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By Julie Crawshaw
Compassionate care in the icu accounted for nearly 20% of the papers presented at the 30th International Educational and Scientific Symposium of the Society of Critical Care Medicine in San Francisco last February. As Leslie Mary Whetstine, MA, pointed out in her paper "End-of-Life Care Considerations in the ICU," the problems associated with defining medical futility need to be reviewed in light of the ethical theory behind it in order if the clinician is to make correct and compassionate choices.
"Whetstine says that claiming authentic medical futility is a dangerous and often misused argument at the end of life. Clinicians should "familiarize themselves with the concept of futility, how it affects medical decision making for the patient and family, and what one’s obligations are as a clinician when dealing with authentic medical futility."
She describes the ethical theory behind medical futility as having the following components:
• A treatment is considered medically futile and should not be offered if it violates recognized standards of care or will fail in strict physiologic terms to support hemodynamics of metabolism.
• A treatment that is physiologically effective in holding death at bay for a "reasonable" amount of time may not be considered medically futile, even if the time involved is a matter of hours or days instead of months and years.
• Clinicians should consider the quality of life that results from the treatment. The patient’s conception of his or her own quality of life is authoritative and staff members cannot unilaterally decide what quality of life is or is not acceptable for an individual, even though most people do not choose medical interventions that would severely compromise their quality of life.
• A treatment with an extremely low probability of success may be considered futile, though this consideration does not carry as much weight as the components above.
Because courts and many medical ethicists have tended to favor the first two definitions, Whetstine says that clinicians are well advised to do so also until legal clarification becomes available. "Making a strong case for futility is difficult under current social, political, and legal traditions, and until the criteria and the public consensus change, this argument may not be one that will be useful but for a handful of instances. Invoking futility is often a lose-lose argument that may alienate the clinician further from the family when, in the end, it is likely that the clinician will have to abandon that position, with many relationships having suffered," she says.
Robert Burt, JD, of Yale Law School observes that "when consensus has failed, the futility argument is raised at the bedside." As an example, the legal history of futility, Burt cites the case of Baby K, an anencephalic baby brought to a Virginia emergency room. The parents wanted physicians to intubate and ventilate their baby and the courts ordered physicians to comply, even though the physicians believed the interventions were medically futile.
Burt observes that courts usually order the treatment that families request because they don’t want to be involved in patient death. However, judges and juries have historically been reluctant to punish physicians who withdraw therapy.
Physicians specializing in intensive care could save thousands of lives each year if only hospitals would hire more of them for ICUs, according to a presentation at the recent meeting of the Society of Critical Care Medicine in San Francisco.
John Hoyt, MD, an intensivist at St. Francis Hospital in Pittsburgh and chair of the new foundation, announced the group would be spearheading an effort to change the way ICUs are organized. Only one out of seven of the 5000 ICUs in the United States are led by an intensivist, he says.
Intensivists gained more attention when the Leapfrog Group, a California consortium of health care purchasers, called for more of them as a way to improve patient safety. The Leapfrog Group has estimated that some 58,000 lives could be saved annually by staffing ICUs with specialists, computerizing the filling of prescriptions, and referring complex operations to high-volume medical centers.
Most hospitals, 85%, employ a full-time intensive care nurse to run the unit, he says, with physicians in each specialty treating individual patients. But Hoyt says recent studies indicate patient care can be improved by employing a specialized intensive care team led by a full-time physician, and including a dedicated intensive care nurse, pharmacist, and respiratory therapist. That dedicated team can also reduce errors and decrease deaths, he says.
Hoyt says the group wants to increase the number of ICUs led by an intensivist to 50% in the next five years. The group plans to raise $1.5 million to educate the public about the need for intensivists, conduct research into the improved safety of having an intensive care team, and convince medical professionals to train for this specialty.