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View the term 'futility' through different context
Case study illustrates dilemma
Hospital ethics committees could clarify and improve the way they handle issues involving life support in the intensive care unit (ICU) if they brought more nuance to any definition of the word "futile," an expert says.
"There are three ways that term can be used: physiological futility, where it just plain won't work; qualitative futility, which includes a value judgment that it's not worth it, and then there's a quantitative futility, which means that you're 99% sure it won't work," explains Robert D. Orr, MD, CM, director of clinical ethics and a professor of medical ethics at Loma Linda (CA) University Medical Center. Orr also is the co-chair of the Healthcare Ethics Council at Trinity International University in Deerfield, IL, a senior fellow with the Center for Bioethics and Human Dignity (CBHD) and chair of the CBHD's advisory board, professor of bioethics at the Graduate College of Union University in Schenectady, NY, professor of bioethics at Trinity International University in Deerfield, IL, and a professor of family medicine at the University of Vermont College of Medicine in Burlington.
The medical maxim that there is no moral obligation to provide futile treatment applies only to physiological futility, he notes. "The problem is physicians sometimes look at a situation and claim qualitative futility, saying, 'I don't think it's worth it to continue this ventilator on someone who won't ever wake up, so it's futile,'" Orr says. "But if the family says it is worth it to them to keep the family member alive despite the fact that there is a very remote prospect of any return of mental function, then I think we should generally support their desire."
There are exceptions to this ethical stand, including cases in which the patient is experiencing unrelievable suffering, he adds. Also, there might be no insurance or government payer to pick up the cost of keeping a person alive well past the point of reasonable hope for recovery, he says.
It's when cases move into these gray zones that ethics committees and consultants might be called in to help. "This is the biggest part of my job description," Orr says. "Just a few days ago, I spent two hours with a family and three physicians, a nurse, social worker, and four family members discussing whether or not to continue a treatment that is postponing a patient's inevitable death."
The patient had no advanced directives, and the patient's family insisted on continuing treatment, hoping for an unexpected improvement, he says. "The physicians said it was unprecedented to use this amount of medication for this amount of time," he recalls.
The patient was on a paralytic agent to keep his body paralyzed for the purpose of staying ventilated, and it had been going on for three weeks, Orr says. "With continued paralysis, the patient would lose any kind of muscle function and wouldn't come off the ventilator," he explains. "The family wanted to continue the ventilator and antibiotics, and they wanted resuscitation if his heart should stop."
The physicians knew that any resuscitative efforts would fail, but they wanted to avoid continued confrontation and conflict with the family, so they did not insist on a do-not-resuscitate (DNR) order signed by the family. Orr worked with all parties over two hours and helped them reach a compromise of stopping one of the patient's drugs. "They agreed to stop this one medication, which is almost certainly going to change the course of events," Orr says. "The decision was to wean the patient off the paralytic drug and not resume it."
This is a major clinical change that in most cases would lead to the patient's death, he says.
As an ethics consultant, Orr helped the family and medical team reach this compromise by first laying out some boundaries, including spelling out how this type of case is viewed from medical and other perspectives. "From a clinical, legal, and professional perspective, it would be OK in this patient to stop all treatment," Orr says.
In this case, stopping treatment is an acceptable action to take since there is no possibility the patient will survive and recover even with treatment, Orr explains. Because the medical team supports patient and family values, they are willing to do what the family requests unless it comes to a point where the physicians believe it is absolutely futile physiologically, and the patient is suffering because of the continued treatment, Orr adds.
In cases in which the patient has an advanced directive, then the medical team will side with the patient's wishes, unless the family can demonstrate a clear indication that the patient had changed his or her mind or had not had this particular scenario in mind when signing the advanced directives, he says. "We lean toward favoring the patient's statement unless the family can rebut it in some way, convincing us the statement doesn't apply in this situation," Orr adds.
An effective way to handle these ethical dilemmas is for an ethics committee and/or consultant to make an effort to understand where the family is coming from, he suggests.
"I put high stock in individual values, and that's necessary for a physician and ethics consultant," Orr says. "I try to show the family the implications for others and how this interacts with their own religious beliefs."
These cases are intensely emotional and should not be turned into adversarial situations, he says. "We're trying to work together here," Orr says.
In the case outlined above, he notes that the hospital team recommended that the patient be placed in palliative care. The family members did not object to the suggestion, but they were not happy with the idea because of a mindset that palliative care equals dying, and they did not think of their family member as dying, Orr says. "We emphasized that our goal was to make him comfortable regardless of the outcome," he adds.