Futile Care Theory

NurCrystal22 · Aug 28, 2005

Hello Timothy.

You are right. This topic needs to be discussed so I would like to offer my opinion.

First... the term "futile care" bothers me. Who is to say that the care is futile? If the care is never given then we don't know if it had the possibility to save the patient's life.

I believe that the patient, or if he/she is incapable of making decisions, his family should have the right to decide if life-sustaining or life-saving measures should be implemented. Unfortunately, this right is being given to medical ethics boards all across the country. Perhaps if people on these medical ethics boards put themself in the position of the patient, they would realize that if a person wants to fight their illness by "any means necessary" then they should be allowed to. Where is the empathy?

And what are the options of a person who is denied treatment? Can they sue the hospital? Sure. But the likelyhood of winning a case is slim, not to mention attorney fees, and the length of time it may take for the case to play out in court. By then, the patient may have run out of time and even money to try to continue to fund their medical care. Correct?

Sorry, back to the point. So why is this occuring? Well it seems to me, in the beginning, ethics boards gave patients the right to say NO to unwanted interventions, treatments, procedures, practically anything... but now they have begun taking away the right to wanted treatments. WHY? Because these ethics boards have took it upon themselves to decide if people have lives worthy of continuing. You all have heard of it, QUALITY OF LIFE... and furthermore, if this quality of life is worth SPENDING MONEY on. Because that's what it all comes down to, MONEY. Does the hospital have the reserves to keep treating a terminally ill or critically ill patient, and if there is a growing number of patients that wish to receive extensive medical treatment, how much money is the hospital going to have to spend? It's almost an immeasurable number, and it's obviously not worth it to them, which means the patients LIFE isn't worth it to them.

That leaves, what can be done about it? I don't have the answer. What are your thoughts Timothy and anyone else with an opinion?...

~Crystal

beesnest · Aug 28, 2005

I would be interested in research about specific situations and the probability of someone surviving an arrest. For example, if someone is over 80 years old what are the chances they will survive the arrest, or be able to leave hospital? I bet its's less than 1%. If families had access to that information they would be able to make an informed decision instead of one based on hunches and hope.

NurCrystal22 · Aug 28, 2005

I would be interested in research about specific situations and the probability of someone surviving an arrest. For example, if someone is over 80 years old what are the chances they will survive the arrest, or be able to leave hospital? I bet its's less than 1%. If families had access to that information they would be able to make an informed decision instead of one based on hunches and hope.

Well, this is just me, but I'm not going to base my decision on statistics or probability. Every individual is different, and I feel that a person's spirit can carry them a long way. And what is wrong with having hope? I know that if it were MY 80 year old grandmother in the hospital, if she wanted resuscitation orders then, regardless if she would PROBABLY die or not, I think she should have them. Because most people like to say "Well, I did everything I could... we did everything we could to save him/her". However, if she had DNR orders and that was her wish, then fine. But that's just me. Perhaps if families did have information about facts, and stats, and probability, it may change their mind.

Anyways, I guess what I was really talking about was terminally ill patients. For instance, lets say that a person had very aggressive cancer.... and MOST LIKELY he/she would not survive it. But, let's say he/she has heard of an experimental but very expensive alternative. Should he/she be denied access to this treatment because his/her doctor and/or the hsopitals medical ethics board feels this is futile care? What do you think?

~Crystal

caroladybelle, BSN, RN · Aug 28, 2005

http://www.zmag.org/content/showarticle.cfm?SectionID=47&ItemID=2087
Should a doctor or hospital ethics committee have the right to end aggressive treatment in hopeless cases, despite the wishes of patient or family?
Indeed, in my last ACLS course, it was pointed out that offering ACLS is not a requirement if the medical team believes it to be a useless effort. It is a method of treatment that only has to be offered if there is a realistic chance of its success.

Actually, this has already been addressed in several states. The Courts in some places have been given the right to override family wishes and end treatment of some cases.

Someone correct me, but did then Governor GW Bush sign something in Texas that permitted a hospital to take a critically ill baby off life support, against the mother's wishes? There was some discussion regarding this during the Terri Schiavo situation.

There was also a case of a twelve year old diabetic child in Sarasota. She had severe brain damage following a DKA incident. The family wanted to keep her on artificial support and the facility/MDs ruled to dicontinue heroic measures.

While hospitals/MDs rarely go against family/patient wishes due to fear of litigation, there is no legal obligation in many places to provide "futile" care. As a general rule, for an issue to fall to Ethics committee it has to be quite egregious.

And, yes, there is futile care in our current system. After you have watched them code the same 90 year old patient with a PEG, Trach, contractures and massive bed sores, over and over, you begin realize what futile is.

In addition, MDs frequently decline to use futile treatments.

SitcomNurse, BSN, MSN, EdD, RN · Aug 28, 2005

http://www.zmag.org/content/showarticle.cfm?SectionID=47&ItemID=2087
Should a doctor or hospital ethics committee have the right to end aggressive treatment in hopeless cases, despite the wishes of patient or family?
I have heard it said that futile care will be the next radical debate in healthcare over the next 10 yrs.
Indeed, in my last ACLS course, it was pointed out that offering ACLS is not a requirement if the medical team believes it to be a useless effort. It is a method of treatment that only has to be offered if there is a realistic chance of its success.
We will all have to address this issue in our practice in the coming years.
What do you think?
~faith,
Timothy

Futile Care? Hmm.. Caring isnt futile, but some medical procedures are. thats how I feel about it.

I have preformed futile CPR on a body deceased for greater than 15 min, on a man older than 75. No he didnt make it. But it is all about doing what the patient wishes. I did the CPR to textbook style.

How about the guy with a GT, going to dialysis 3x weekly, losing his teeth every time we get him new ones, severe end stage Parkinsons, Unable to walk or stand without assist? Only in his 60's.

We ran that code too. I started the IV.

Who is to decide when life is valuable? Isn't there enough of that debate over fetuses? Now we are going to have legistators telling us when life is starting AND stopping...

too many ramifications.

:uhoh3:

:nurse:

caroladybelle, BSN, RN · Aug 28, 2005

Anyways, I guess what I was really talking about was terminally ill patients. For instance, lets say that a person had very aggressive cancer.... and MOST LIKELY he/she would not survive it. But, let's say he/she has heard of an experimental but very expensive alternative. Should he/she be denied access to this treatment because his/her doctor and/or the hsopitals medical ethics board feels this is futile care? What do you think?

So are you going volunteer to donate your services as a licensed nurse - free from any compensation - and pay out of your pocket for that patient's treatment?

Because in the end, someone has to foot the bill for all these treatments. If it doesn't come directly from someone, it comes from increased insurance costs, increased medical fees, etc.

UM Review RN, ASN, RN · Aug 28, 2005

So are you going volunteer to donate your services as a licensed nurse - free from any compensation - and pay out of your pocket for that patient's treatment?
Because in the end, someone has to foot the bill for all these treatments. If it doesn't come directly from someone, it comes from increased insurance costs, increased medical fees, etc.

Why is it that in every medical ethics debate, the "cost card" is ultimately played?

It's not about money. It's about doing the right thing. Many of the treatments and the information that we have today were once considered so cutting-edge that they were only performed on patients whose prognosis was nil.

Years ago I saw a 16-year-old leukemia patient's doctor give a 40 ml IVP of some nasty orange-colored stuff containing a form of orificenic. She died 3 months later. But because that family and others like it opted for heroic, expensive measures, young leukemia patients can live longer or even be cured.

So how do we put a price on a human life? If we do value life as priceless, then the saving of it is certainly affordable. It's the maintaining of it that might give us pause. The anencephalic baby, the elderly dementia patient, the comatose end-stage liver disease patient who is unable to receive a transplant....

I think that yes, there should be an end to aggressive treatment for certain individuals, but this needs to be determined on a case-by-case basis, without weighing cost into the equation.

beesnest · Aug 28, 2005

I think that we need to realize that resources are limited, no matter what we might want.

If healthcare has a set amount of resources, and keeping a 90yo alive for another week will prevent prenatal classes from being available next month...I don't know...

If we had the hard numbers about whether that 90yo will even live, let alone know who and where she is we could all (family included) talk about the situation in a more sensible way. I'm not saying that family shouldn't get to decide, just that they should have the facts, rather than some MD's statement that can't bring himself to talk about DNR.

caroladybelle, BSN, RN · Aug 28, 2005

Sigh!!!!!

The point that I was trying to make is....

that it easy to talk about doing "the right thing" when it involves someone else's time...someone else's skills....someone else's resources.

What about when it is yours'?

We hear every gripe on this BB about not getting paid enough, not getting our required and unpaid breaks, being not paid for call time, etc. How many of these people pushing expensive and "futile" treatments for people because it is "right" would work a full unpaid schedule for a couple of monthes taking care of that "experimental" BMT patient, to watch them suffer, lash out in anger and die. Frequently in much more discomfort and with their life frequently shortened by the treatment.

For a stranger and no pay.

Which is what in essence, we would be asking others to do.

If you want to push the "everyone deserves any treatment that they want", then you need to be willing to front the free use of your time to do them.

Tweety, BSN, RN · Aug 28, 2005

Futile care is care that doesn't alter the outcome usually death. There is a bit too much of that going on in my opinion.

To me it isn't about deciding whether someone's life is "valuable" or not.

Suppose there's no cutting edge treatments. Suppose someone is eaten up with cancer and is going to die no matter what. Why woiuld you want to be aggressive with surgery, chemo and radiation?

I recently took care of a patient with a brain tumor, which biopsy showed had mets from the lung. Also mets to the liver. She was 80 years old. I sent her to surgery for a resect of her tumor, and the day before sent her for radiation. She was confused and the oncologist said it was too late, the cancer had spread to far, to too many organs. Her treatment is not going to prolong her life, isn't going to improve her quality of life at the end, indeed will cause pain and yes will be an unnecessary expense to a society and increasingly can ill afford it.

Yeah, if there's a cutting edge experimental treatment that offers hope, then yes, that should be offered because that doesn't necessarily fall into the definition of "futile". Many presumably terminal AIDS patients were brought back from the brink of death in the 90s because of the new drug cocktails which at the time were experimental.

It could be a slippery slope as to what consitutes futile care and who decides.

DusktilDawn · Aug 28, 2005

Futile care is care that doesn't alter the outcome usually death. There is a bit too much of that going on in my opinion.
To me it isn't about deciding whether someone's life is "valuable" or not.
Suppose there's no cutting edge treatments. Suppose someone is eaten up with cancer and is going to die no matter what. Why woiuld you want to be aggressive with surgery, chemo and radiation?
I recently took care of a patient with a brain tumor, which biopsy showed had mets from the lung. Also mets to the liver. She was 80 years old. I sent her to surgery for a resect of her tumor, and the day before sent her for radiation. She was confused and the oncologist said it was too late, the cancer had spread to far, to too many organs. Her treatment is going to prolong her life, isn't going to improve her quality of life at the end, indeed will cause pain and yes will be an unnecessary expense to a society and increasingly can ill afford it.
Yeah, if there's a cutting edge experimental treatment that offers hope, then yes, that should be offered because that doesn't necessarily fall into the definition of "futile". Many presumably terminal AIDS patients were brought back from the brink of death in the 90s because of the new drug cocktails which at the time were experimental.
It could be a slippery slope as to what consitutes futile care and who decides.

In Tweety's first scenario, I agree, why put someone like this woman through treatment that will only prolong suffering and the inevitable, if the treatment is ultimately of no value. I have seen too many examples of patients, despite their wishes, subjected to treatments because it was what the family wanted.

In the case of an experimental therapy or treatment, I also agree, why not if that is what THE PATIENT WANTS. I have also seen this first hand where a patient that I thought would be dead in few months time make a complete turn around and a year later was healthy. No, this wasn't an AIDS or cancer patient. Yes, I believed that this person's situation was hopeless, glad I was wrong, good thing HE made the decision about what treatment he wanted.

I could be wrong about this but I'm sure in Canada, if a specific treatment IS OF NO BENEFIT to a patient, a doctor does not have to provide it. I don't have a problem with treatment if it is beneficial to a patient, I do have a problem with continuing the treatment when it ceases to be of benefit to the patient. I've seen examples of continued treatment that had ceased to be of benefit for the patient and despite the fact the patient didn't want to continue treatment, their wishes were ignored.

Ultimately I feel it is up to THE PATIENT to decide what course of action THEY CHOOSE to follow. If the patient is unable to speak for themselves, the situation needs to be explained throughly, for example, "surgery would only prolong the inevitable and the patient would only suffer more for a longer period of time."

I have seen situations resolved that involved doctors, hospital ethics commitees, patient & family, or just the family (if the patient was unable to speak on their behalf) resolve issues involved in continuing care that would ultimately be of no benefit. In the end, usually treatment was ceased because that was what the patient wanted or the family realized it was futile, either the family came to realize that the important issue was what the patient wanted or what was in the best interest of the patient.

I have more of a problem with the patient's wishes being ignored or families continuing treatment because no intervention was done to educate them or discuss their feelings or beliefs about the situation.

Frankly the thought of a doctor or hospital ethics committee deciding without patient or family input scares the hell out of me because it would be these people deciding what treatment would be "inappropriate".