Saturday, July 30, 2011

Futility Revisited

Thanks to all to took the time to provide excellent comments my previous post "Was it Futile? Here are a few of my additional thoughts.

A DNR (do not resuscitate} order is indeed a physician order. However, even with a co-signature of a colleague, it's probably quite rare and certainly ethically questionable in the USA for this order to be written without the consent of the patient/surrogate. In the futility case I presented, even at the beginning I thought it was medically unwise and non-beneficial to intubate this patient with end-stage lung cancer. But respecting the patient's autonomy ("do everything, I'm hoping for a miracle"), I felt obliged to go down the extraordinary life support path.

This particular patient was persistently hoping for a miraculous religious healing, hence she sought additional therapy in another country even with stage 4 lung cancer having "failed" with the best the USA has to offer. Atul Gawande in his New Yorker article, "Letting Go", points out that there is almost always more that we can do. It may turn out though that "more" ends up only prolonging suffering and the dying process.

Ethics Committees (EC's) vary in their effectiveness from hospital to hospital and appear to be quite underutilized. The more robust EC's will include the patient/surrogate in their deliberations, rather than having a closed door process making a pronouncement. I agree that EC's don't make clinical decisions, but when agreeing that withdrawal of a ventilator is permissible, they are basically tacitly agreeing with the physician assessments. Sue Rubin, Ph.D does excellent training for a methodology of EC's to use which she recently presented to the EC I serve on.

In this particular patient the husband had the DPOA for Health Care and would also be so designated under Washington State law. He was competent even though he'd had a stroke. He was firm in supporting his wife's wish for a miracle to the end, though the children felt very conflicted and saw the hopelessness of the situation.

When to stop CPR is an interesting question. In the old days, we'd do a "slow code" and allow the patient to die without much trauma. The "slow code" is really dishonest and unethical, so what about calling off a code after 10 seconds? Shouldn't a "no-code" order have been written if that's the case? Are there published policies on this?

I'm going to guess that Jecker and Schneiderman would recommend as follows: in this case the physician had no duty to provide a treatment which was not going to benefit the patient, despite the patient's hopes for a miracle. The doctors should so inform the family. If there's disagreement an EC consultation could take place. Assuming the EC felt that discontinuation of life support was reasonable, the surrogates can agree or work on a transfer plan.

Dr. John Luce several years ago wrote an editorial in the journal Chest, in which he likened a situation like this is France and in the USA. In France, there is much more of a tradition of the doctor's authority or what might be called a benevolent form of paternalism. There are limited visiting hours in France in their ICU's. When the doctors find the situation hopeless, they would extubate the patient, allow them to die with appropriate comfort measures, and then let the family know that their loved one was gone. In the USA, autonomy of the individual has the highest value and often trumps other ethical values. Thus, we expend lots of energy, angst, time, and money in honoring the patient's autonomy. In theory this should work well and it often does. However, I think the case in point shows that some kind of limits need to be set. Schneiderman and Jecker talk of both quantitative and qualitative futility. They plead for communities of patients, doctors, hospitals, and nurses to come together in some common understanding of a community wide futility policy. Lots more discussion is needed.

Sunday, July 24, 2011

Was it Futile?

I was surprised to get a call from security at SEA-TAC airport that my patient was being transported by Medic 1 to our hospital shortly after touching down. Mary had been insisting on more care for her stage 4 lung cancer and was holding out for a miracle. She had gone to another country for what she described as "the miracle cure" so I had lost touch for the past few months. The Medics called in that she had shallow respirations and had borderline BP so we admitted her directly to the ICU since she was still "full code" status per her wishes and written advance directive.

Shortly after arrival, Mary's status deteriorated with falling oxygen saturation despite non-invasive ventilation and other support. She was intubated and placed on a ventilator with the usual accompanying measures of tube feeding and close monitoring for infection or other complications. The chest X-Ray showed her tumor masses had grown in the relentless way they do. She had known liver, bone and brain metastases.

The family was conflicted. Her husband had had a stroke and was unable to actively communicate yet he attended our discussions and expressed support for his wife's wishes. The children were more unsure. One wondered if we were only prolonging her suffering, another felt his mother couldn't have been in her right mind to keep going on with invasive treatments that were hopeless.

I was frank with the family. Mary was beyond any hope of recovery and extremely unlikely to ever get off the ventilator. I couldn't hold out hope for Mary, now unconscious, and recommended that the family consider withdrawal of ventilator support (a better term here than life support). This conversation took place in steps over several meetings and I tried to introduce the concept of non-beneficial or futile care. The family remained conflicted and could not come to a decision. After three weeks in the ICU, Mary's heart stopped and the nurses, much against their wishes, had to perform fruitless CPR. Mary thus died in a traumatic way, ribs broken from chest compressions, suffering the kind of technological imperative that's sarcastically referred to by the staff as "medical last rites."

Comment: There are two books out with take opposing views on the concept of futility. Susan B. Rubin, Ph.D argues that " current formulation of futility is sufficient to justiy physician unilateral decision making." The author, in her book "When Doctors Say No" has well reasoned concerns that futility may not really be the issue, may deflect important discussions, may trump the autonomy of the patient, and is simply a concept that society (and the law) has not really come to terms with.

An opposing view comes from Schneiderman and Jecker in their book, "Wrongful Medicine". They argue that physicians have the duty in defined circumstances not to provide certain treatments based on doing no harm, non-beneficial effects, and their definition of futility. They point out that many specialty societies and hospitals now have futility policies in place.

I think the debate is healthy and that we will gradually develop robust policies in our hospitals and long term care facilities that can balance the sometimes conflicting ethical principles of autonomy, non-maleficence, beneficence - and come to some reasonable process of dealing with the futile cases in our ICU's. I suspect that in nearly every ICU in the USA, that there is a current or recent patient where this discussion applies. For the legal aspects of the futility debate please see Thaddeus Pope's excellent blog.

Now I have a question. Assume that our hospital does have a futility policy, assume that a formal Ethics Committee opinion on day 3 is that this patient's care is indeed futile. Should I tell the family that we plan to discontinue ventilator support and provide excellent palliative end-of-life care? Let's say the hospital policy gives them 48 hours to find another facility willing to provide on-going ventilator care (It's doubtful even with our help they can find one willing to take her). Are we ready to pull the plug against the wishes of the family and previously stated wishes of the patient?

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