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.
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.
I understand what you're saying about cost containment, and I agree that cost containment certainly has its place in medical discussions, but I respectfully disagree that it belongs in any discussion reviewing an ethical situation.
There are plenty of now-healthy people who do not pay their medical bills, and others who will not pay their medical bills, in a system that is PROFIT-DRIVEN, for the onus of the cost question to be borne solely by those whose continued maintenance could be said to be "futile."
If everyone paid their medical bills on time, if care was never done that was "too costly," if the standard of care was to refuse delivery of care to those who could not afford it, if all insurance was delivered by the government, then I would agree that cost had its place in this discussion.
I hope you understand my viewpoint better now. I already understand that you might probably disagree. I know that my viewpoint is way off-center from the usual ethical argument because those (wrongly, IMHO) weigh cost as a factor.
Finally, let me reiterate that I do agree that these cases should be reviewed and taken as a case-by-case basis, and that care should be terminated in some cases. I just disagree that the cost factor should ever enter into the discussion.
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.
How priceless is it when someone has lost most of themselves, is hooked up to a feeding tube, is incontinent, is unaware of what's going on around them, is contracted, moans all the time in pain? I agree that every life is priceless and should be cared for as if it was someone that we loved dearly. I do think that some family members either don't understand what they are putting their mom or dad's through or have a sense of guilt if they just " let them go". As someone who a year ago had to assist in making a "code status" decision on my 90 year old grandmother, I can say that even though we new it was the right thing to make her a DNR, it was a very difficult thing. She passed away in peace and I am at peace with that decision. Everyone has to be at peace with their decision. I've had to explain to families what a "code" looks like. Allot of them had no idea what it meant when they said " I want everything done". Allot of them thought that when you made someone a DNR it also meant stop all care which I explained to them that that was not the case at all. Sometimes it can boil down to just simply taking the time to explain things and be compassionate. Care should never be about cost.
How priceless is it when someone has lost most of themselves, is hooked up to a feeding tube, is incontinent, is unaware of what's going on around them, is contracted, moans all the time in pain? I agree that every life is priceless and should be cared for as if it was someone that we loved dearly. I do think that some family members either don't understand what they are putting their mom or dad's through or have a sense of guilt if they just " let them go". As someone who a year ago had to assist in making a "code status" decision on my 90 year old grandmother, I can say that even though we new it was the right thing to make her a DNR, it was a very difficult thing. She passed away in peace and I am at peace with that decision. Everyone has to be at peace with their decision. I've had to explain to families what a "code" looks like. Allot of them had no idea what it meant when they said " I want everything done". Allot of them thought that when you made someone a DNR it also meant stop all care which I explained to them that that was not the case at all. Sometimes it can boil down to just simply taking the time to explain things and be compassionate. Care should never be about cost.
Alot of people don't know what the terms DNR, palliative care, or comfort measures mean. Your right about taking the time to explain things and be compassionate.
Quote: 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.
That is actually true here in the states. It's just not practiced.
I've heard several people suggest that human life is priceless. Not so. Everyday, Gov't officials, engineers, pharmaceuticals, etc. set standards based on the value of human life.
If we recall this car, it might save 200 lives but cost 75 million dollars, is it worth it?
If we build this levy, it might save 1000 lives but cost millions a years to maintain.
If we set a national speed limit of 30 mph, it would save countless lives. Where is the tradeoff between lives and efficiency?
If we go to war, it might cost 3000 lives but save 50,000 down the road.
If we allow this drug eluting stent to hit the market, some people will die of anaphylatic shock, but many more will be saved by not having their stents re-occlude.
If we set this standard here (you pick, fire retardant mattress, the safety of a specific toy, piece of clothing, etc. etc.) it will cost more to make but might save more lives.
Everyday, tradeoffs are made between the cost of doing something and the effect of that cost on lives.
In truth, in each of the above scenarios, if human life was the overriding consideration, regardless of cost, then the products or services couldnt' be provided because they would be cost prohibitive.
And medical care is fast becoming cost prohibitive, growing at many multiples of inflation a year.
So, where do you draw the line? It's not a matter of IF the line will be or is being drawn, but where.
By 2040, social security will start to run in the red. So we are having a national debate about it.
Medicare however, at current costs plus anticipated rises greater than inflation, will be in chaos by 2020 and will bankrupt this nation at current levels by 2040. Where do you draw the line? The current line, near providing care at all costs and without monetary consideration, is simply unsustainable.
"Professionals" make decisions for you everyday that affect lives. The FDA, NIH, CDC -they couldn't function if the mandate was saving lives at all costs. Engineers couldn't build infrastructure if every decision was 'life-proof'. Allocation of resources couldn't trickle down if they all had to be spent on 'life-sustaining' measures.
How can we study diabetes when cancer can kill much quicker. Better to divert all funding to cancer research, otherwise, we are not placing a premium on life. Etc. Etc.
Everytime health insurance rises to pay for all care at all costs, there is a percentage of covered individuals that can no longer afford the coverage.
I've heard several people suggest that human life is priceless. Not so. Everyday, Gov't officials, engineers, pharmaceuticals, etc. set standards based on the value of human life.
But insofar as a purely theoretical ethical debate is concerned, it's not about what's practical or what is actually practiced, it's about what's moral. You may believe what you wish, but I take the position that human life IS priceless and that cost should not enter in on this "futile care" theory.
Why? Because money clouds the issue, as your examples suggest. If we start talking about cost, then we're not talking strictly about care, are we.
To paraphrase ala Star Trek: Fer gawd's sake, Tim! We're nurses, not cost analysts!
[Once again, for those of you who haven't read the entire thread, let me also clarify that in previous posts, my position is that each of these types of cases need to be decided on a case-by-case basis, and yes, I do believe in certain circumstances it is wiser to let go than to continue with care.]
How priceless is it when someone has lost most of themselves, is hooked up to a feeding tube, is incontinent, is unaware of what's going on around them, is contracted, moans all the time in pain? I agree that every life is priceless and should be cared for as if it was someone that we loved dearly. I do think that some family members either don't understand what they are putting their mom or dad's through or have a sense of guilt if they just " let them go".
Sometimes it can boil down to just simply taking the time to explain things and be compassionate. Care should never be about cost.
This is a debate that IMHO will never be settled because it is not black and white, there are too many grey areas.
I've had family say "just keep him alive, his son/daughter is trying to get here, they are coming from out of state, they'll be here in 1-2 days". The man had already been coded 2 times and was on a vent, in multi organ system failure. You know that the person who is trying to get there, had to have money DONATED to them to be able to afford the plane ticket and afford to have their disabled child (child requires 24 hour nursing care) placed in respite care services.
I've had family say "we want everything done and he will never be DNR", man is in persisitive vegetative state for years, fed by PEG tube, contractured so severely that he almost looks like a pretzel, but you know he is 100% service connected, and that his large disability check is going to the wife he was in the process of divorcing when he had the MI that eventually put him in this state. Sent to hospital at least 2 times a year for pnuemonia, (hard to prevent, he was so contractured, it was hard to prevent him from aspirating, no "good" way to position him). Worked in that NH for 2 years, NEVER saw or heard or seen written in the chart that he had a visitor. Social work greatly involved, along with ethics committee, but always comes down to it's the families right to judge for his care.
Two scenarios of family wanting everything done, and each evokes a totally different emotional response from me.
I think it's a case by case basis. And I don't think that there will ever be a right answer.
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
Even after throughly explaining, I think many times the family chooses to do "everything possible" because they are not ready for their loved one to pass. We had a patient who was a full code per the daughter's wishes. The patient was in her 90's, unresponsive, incontinent, contracted, had a PEG, and bedsores so severe that her flesh was actually rotting off. The smell was horrible. The docs and social worker tried to get the patient into hospice but the daughter refused. I felt terrible for that patient. Wondering about her quality of life. Eventually, she was transfered to a nursing home with a full code status.
But insofar as a purely theoretical ethical debate is concerned, it's not about what's practical or what is actually practiced, it's about what's moral. You may believe what you wish, but I take the position that human life IS priceless and that cost should not enter in on this "futile care" theory.
Why? Because money clouds the issue, as your examples suggest. If we start talking about cost, then we're not talking strictly about care, are we.
To paraphrase ala Star Trek: Fer gawd's sake, Tim! We're nurses, not cost analysts!
First, let me suggest that this isn't a theoretical debate; this is coming. In five years, EVERY nurse will have to be dealing w/ the concept of denying futile care.
2nd, We might not be cost analysts, but the costs analysts are going to be the ones making these decisions if we don't step up to the plate. Saying, 'Damn the cost, full speed ahead' isn't stepping up. It's putting our heads in the sands.
And I agree this will always be a grey area. It's a shifting line. Where does this line get drawn? I think nurses have a better idea of this than some cost analyst. But, we can't just ignore the cost analysts, else they ignore us.
Members of hubby's family just went through this situation. BIL, no hope of recovery, family was split right down the middle. Finally, wife said just what was to be done. Thank goodness hubby, daughters and I have all made clear our wishes and have it in writing. No horrible fights, no scenes, just want love and dignity in last hours.
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.
First of all, I know that someone has to foot the bill. I said in my original post that it comes down to MONEY. I quite positive that I stated that. I just feel that it shouldn't be. And that's simply just MY OPINION.
Second, I was just posing a question, using an exampe of a cancer patient, this question was for everyone. As a nurse if I could volunteer my services, I would. Unfortunately, that is not practical. But your veering from the question, should a patient be denied REGARDLESS of who has to foot the bill?
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UM Review RN, ASN, RN
1 Article; 5,163 Posts
I understand what you're saying about cost containment, and I agree that cost containment certainly has its place in medical discussions, but I respectfully disagree that it belongs in any discussion reviewing an ethical situation.
There are plenty of now-healthy people who do not pay their medical bills, and others who will not pay their medical bills, in a system that is PROFIT-DRIVEN, for the onus of the cost question to be borne solely by those whose continued maintenance could be said to be "futile."
If everyone paid their medical bills on time, if care was never done that was "too costly," if the standard of care was to refuse delivery of care to those who could not afford it, if all insurance was delivered by the government, then I would agree that cost had its place in this discussion.
I hope you understand my viewpoint better now. I already understand that you might probably disagree. I know that my viewpoint is way off-center from the usual ethical argument because those (wrongly, IMHO) weigh cost as a factor.
Finally, let me reiterate that I do agree that these cases should be reviewed and taken as a case-by-case basis, and that care should be terminated in some cases. I just disagree that the cost factor should ever enter into the discussion.