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 "...no 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?

6 comments:

  1. I am not sure I agree with the way the question is posed. It is not clear that stopping is against either the wishes of the family or against the wishes of the patient. The family, as you describe it, is conflicted. So, stopping would be against the wishes of only some family members. Which ones are the authorized surrogates? The patient wanted to pursue all sorts of treatment options. But now that that hope is gone and she even lacks consciousness, it is unclear even she would want to continue under these circumstances.

    Your question, "should I tell the family that we plan to discontinue," can be answered affirmatively. You are likely to get assent to that plan. The tougher issue is whether you will actually discontinue if they object to your declared plan. In that case, 48 hours is probably not sufficient to find a transfer or to get a court order. Texas law provides 10 days to find a transfer. Virginia provides 14.

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  2. I think not, but as you are so aware, each case is different. Discontinuing ventilator support would be the LOGICAL decision but logic does not drive end-of-life decisions.

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  3. I agree with the difficulty that these cases pose. Although, I too often see that physicians are unwilling to actively promote their role in end-of-life decisions. We have a shared responsibility in the decision making process and in their care at the end of life, but we often don't acknowledge this or act upon it. For instance, even without a futility policy and even with her full code status, I don't see why someone who the team felt had no chance of benefit from "fruitless CPR" would actually receive chest compressions and other components of CPR beyond a basic assessment at the time of time of the code. A code may be called after 2 hours, 30 minutes, 2 minutes, or after assessment that further CPR would be unsuccessful after 10 seconds.

    There will always be hurdles to calling a code after 10 seconds, including that the MD may not be in the ICU at the time of the code or that the MD may not know anything about the patient. But far too often I hear about teams continuing CPR thinking that there is some magical time or number of compressions that they need to hit before they can say the code is called. It's the modern day "slow code" although I dont think anyone has coined a nice phrase for it.

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  4. I think the starting point should be the patient's code status. Because a DNR is a physician order, there are times (although admittedly rare) when the physician can write a DNR order, regardless of the family's opinion on the subject. Usually, for the sake of CYA, two Attendings must agree that the patient's condition is such that resuscitation efforts would be futile (not to mention brutal!)

    However, I do not think that a Hospital Ethics Committee should have any say making clinical decisions, including and especially discontinuation of treatment (even if treatment is futile). I served on my hospital's Ethics Committee for several years and the most we would have offered in such a situation is the opinion that it is ethically permissible to discontinue extreme measures and allow a natural death or perhaps the decision to continue extreme treatment measures for a patient in the last stages of a fatal disease is ethically questionable at best.

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  5. A few observations...

    1. Re family conflict, I agree Dr. Pope's points that (a) the wishes of patient appear to be unknown, and; (b) one appropriate surrogate should be identified who is in the best position to advocate for the patient's actual (or likely) wishes.

    2. While aiming for family consensus is the ideal, this process can also impede both surrogate identification and the surrogate decision-making in such cases. Surrogates for incapacitated patients should be identified as early as possible, and his/her role should be clarified with all stakeholders.

    3. Any hospital futility policy should follow applicable statutory guidelines (where they exist) or at least be consistent with the due process guidelines set forth in the AMA's Opinion 2.037 - Medical Futility in End-of-Life Care. Again, as Dr. Pope suggests, three days may not be considered "reasonable."

    4. If other life-sustaining measures had already been discontinued for this patient (transfusions, chemo, etc), intervening at the moment of death with a code attempt would have made no medical sense and could almost be considered duplicitous. This happens all too frequently in my experience.

    Thank you for sharing this case.

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  6. As a Stage IV breast cancer patient, I have done my advanced directive stating no heroic measures. When the time comes I will go into hospice. I have designated medical surrogates in case I am mentally incapacitated, and they know my wishes.

    However, although your real question is about medical ethics and what resources a hospital should be willing to expend in a hopeless case, I think your phrasing of "Should I tell the family that we plan to discontinue ventilator support and provide excellent palliative end-of-life care?" is a bad one. Phrased like that, you immediately put the conflicted family members on the defensive, and puts you in a light of refusing to heal.

    It is very important that the family be educated in the woman's condition, not only at end-of-life but all along if at all possible.

    It may take a lot more than three days for somebody to come to terms with reality and a "three day and you are out" policy would definitely make people who know about it think twice about choosing that hospital.

    Education is key and since one son seemed to understand, he should have been the one that was encouraged to help the family come to the right decision.

    There are no easy answers. I agree that an ethics committee should not be making clinical decisions. This should be left to the physician and the family.

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