Futile Care Question For You
So I’m reading this post by The Happy Hospitalist (note: he sure does complain a whole hell of a lot for being ‘happy’) and I’d like some medical ethic weigh-in.
The HH describes an 88 year-old man whose heart stopped, so his brain didn’t get any oxygen. According to him, the wife believes the patient will make it home. According to HH, that’s an unrealistic expectation. So doesn’t this qualify as futile care? That the treatments involved will not meet the goals of care? And doesn’t a physician have a right not to provide care that is seen as futile? And also, doesn’t a physician have an obligation to “first, do no harm?”
I guess I’m asking from multiple perspectives, so I’d really like to hear people’s thoughts on this, from the ethical perspective, the legal perspective, and the practical perspective.
Teams I’ve been on have certainly done just as many treatments for people in situations like HH’s patient, so I’m not trying to call him out or anything, I’m just genuinely curious how others think through all of this. Thanks!
One of the reasons I hated my MICU rotation was because of the fact that I found myself taking care of patients like HH (or breathing cadavers) time after time. And they all died…after “suffering” from more diagnostic procedures a.k.a salvage medicine.
Technically, no one can accuse you of doing harm if your team agrees with the treatment plan and it is in accordance with the patient’s wishes. However, it may be tough to discern if you are truly doing harm because labs from these patients are always out of wack. You do have to wonder if continued treatment is doing more damage or the organs are just failing.
From a practical perspective, i say stop supportive treatment. Unless there is a miracle, patients like HH never come back and we spend 3,4,5 thousand dollars/night on them, take up ICU space and (the most painful part), extend their families hopes for no reason at all.
From a legal point, you may refuse some treatment if you feel it is futile but I think you are still obligated to provide some basic support and pain care. I’m not sure about this but I AM sure there is no way on earth I’d specialize in critical care or palliative care.
Overall, as physicians or physicians to be, I think the appropriate thing would be to educate the family and provide the care desired. if this is deemed futile by the MD, the MD should consult with colleagues. If the futility of the treatment plan remains the persisting conclusion, then the MD should explain this to the family and can go further to discuss this with the institution’s legal team. Those guys usually have an answer. Believe me, I did this for 8 weeks.
In our hospital, we have something called an “ethics team consultation” for things like this. Generally, this will be ordered when a physician feels the level of care for a patient is inappropriate given the futility of said care. The multi-disciplinary team discusses the case, chances of survival, chances of making meaningful recovery with heroic treatment, things like living wills and expressed patient wishes prior to becoming incapacitated, and ethical concerns with discontinuing or continuing some or all forms of non-comfort-care treatments (standard comfort care treatments include supplemental oxygen through nasal cannula to prevent air hunger, turning every 2 hours, rectal tylenol for temperature fluctuations, and morphine/roxinol).
The family gets involved and then the team discusses the findings with the family and makes a non-binding, informal recommendation which they can choose to follow or not choose to follow.
In the absence of a written living will, it’s hard for a doctor to singlehandedly discontinue heroic treatments though if it is not the next-of-kin’s wishes. I can’t say I’ve ever seen a doctor say ‘pull the tubes’ while the family protested.
Graham several things. In the perfect world that you believe exists I could extubate this patient who hasn’t got a chance and all would be good and dandy. Now back to reality.
In my state of practice I have ZERO protection from extubating a patient against the wishes of a POA.
ZERO protection.
As my hospital lawyers tell me. If I do it, and the POA sues my ass, I have no legal grounds of defense in my state of practice, regardless of how futile the care is.
Futile care simply exists in your utopia.
So you will NEVER find me or any doc in my state who will extubate a patient with the intent of end of life care without the consent of the POA. I simply don’t have a legal protection to do that, no matter how futile the care is.
That is reality.
As far as being Happy. I love my job because I have exited the fixed pot of payment called Medicare Part B, with a great lifestyle to go withit.
My complaining is hardly that. It is educating others on the major pitfalls that plague our system which has been categorically decimated and destroyed by government intervention.
Real practice is so different from school.
There simply is no comparison.
I should say that ethics team includes at least one of the patient’s doctors and usually a neurologist if brain death or very poor EEG findings are involved. There is at least one layperson trained in medical ethics, the case manager or social worker for the patient, and the patient’s nurse if possible. Doctors may, in addition to actual data from the patient’s chart, present research articles, discuss the projected quality of life for the person and other such things.
There was one meeting I sat in on where the doctor wanted comfort cares only for a profoundly mentally retarded young man who’d never spoken nor walked nor fed himself who had ?urosepsis or something and the team recommended full cares because baseline cognition of an infant was not enough to say care was futile, so the recommendations disagreed with the doctor’s.
In line with what HH just said, if Graham or someone else said “Nurse K, help me pull out this patient’s breathing tube, the care is futile”, I’d tell him Hell no if the patient’s POA was protesting, even if I agreed that the care was futile.
In fact, I’d probably physically prevent the doctor from doing so if I had to.
I certainly don’t believe any perfect world exists, besides in the movies. Just looking for opinions!
In a slightly related story, this kinda brings up my first code as an intern. I was at the VA, and a local politician had a benign nodule taken out of his colon. His roommate (he was in a room with four other guys – socialized medicine after all, but I digress) called the nurse to report that when my patient was sitting up to eat, he just keeled over and didn’t look so good. (Side story – turns out his roommate – who was NPO – first went over and ate the guys food, THEN called the nurse, but again I digress).
I started the code, then stood back while the code team took over. After 45 min of no response, they called it. Then, as the last flea was walking out, he put his finger on the femoral artery and called out “I got a pulse!”
Long story short, after 5 weeks in the ICU and gradually declining EEGs, the patient’s hypoxic brain slowly turned to jelly and he died, again, having never regained consciousness.
Lesson learned, when you’ve done all you can and call it… turn off the monitors (it can be difficult to explain PEA to a family) and stop touching the patient.
I love how nurse K is always tooting her own horn. In reality about 90% of all medical bloggers know she is a co-workers worst nightmare. I love how she is always going to “physically” stop someone, including the doctors, from doing something. It mus tbe great to be as good as she thinks she is and be able to physically attack doctors at will, just because you’re so good.
In reality I bet she is as timid as they come. She sure as hell has no upper hand over any doctors.
In Canada we actually have a real law that says no health care provider can be sued if they refuse to provide treatment if that treatment is futile.
Despite the legal protection most docs don’t have the balls to even whisper “this care is futile” to a patients family.
This is why I always laugh when I read a doc blogging away about patients families that refuse to stop treatment.
The families have no say in ANY treatment. Docs tell the patient and the family what treatments are being done. If a patient or a family try to get involved in treatment choices we then get to read docs blogging about dumb people interfering with their medical judgment by having the audacity to say they read some stuff on the internet. So patients and families are just too stupid to be trusted to make treatment choices when there are choices but suddenly when the doc has nothing left to offer patients and their families become insightful, deeply intelligent medical professionals responsible for making fatal treatment choices.
If doctors would be honest and stop couching everything they say in bs legalese maybe patients and their families would be able to say enough is enough.
I have worked in the ICU for twelve years. I have had patients literally rotting in the bed, toes and fingers snapping off, comatose wholly dependent on tropes with end stage multiple organ failure and the docs go in to the conference and mumble some bs and then tell the family “the patient is very, very sick”. When the families reach out for anything these docs always say “we can always hope”. Then they skip happily out of the room as if they have accomplished some thing.
I have forced docs to admit that they have no further treatments to offer but in 12 years I have never got a doc to say “we need to stop this is futile” despite the fact we have on hand on a laminated card the law that states we have NO OBLIGATION to provide treatment if we believe that treatment will be futile and will prolong death.
These docs are trained to believe death is a disease and like all diseases should be treated and when it all becomes futile the docs disappear and the patient gets forgotten and the nurses bear the brunt of caring for the living dead.
Just because a doc couldn’t accept the blow to their ego, couldn’t accept that death is natural, couldn’t accept that their treatment failed.
Stop blaming the patients and the families..they are only doing what you TOLD them to when you said there is always hope.
Next time try telling them there isn’t any hope and it’s time to stop. Be firm. You would be amazed.
How do I know this? Because as an ICU nurse I am the one that eventually tells the family the jig is up and guess what? By the end of the day we are pulling the tube and ending this travesty created by cowards.