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Medical
Ethics
Medical
Futility
By Kate
Scannell, MD, Editor
Commentary by Stephen
C Henry, MD
To commentary
The case and commentary are reprinted from Ethics Rounds, 10(2),
2001. KFHP Inc, and TPMG, Inc.
While
our therapeutic armamentarium and scope of medical practice have broadened
considerably since the time of the ancient Greeks, both the concept
of medical "futility" and the argument about who defines it
continue to be debated at a level that resonates with earlier articulations
by Plato and Hippocrates. Both men argued that medical practitioners
should recognize limits in applying their art and science. Relevant
to modern-day discussions about health care resource allocation, they
also maintained that it was a defining characteristic of a good physician
to withhold therapeutic interventions when limits had been reached,
regardless of the patient's ability to pay for them. Hippocrates advised
his students "to refuse to treat those who are overmastered by
their diseases, realizing that in such cases medicine is powerless."
Modern-day
society continues to struggle with the old arguments about whether medical
limits should be set, if the medical profession should decide when treatments
are futile, and whether the scope of medical care that one actually
receives should depend upon one's personal wealth. This macroscopic
struggle also occurs in an era of rapidly expanding, life-sustaining
technologies (like organ transplants and advances in cardiopulmonary
life support) and, indeed, even life-creating capabilities (like cloning
and stem cell work). These developments stretch the notions of both
"medical limits" and "futility."
Meanwhile,
on a clinical or "microscopic" level, patients and medical
personnel routinely decide through highly individualized negotiations
at the bedside which limits they will observe according to which treatment
goals they choose to pursue, framing as "futile" whatever
lies outside those limits. In these circumstances, "medical limits"
and "futility" will be defined in highly individualized and
diverse ways.
But
what happens--as in the case that follows--when doctors and patients
and/or their surrogates disagree about the meaning of futility and the
appropriateness of limit setting? And while it has been pointed out
that discussions about medical futility should be carefully separated
from those concerning health care rationing and resource allocation,
like Hippocrates, others have asked for a moral accounting that reflects
the reality of the relationship between the macroscopic and microscopic
dimensions of health care as it is actually made available.
While
few people would openly advocate that medical care should be linked
to a person's wealth or capacity to affect the distribution of health
care resources, reality shows us that this often pertains. Health care
access is unevenly distributed, and, as such, some real medical "limits"
prove to be truly elastic around expansions and contractions of wealth
and insurance status. Consequently, the meaning of futility can bend
around the real variations of differently set limits.
As
one example, we can consider limits and futility in the setting of antiviral
therapies for AIDS
patients. There are factors other than democratic biological considerations
that determine who gets treated, who faces which limit, and for whom
treatment becomes defined as futile. While in theory easily separable,
notions of "limits" and "futility" become linked
to social and economic factors when they become the embodied notions
that they must become in the reality of clinical settings. The strain
of this embodiment taxes us intellectually, and it disturbs idealized
notions of ourselves as a just and compassionate society.
CASE
Who
Decides the Futility of Medical Care?
Mr Longsley is an 80-year-old, widowed, demented nursing home resident
who takes multiple medications for his chronic lung disease and congestive
heart failure. He arrives in the emergency room for the fifth time in
six months with acute-on-chronic respiratory failure due to yet another
aspiration pneumonia. When the lone emergency room physician suggests
that a repeated intubation and ICU admission would prove to be futile,
Maura, the patient's daughter and only kin, disagrees. She asserts that
her father enjoys his life in the nursing home, and that his life remains
meaningful to her.
The
physician asks Maura if she truly believes that her father would want
to undergo the repeated trauma of intubation, especially when the underlying
neurological problem causing his recurrent aspirations was unlikely
to improve? He performed Mr Longsley's last two intubations, and he
believes that they caused him terrible distress. There are no advance
planning documents, and Mr Longsley hasn't spoken since his most recent
stroke one year ago. Still, Maura contends that her father conveys his
unambiguous desires to her through nonverbal cues. She insists that
he wishes for aggressive treatment as needed to sustain his life, but
that he does not want a permanent tracheostomy. A decision about intubation
must be made within minutes of Mr Longsley's imminent death.
Should
the physician honor the daughter's request?
What
are the doctor's professional obligations to himself, the patient, and
the daughter?
What
is "futile" treatment?
Who
decides?
What
should the physician do in an urgent situation when he firmly believes
that the treatment he is asked to authorize violates his conscience?
| Additional
information, including complementary and/or dissenting views on
this issue can be accessed on the Kaiser Permanente Intranet by
visiting The Permanente Journal Web site (www.kp.org/permanentejournal);
click on this article in the Table of Contents and then click on
the link to Ethics Rounds. |
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Commentary
By
Stephen
C Henry, MD, Chair, Ethics Committee, KPMC San Jose/Santa Teresa,
CA
Wouldn't it be nice if we could just have "the big one"
and die quickly without having bothered much with the medical profession?
Less than 10% of us will die in this fashion. It is much more likely
that we will enter a situation like Mr Longsley's in which the period
preceding our death is characterized by a slow decline punctuated
by periodic crises, any one of which could cause death unless aggressively
treated. Because our commonly held ideas suggest that death is either
sudden or follows a relatively short and steady progression to a
predictable death, we are not well prepared as physicians or patients
to deal with recurring life-threatening episodes. We do not have
a good model to help us decide which of these episodes ought to
be the last, so that the unpleasantness of aggressive treatment
could be avoided.
The
physician in this case appears to be invoking futility as a reason
not to initiate treatment. He seems to define futility as, "This
stuff hurts; he's demented, and he'll just be back next month no
matter." Maura disagrees, contending that, despite his disabilities,
her father has a meaningful life and should continue to receive
aggressive treatment.
Dictionaries
define "futile" as completely ineffective, serving no
useful purpose. Since people differ in their assessments of utility
or purpose, claims of medical futility are, inherently, value judgments.
Several
approaches have attempted to refine the definition. One approach
is quantitative, posing that if an intervention has failed more
than 99% of the time, it is deemed to be futile. Other standards
include strict physiologic criteria, established community standards
and/or professional criteria, or institutional standards based on
policy. Others define futile treatment as that which would only
prolong dying. More recently, several authors suggest that futility
should be decided on a case-by-case basis after engaging in appropriate
discourse among the involved parties. They caution against using
the term "futility" as a shortcut to avoid meaningful
and sometimes difficult discussions.1
Some
institutions have developed futility or "non-beneficial treatment"
policies based on various criteria. For example, in the model policy
adopted by the Santa Clara (CA) County Medical Association Ethics
Committee, non-beneficial treatment is defined as: "a treatment
that has not or will not be reasonably expected to meet a goal wished
by the patient; a treatment whose burden or harm outweighs any expected
benefit; a treatment that is ineffective or harmful." In addition,
non-beneficial treatment includes the following: provision of treatment
when a patient or surrogate requests only comfort care; treatment
to a patient in an irreversible coma or persistent vegetative state;
treatment to patients permanently dependent on intensive care to
sustain life; and cardiopulmonary resuscitation in patients with
severe irreversible dementia.2
The
Education for Physicians on End-of-Life Care (EPEC) project of the
American Medical Association outlines a six-step "Due Process
Approach to Futility Situations." These steps are: 1) attempt
to negotiate understanding among the involved parties in advance
to preempt conflict; 2) negotiate solutions to disagreements; 3)
if disagreement persists, suggest the participation of other consultants,
colleagues, or the institutional ethics committee; 4) if the review
supports the patient's position and the physician remains unpersuaded,
arrange transfer of care to another physician; 5) if the review
supports the physician's position and the patient/surrogate remains
unpersuaded, consider transfer to another institution; 6) if it
is not possible to transfer the patient to another physician or
institution, the treatment need not be offered, but only after a
diligent search is conducted. If institutional policy allows for
this last option, there should be open disclosure of this policy
to all parties involved. Great care should be taken not to join
a futility policy with utilization management considerations. Nor
should a futility policy be used to blatantly override patients'
or surrogates' autonomy.3,4
So
what should our physician do? I believe that he should proceed with
intubation and should initiate life-saving treatment along with
measures to relieve Mr Longsley's discomfort with the procedures.
Mr Longsley does not meet the criteria set out above for conditions
that would suggest that treatment is futile. It does seem that the
physician is using futility as a substitute for discussion, especially
when there seems to be disagreement about Mr Longsley's ability
to communicate and express his own wishes. Aggressive treatment
is not likely to be physiologi
cally futile: we seem to be quite good at treating aspiration pneumonia
with respiratory insufficiency. The protocols and policies regarding
non-beneficial care all require substantive discussion over time;
a crisis situation in the Emergency Department is hardly the time
in which to make a decision that cannot be reversed.
We
do not have a good way of prospectively managing patients whose
course is characterized by these recurring crises amidst a steady
decline. Neurologically compromised patients, along with those who
have exacerbations of chronic lung disease or congestive heart failure,
often present challenging clinical and moral decisions about when
the "last" crisis episode should occur. It is usually
after a failure of intensive therapy that we make a decision to
forgo further treatment. Incorporating discussions regarding these
issues into long-term care as part of advance care planning could
help avert potential conflict in the acute care setting.
References
-
Medical Futility in End-of-Life Care: Report of
the Council on Ethical and Judicial Affairs. JAMA. 1999;281:937-41.
-
Prototype for a Non-Beneficial Treatment Policy. Santa Clara County
Medical Association, 1997.
-
Rivin AU. Futile Care Policy, Lessons learned from three year's
experience in a community hospital. West J Med. 1997;166:389-93.
- Education
for Physicians on End-of-Life Care (EPEC), American Medical Association,
1999. See Module 7: Goals of Care; Module 8: Sudden Illness; and
Module 9: Medical Futility.
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