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.
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.
And that itself is another cost.
When I refer to cost, it is not merely financial.
How many healthcare workers do we lose to burn out? That retire because they just can't do it anymore.
How many healthcare workers do we lose to burn out? That retire because they just can't do it anymore.
Working in the SICU this past year has been a great dissapointment, it's true. My hospital is the local repository for all train wrecks in the Washington D.C. area (uh, I mean high acuity teaching facility) and my experience is thus a bit skewed. At least 50% of my pts fit the too sick to really graduate to even a semi-normal life ever bill. Another 25% are in the SICU for observation and aren't really that sick. Finally the last 25% are the inspiring stories that you wake up every morning at 05:00 A.M. for. My first and only "save" occured this weekend. A less than 20 yr old who got shot in the chest and lost 4.5 liters of blood and bought himself a R side lobectomy (90% post-op mortality). I worked that kid and his lung like a drill sargeant and today he was transferred to the floor on room air. I couldn't be more proud. You're right though, these cases are FAR too rare and certainly the exception.
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.
Except, as has been seen with HMOs, the bean counters have an amazing ability to place doctors under their thumb. . .
Excellent point. They day has already arrived that the bean counter insurance companies and HMO's say "we're no longer paying for it". They do this with non-futile care. "You should be home in two days with this kind of surgery and after two days we're not paying.".
So I suppose it's not a stretch to for them to say....."the care is futile and we're no longer paying". This could perhaps nudge MDs to say "yes, the care is futile and we must stop (i.e. I'm no longer getting paid to help you anyway)".
That is cause for concern.
Angie, unfortunately in your scenerio it's not the person without insurance that's getting the bite, it's those with insurance.
I think though as a society with such advanced medical care, we do need to think of the economic costs of futile care. Who decides what care is futile. Because medicine is full of stories of people who were told they were going to die, nothing more could be done, and their walking around today healed.
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.
Okay then, the answer for you is no. That's great. Careful about statements about retired nurses, two whom of which I am related to fit all of your little qualifications.
Well, the bottom line it is RIGHT to do something. I mean, I'm not gonna be the one to go into a room to tell someone "sorry, hopital can't cover this, you're gonna die".
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.
I see you def. of futile care. Good. Sorry you're patients don't say thank you, that's rather sad.
I'm just saying if a patient wants it, that should get it. Sorry people it's my opinion, i'm entitled to have it right? Aww... THANKS.
I'm looking at it from this stand point just so you know. I HAVE and aunt, and I emphasize HAVE because she is still alive when she shouldn't be. WHY.... EXPENSIVE, EXPERIMENTAL TREATMENTS, she HAD cancer, now it's GONE due to this "futile care". Doctor said she was going die but if SHE WANTED to, we could try one more thing. Glad no one came and told her it was FUTILE care. Glad I still have her.
I see you def. of futile care. Good. Sorry you're patients don't say thank you, that's rather sad.
I'm just saying if a patient wants it, that should get it. Sorry people it's my opinion, i'm entitled to have it right? Aww... THANKS.
I'm looking at it from this stand point just so you know. I HAVE and aunt, and I emphasize HAVE because she is still alive when she shouldn't be. WHY.... EXPENSIVE, EXPERIMENTAL TREATMENTS, she HAD cancer, now it's GONE due to this "futile care". Doctor said she was going die but if SHE WANTED to, we could try one more thing. Glad no one came and told her it was FUTILE care. Glad I still have her.
~Crystal
This isn't my definition. It's the definition of the physicians and nursing managers on the ethics committees who are pushing for these rights. I just feel that from your post you don't really have an understanding of the ICU or the patient population that we are talking about. I joked about their not being able to say thank you because they are not able because they will never speak to you again because their brain is gone and they are ventilator dependent. They are not alert and oriented, they are for all intensive purposes corpses whose physiological functions are being maintained artificially- thereby saying that they could say thank you is sarcasm. Why don't you come to my unit sometime to see what I'm talking about. I repeat no one is talking about the a&o X3 pts who are at end-stage of some chronic illness who you see in tele or whatever. We are talking about the very end of that road. It would be seriously unethical to try to influence those pts when they are still able to make decisions for themselves and I don't take it upon myself to comment on someone else's area of practice because I am not qualified. I am very glad your aunt survived. What she received was not futile care by the standards defined in the debate of policy makers.
Well, the bottom line it is RIGHT to do something. I mean, I'm not gonna be the one to go into a room to tell someone "sorry, hopital can't cover this, you're gonna die".
Thanks for sharing and caring
~Crystal
Is it truly "right" to do something in futile care. I'm not talking about "the hospital can't cover this and you're gonna die". I'm talking "you're gonna die...period, end of discussion". Then what is right? Is it right to give an emaciated dying person, whose gasping for air chemo, or even offer it? When they are on their last breath is it right to put a ventilator on them to make them breathe?
Palliative care? Supportive Care? Futile care? "too expensive and it's not going to make a difference care"? Who decides?
This is just another reason ALL people ,above the age of majority,need to have properly prepared living wills. So that regardless of their condition, they are able to "speak" for themselves. My husband had a massive cranial hemmorhage at the age of 56. Never ill, very sudden. On life support for 24 hours. His brain was literally destroyed. He was able to speak his wishes through his living will and I of course knew what his wishes were. If we had never prepared those or never discussed the subject at length, which we indeed did many times, the heartbreak of making that decision, horrible in itself, would have been so much worse..
I see you def. of futile care. Good. Sorry you're patients don't say thank you, that's rather sad.
I'm just saying if a patient wants it, that should get it. Sorry people it's my opinion, i'm entitled to have it right? Aww... THANKS.
I'm looking at it from this stand point just so you know. I HAVE and aunt, and I emphasize HAVE because she is still alive when she shouldn't be. WHY.... EXPENSIVE, EXPERIMENTAL TREATMENTS, she HAD cancer, now it's GONE due to this "futile care". Doctor said she was going die but if SHE WANTED to, we could try one more thing. Glad no one came and told her it was FUTILE care. Glad I still have her.
~Crystal
I think when there's experimental treatments that might possibly help, then the care isn't futile.
Perhaps the reason some of us aren't coming to agreement is we have differing ideas as what is futile care.
caroladybelle, BSN, RN
5,486 Posts
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.
And that itself is another cost.
When I refer to cost, it is not merely financial.
How many healthcare workers do we lose to burn out? That retire because they just can't do it anymore.