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.

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