Futile Care Theory

[ZASHAGALKA]

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

[SitcomNurse, BSN, MSN, EdD, RN]

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.

For the amount of $$ some of us nurses agre to get paid, we may as well volunteer and let God apy the bills.

When I start thinking about the bottom line..cost effectiveness, I need to either change professions or go into management.

[UM Review RN, ASN, RN]

But, we can't just ignore the cost analysts, else they ignore us.

~faith,

Timothy.

Tim, I'm gonna say this gently: When in heck did they ever care about what we nurses thought, believed, practiced?

Nursing is not about monetary cost. Suppose for instance (and I hate putting myself out on a limb like this because suddenly everyone's arguing the example instead of the premise), my child has a terminal illness. Suppose a bone marrow treatment might save that child, but insurance doesn't cover. Without insurance, the treatment is upwards of $150,000.

(Sound familiar? It should because it's happened. This is not a futile care case at this point, but one that insurance companies have refused in the past because it was argued that benefits of this treatment were unproven.)

We raise the $150,000 and the child is in the hospital, has the treatment, and now gets an infection, which makes the child critically ill. We're at a decision point in the child's care and we have no more insurance coverage. Months go by and the child is only barely holding his own.

Does that mean that one arbitrary day, my child will go without treatment, since treatment is deemed ultimately "futile" by a certain group of number-crunchers?

I can easily see that scenario happening. IMO, just because it happens every day, doesn't make it right. I don't need to get on a bandwagon that's going in the wrong doggoned direction.

Posters please note: you might have skipped over that part of my previous posts in which I stated why I feel cost should not be part of the futile care debate, but that it should be decided on a case-by-case basis, irregardless of cost.

[Tweety, BSN, RN]

Does that mean that one arbitrary day, my child will go without treatment, since treatment is deemed ultimately "futile" by a certain group of number-crunchers?

I can easily see that scenario happening.

I don't see that hapeening. MD's have the final say in what is futile care and what isn't. Not number crunchers. In the case in Texas where the vent was removed from a child who couldn't breath and was severely brain damaged, it was the MDs that removed the vent, not the number crunchers.

What we have to decide as a society is do we want MDs to have that power.

And yes we have to consider the economic cost of futile care. But I'm having trouble visualizing the day the MDs surrender this decision to insurance companies.

[UM Review RN, ASN, RN]

I don't see that hapeening. MD's have the final say in what is futile care and what isn't. Not number crunchers. In the case in Texas where the vent was removed from a child who couldn't breath and was severely brain damaged, it was the MDs that removed the vent, not the number crunchers.

What we have to decide as a society is do we want MDs to have that power.

And yes we have to consider the economic cost of futile care. But I'm having trouble visualizing the day the MDs surrender this decision to insurance companies.

And you've caught my point, Tweety. If you start thinking "cost," you have to let the number-crunchers in. I probably don't need to remind you that they already have taken over. Remember who thought up DRGs? Doctors didn't give that decision away; it was usurped by accountants.

[bluesky, BSN, RN]

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.

ITA with this point. There are tradeoffs in this game, like it or not. Like keeping an old obese person who has treated themselves like crap for years on IABP and VAD for weeks and sometimes months to the tune of millions of dollars yet deny the most rudimentary cardiac preventive health care to a human being that doesn't have a job.

When I think of situations that need serious ethical consideration, I am thinking of a pt who has been coded and had their chest open SEVERAL times with end-stage chronic disease, anoxic brain injurry, and multiple system organ failure. Why let them linger for another week or two? It is a crime (figuratively) in the sense that it merely promotes their suffering and costs the healthcare system. I think that these types of comittees would be very useful in the ICU setting, not so good for the ER ( I have worked both).

[ZASHAGALKA, RN]

And yes we have to consider the economic cost of futile care. But I'm having trouble visualizing the day the MDs surrender this decision to insurance companies.

Except, as has been seen with HMOs, the bean counters have an amazing ability to place doctors under their thumb. . .

~faith,

Timothy.

[suebird3]

Love the thread, folks. One of my classes, Policy and Politics covered this. One thing that I thought of is "What happened before all the present technology came about?" IMHO, money may or may not be the final answer; making the patients comfortable is.

[caroladybelle, BSN, RN]

And you've caught my point, Tweety. If you start thinking "cost," you have to let the number-crunchers in. I probably don't need to remind you that they already have taken over. Remember who thought up DRGs? Doctors didn't give that decision away; it was usurped by accountants.

We don't "let the number-crunchers in". They are already here. If one gets a paycheck for a job in healthcare, then the "money-crunchers" are inside the house.

My question stands and no one has answered it.

If you believe that money should have nothing to do with availiability of futile care, when was the last time you offered up a large block of your time to work with patients undergoing a futile treatment...would you do so????? and not just at a time when it is "convenient", eg I am retired so I have the time.

But a time when it actually impede on your life and financial support.

Because that it was we are asking of the MDs, pharmacy companies, scientists, hospitals and others that must take these cases.

[NurCrystal22]

We don't "let the number-crunchers in". They are already here. If one gets a paycheck for a job in healthcare, then the "money-crunchers" are inside the house.

My question stands and no one has answered it.

If you believe that money should have nothing to do with availiability of futile care, when was the last time you offered up a large block of your time to work with patients undergoing a futile treatment...would you do so????? and not just at a time when it is "convenient", eg I am retired so I have the time.

But a time when it actually impede on your life and financial support.

Because that it was we are asking of the MDs, pharmacy companies, scientists, hospitals and others that must take these cases.

Actually, I think your question has been answered. Perhaps you should re-read the posts.

We all understand that it's about TIME and MONEY. However, the question is... IS THIS FAIR PRACTICE? REGARDLESS, of the fact that there isn't enough time and money in the world to support this practice.

I believe people here are simply offering their opinions. No one is right or wrong. If it were practical to give a large block of my time to work with futile care patients I would. And why CAN'T it be convenient? Why couldn't a retired nurse offer up her time to help those patients?

I think what most people are trying to say is that it SHOULDN'T be about $$$, but unfortunately it is. There's really nothing that can be done about it for the time being except for reviewing each case individually... but that can also lead to problems.

Anyways, thanks for expressing your view, I understand your point, I just disagree.

~Crystal

[caroladybelle, BSN, RN]

Well, then the answer is no.

That somehow we expect researchers to work for free, MDs to work for free, etc. because "we" mandate that is the right thing to do...but don't feel that "we" should have any financial/time/energy loss at all.

As far as retired nurses go, when was the last time you saw a retired nurse that:

Stayed licensed.

Was still physically and emotionally able to nurse the difficulty that "futile" cases are.

That were keeping up on the latest technology that such things require.

Was capable in the required types of nursing.

That had that much time to give.

That aren't burnt out...especially from dealing with "futile cases".

That didn't need the money much like the rest of us.

That wanted to deal with the liability issues.

Again, it is easy to say that it is right to do something...yet, take no responsibility for the problems that it imposes on others. To say, "Well, retired nurses can ....", yet ignore the fact that most nurses that are retired...are retired for a reason.

When are the "we" that are mandating actually start "doing" and making the sacrifices for what "we" mandate others provide.

[bluesky, BSN, RN]

Actually, I think your question has been answered. Perhaps you should re-read the posts.

We all understand that it's about TIME and MONEY. However, the question is... IS THIS FAIR PRACTICE? REGARDLESS, of the fact that there isn't enough time and money in the world to support this practice.

I believe people here are simply offering their opinions. No one is right or wrong. If it were practical to give a large block of my time to work with futile care patients I would. And why CAN'T it be convenient? Why couldn't a retired nurse offer up her time to help those patients?

I think what most people are trying to say is that it SHOULDN'T be about $$$, but unfortunately it is. There's really nothing that can be done about it for the time being except for reviewing each case individually... but that can also lead to problems.

Anyways, thanks for expressing your view, I understand your point, I just disagree.

~Crystal

I don't really think money is the only, primary consideration. The primary consideration is the suffering of the patient. Futile means absolutely gone on my unit. Not a child with an end-stage disease or someone with metastatic cancer, not someone with a poor prognosis . Futile is someone who has multiple organs that are never going to work by themselves again like their brains, their lungs, and their kidneys. Or someone with a heart that is so very weak that even the the CABG they got was too late and all they can look forward to is, at best, months in bed unable to move significantly because their reserve is caput. Gone is someone who during a stabbing lost oxygen to their brain for over 20 minutes, whose EEG shows massive diffuse brain injurry, who will remain in a vegetative state forever. Futile is someone whose liver is gone, who is not eligible for transplant or has failed livers already, who is bleeding from every orifice, requiring massive blood product supplementation for the week they have left. These days, weeks and occasionally months of pain and complicated interventions that you are giving these people are an insult to their humanity. I know, as a SICU nurse, I am the person who has to implement this care. You may speak of price and right and wrong, but I am the one who has to do the dirty work, and I'll tell you not a single one of these pts ever said thanks because they can't and they won't. I see what is at worst their agony and suffering and at best a long early sleep as close to death as you can get with the monitor flashing the numbers you want. People have this vision of a young, perfectly alert person in some end-stage disease being neglected and left to die. That is just not the real world situation, I am sorry. The fact that the complicated and painful, pointless interventions are expensive and use limited resources which could better be used elsewhere is true, but it is not my primary concern.

[psalm, RN]

...just recently the docs working with a pt. discussed with him and the family that he is at the end stage of his disease and to resusitate would be "medically contraindicated" because he will not get better or improve. We are having a very difficult time as it is with managing his pain q1h with IVP meds. We try to be positive around him but it is hard to see him going downhill for years.