PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me Googling………to learn about FUTILE TREATMENT

PART 16. March 27, 2020. CORONAVIRUS. I am not a clinician or a medical ethicist but articles on Coronavirus patient triage started me  Googling………to learn about FUTILE TREATMENT

to read posts 1-16 in chronological order click on

CORONAVIRUS TRACKING – Jonathan M. Metsch, Dr.P.H. PARTS 1-16 (and prequels). March 28, 2020

More than ever let’s respect and appreciate all the providers who are protecting us under the most challenging circumstances.

“Providing futile treatment in the intensive care unit sets off a chain reaction that causes other ill patients needing medical attention to wait for critical care beds, according to a study by researchers from UCLA and RAND Health.

The study is the first to show that when unbeneficial medical care is provided, others who might be able to benefit from treatment are harmed,…

 “Many people do not realize that there is a tension between what medicine is able to do and what medicine should do. Even fewer realize that medicine is commonly used to achieve goals that most people, and perhaps most of society, would not value – such as prolonging the dying process in the intensive care unit when a patient cannot improve,” … “But almost no one recognizes that these actions affect other patients, who might receive delayed care or, worse, not receive needed care at all because futile medical treatment was provided to someone else.”” (A)

“Futility” means the absence of benefit.

a consensus definition of medical futility does not exist.

~80% of ICU patients who die do so as a consequence of a decision to withhold or withdraw life support.

it is more useful to consider the utility of any intervention (the balance of benefits and harms) rather than futility

TYPES OF FUTILITY

Physiologic futility — when a procedure cannot bring about its physiologic objective (e.g. when CPR cannot achieve a BP target) — involves a “value choice” of the measurement of organ function rather than the value of the outcome for the patient as the patient might perceive it.

“benefit- centered” futility — involves a quantitative estimate of futility is one in which an intervention is considered futile if it has failed in the last defined number of times attempted (e.g.  100 successful attempts as the threshold) or a qualitative component, where the patient’s resulting quality of life falls well below the threshold considered minimal by general professional judgment (e.g.  treatments which merely preserve unconsciousness or cannot end dependence on intensive medical care)

Operationalising futility — treatment that is so unlikely to succeed that many people—professional and lay persons—would consider it not worth the cost (aims to precludes individual caregivers from having to make qualitative or quantitative value judgments) (B)

“Doctors who were asked about causes of inappropriate care at the end of life didn’t have to look far to place blame. They blamed themselves.

Australian researchers interviewed 96 physicians from 10 medical specialties and asked them to describe situations when patients received end of life care that the doctors felt was inappropriate.

Futile medical treatment at the end of life has been shown to harm patients, cause moral distress to clinicians and waste scarce resources, as the researchers note in the Journal of Medical Ethics.

But 96 percent of physicians pointed to themselves – or “doctor-related factors” – as the main drivers of futile treatment. Poor communication, emotional attachment to patients and aversion to death were also among the causes they cited.

Patient-related factors were important, too. Ninety-one percent of the doctors cited reasons such as family or patient requests for treatment, prognostic uncertainty and not knowing the patient’s wishes as contributors to inappropriate care….

Close to 70 percent of the surveyed doctors also cited hospital-related causes, such as specializations, medical hierarchy and time pressure, as factors in futile care.

It isn’t a matter of one doctor stepping back and considering the overall health of the patient, explained co-author Benjamin White, a law professor at the Queensland University of Technology.

“There are many specialists involved, each focused on a particular organ,” he told Reuters Health. The narrow focus of the individual specialists can make it difficult to coordinate a patient’s care, he and his colleagues noted in their report.

Roughly one quarter of physicians said aggressive treatments are “hard to stop once started.”..

“We don’t know how to manage or negotiate it,”… “It is easier behind the scenes to complain that a treatment may be inappropriate, but we haven’t taken a step back to think if we are providing care that furthers a patient’s goals.”..

Pope urges doctors to present medical options in even-handed ways.

“If physicians are too aggressive, families are going to fall in line,” he told Reuters Health. “It’s emotionally hard for (families) to pass up what doctors say is a reasonable option. If they knew the real risks, benefits and alternatives, they may not pick the treatment they are receiving.”” (C)

“Because it is often used imprecisely, the term “futile” can cause confusion and exacerbate conflict in disagreements about end-of-life care. It is more helpful for patients, families, and physicians to discuss the benefits and burdens of medical procedures.

The term “medical futility” is widely used in end-of-life care, but it may be time for an update in vocabulary. In some cases, “medical futility” has exacerbated conflict between medical professionals and patients’ families, led to ugly litigation, and undermined trust in the medical profession. Better language is available, so it is time for the phrase “medical futility” to be restricted to the few cases to which it truly applies.

Every day in hospitals across the nation, physicians cite “medical futility” as a reason to withdraw or withhold life-sustaining treatment when patients—or, more often, their families—insist on continuing it. A procedure is properly called “futile” when the patient’s medical condition renders it ineffective, so that it cannot achieve the benefit it was designed to bring about. The term is typically applied to mechanical ventilation, assisted nutrition and hydration, and cardio-pulmonary resuscitation, but it is applied to many other treatments as well. The fatal error arises when medical professionals invoke “futility” to discontinue a procedure that may retain some benefit for the patient, but which nonetheless may not be worth continuing….

When physicians recognize that a treatment is ineffective, they have a duty to say that it cannot benefit the patient. Most patients and their surrogate decision-makers are not trained in medicine and, quite appropriately, cannot contribute to this kind of judgment.

The ethical discussion changes if there truly remains some medical benefit to performing the treatment. In that case, the treatment may help the patient to achieve goals of care, even if it does not cure the underlying condition. The decision to use the treatment is based not only on how well it works but also on what its benefit would mean to the patient and family. The patient and family are in the best position to judge what the benefits of treatment—even marginally beneficial treatments—would mean to them.

Members of the medical team might explain what they would do under the circumstances, without necessarily imposing their values on patients. They could offer thoughtful perspectives based on their values, not only on clinical judgments. Offering these values-based perspectives can be of great benefit to patients, surrogates, and families—but presenting such perspectives as if they were based on clinical judgment alone does not accurately represent the kind of judgment being offered…

There is no guarantee that such a discussion will prevent intractable conflict over end-of-life care. There is no language that automatically reconciles opposing views. Sometimes we can hope only that views are expressed and decisions are made with enough respect and transparency to avoid intractable conflict.” (D)

“Every day in intensive care units across the country, patients get aggressive, expensive treatment their caregivers know is not going to save their lives or make them better.

California researchers now report this so-called “futile” care has a hidden price: It’s crowding out other patients who could otherwise survive, recover and get back to living their lives.

Their study, in Critical Care Medicine, shows that patients who could benefit from intensive care in UCLA’s teaching hospital are having to wait hours and even days in the emergency room and in nearby community hospitals because ICU beds are occupied by patients receiving futile care. Some patients die waiting.

On one day out of every six, the researchers found, UCLA’s intensive care units contain at least one patient receiving useless care while other patients are unable to get into the ICU.

More than half the time, over a three-month period the researchers examined, the hospital’s intensive care units had a least one patient receiving futile care. The study shows the ripple effects of that futile care within the UCLA hospital and in surrounding hospitals where patients were waiting to be transferred.

“It is unjust when a patient is unable to access intensive care because ICU beds are occupied by patients who cannot benefit,” the authors write.

“The ethic of ‘first come, first served,’” they say, “is not only inefficient and wasteful, but it is contrary to medicine’s responsibility to apply health care resources to best serve society.”..

This is a third-rail kind of issue. Some might say we dare not touch it. How do you confront that?

The only solution I can think of is to shed as much light on it as possible and allow the warts to show. Be very explicit about what we’re talking about – using a machine to keep someone alive who will never wake up or leave the ICU. And let the public decide if they believe that medicine should use resources toward that end, especially if there’s an opportunity cost to others. Maybe these conversations on futility are all wrong, that’s what medicine should be doing. Let’s discuss that out loud and not pretend we’re not using resources in this way.” (E)

“In most cases, this goal of prolonging life is intended to give the patient a chance to recover or achieve another goal. Good communication is crucial to resolving these conflicts, but can easily be undermined by failing to understand how the words used reveal each side’s positions and interests. Here are a few statements and questions I have overheard over the years.

 “There’s nothing more we can do.” Families may interpret this to mean the team has given up on the patient. What needs to be explained is that efforts to cure the patient have failed and the technology used to sustain the body long enough to facilitate a recovery are not able to serve that purpose. What remains to be discussed is what alternative purpose the technology should have, if any. Also to be discussed is whether that purpose aligns with what is important to the patient and what the medical team thinks should be done with limited resources.

“Would you like us to do everything?” This statement puts an enormous burden on families to make life and death decisions. Many families do not want this burden because they do not want to be responsible for determining whether their loved one should live or die. The question is also quite vague. It is neither clear what “everything” means nor what “doing everything” would accomplish.

“I don’t have a crystal ball” This claim is often heard when families ask physicians for a timeline to see signs of improvement or deterioration. It may also be heard when families ask about how long a patient is expected to survive with or without life-sustaining treatment. Saying this allows physicians to then hedge when it comes to making these predictions, but also gives families a sense they are not being heard.

In these situations, families likely want to hear suggestions for what they should be doing to prepare for their loved one’s death. Their goal is to plan for next steps and the team’s recommendation is a vital part of that process…

Patience is needed on both sides to try to understand what is being said and not said. Clinicians can help avoid miscommunication by thinking carefully about how they are presenting information and avoiding stock phrases that create more confusion than clarity. Families can help by asking clinicians to explain what they mean by some of these stock phrases and trying to be open to hearing bad news when delivered compassionately.” (F)

But here, we want to stress the critical role of doctors individually and the medical profession, and the opportunity to bring about change.  First – and we think this is critical – doctors themselves are pointing to their own behaviour as an important factor to be addressed, as well as the way tertiary hospitals currently operate.  Doctors are owning the problem, and not just blaming this phenomenon on patient/family demand or the law.  Secondly, change will not occur unless doctors are prepared to act and to lead.  It is not enough to educate the community about the limits of medicine or the importance of ‘a good death’ and so on.  Doctors should not be offering treatment that evidence tells us will not work.  They should stop ordering routine tests that will not alter treatment or affect patient outcome.  They must have the difficult conversations with patients and family instead, notwithstanding how long this conversation may take, or how many times they may have to have it.

This call for action and leadership by doctors does not mean that patients and families are irrelevant and should not be involved in the decision-making process.  On the contrary, they need to understand the medical diagnosis and prognosis and what to expect as they or their loved one approaches death.  And as we have argued elsewhere, futility is a subjective concept so engagement with patients and families about their values and goals of treatment is essential.  As identified by many doctors in our study, communication is the key.  And, of course, doctors need to be supported institutionally to do this.  Taking the time to have the conversations need to be recognised as part of their day job, and valued as highly as reducing surgery waiting lists or efficiencies in emergency departments.”  (G)

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