A “Do Not Resuscitate” (DNR) order was temporarily rescinded at the patient’s request (to be restarted after leaving the cath lab), and we went to the lab.  


Teresa,RN--Cath Labsays: January 16.2013 at 09:14 am

As a travel nurse in the Cath Lab, I enjoyed your article. I have often questioned the appropriateness of PCI for some patients. The ones with metastatic cancers, the young man that is found unresponsive and a blood level of drugs over the top...My experience has been that we treat them. I wish we had more physicians that displayed the thoughtfulness that you and your fellows speak of. Sometimes it is better to act slowly.

Reply to this comment »
Morton Kernsays: January 16.2013 at 12:23 pm

Thank you for your comment. It is always a tough decision on how to manage these patients. It often harder to do nothing than something even if you know it's futile. In these circumstances, we gather all the information and needs of the patient. It goes slow but it's worth it.
M

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Kleber Martinssays: January 27.2013 at 18:33 pm

You said that the patient was alert, conversant, intelligent and coherent. This was the most import think to decide with the patient very quickly, but you lost one hour talking to the patient and family and one hour more try to get access. These were not the cause of death but in this situation you had little to offer.
I would try to open the artery with the balance of risk / harm. In this case if you had enough time to save myocardial tissue the risk was less than harm, but 2 hours of delay the risk was bigger.

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morton kernsays: January 28.2013 at 11:48 am

The point of the article was that at times you cannot go faster than the patient and family want and also that some circumstances prevent rapid access. Both situations existed. I did not believe there was anything to offer once we saw the anatomy in this clinical setting.

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mohamed k ajjour says: January 27.2013 at 19:23 pm

i hink it was a mistake to take her to the cath lab ,our resources are limited ,and wasted ,u admitted pt with poor prognosis ,bed ridden.multiple complicated medical problems ,with poor prognosis ,2 days after MI ,by your experience ,as I was reading i was hoping u would not take her to cath lab,palliative and comfort care is a good option for a lot of patients.

Reply to this comment »
morton kernsays: January 28.2013 at 11:49 am

You've made my point precisely. To cath or not to cath? It is no easy decision. Thanks for your commment.

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Ahmad Salemsays: January 28.2013 at 15:41 pm

Dear dr. I congradulate your patience with your pt . But dont you think that Echo and extent of WMA and EF would affect your conversation and if extensively affected can we think about managing what could kill the patient immediatly

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morton kernsays: January 28.2013 at 17:42 pm

We had an ED bedside echo which was of poor quality but indicated LVEF 30-40%. Unless it was <20% this would not have influenced our decision. Consider the routine STEMI with EF <25% for unknown reasons. This person goes to cath and primary PCI is done even though a cardiomyopathy is often coexistant. Certainly every piece of data helps formulate the approach to the critically ill and difficult decsions.

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imagehrtsays: January 28.2013 at 23:25 pm

Our American culture under the influence of Dylan Thomas' "Do not go gentle into that good night" and the practice dilemma of treating patients that present with acute pain confounds these decisions. Thank you for sharing how you addressed such complex case.

One could argue that the lack of support of hospice in our culture confounded this issue. It seems that the decision to proceed was an effort to relieve suffering and I applaud you and your team for that. However, I submit that comfort might have been achieved with an alternate treatment plan. Clearly, the article addressed an ethical dilemma. However, it obviously did not help one decide when not to take a case to the lab.

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