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

[bluesky, BSN, RN]

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..

And thankfully most of the patients I see are wise like your husband. I am so sorry for your loss- that must have been so sudden and shocking.

[caroladybelle, BSN, RN]

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.

l

First, I am still alive 20 years past my socalled expiration date because of "experimental treatment". Experimental does not equal futile.

If the patient wants to have it, they should get it.

EXACTLY WHO IS GOING TO PROVIDE IT?????

There are hardworking people in this country, that do not have heat, that do not have a place to live, that do not have food for their children. They want it .....so why can't they have it???

[elthia]

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?

I've seen patients who are DNR/DNI, kept alive in a comatose state for days by the use of bipap. It's still artificial ventilation, the only difference is one is invasive, there other isn't. In my opinion, this is totally against the patient's wishes, they decided to be DNR/DNI, so when they couldn't breathe on their own, we used BIPAP with a full face mask. But I've been told that "so long as the family has hope" the bipap stays on.

I think a lot of it is denial on the part of the patient and the family, and until they move past this stage of the grieving process, they will fight to have everything done even if it is futile.

Perhaps sometimes as a PERSON I forget things like that, that's when I need to remember I'm a NURSE and this is a psychosocial need of the pt/family that is not being recognized and treated properly.

[fergus51]

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.

It is no different in the US. A doctor is not required to offer a procedure that won't benefit the patient. The reality is that most will offer anything to avoid upsetting the family (and that happens in Canada too).

I wish ethical committees had more power to stop futile care. I've never seen them actually intercede and I've seen A LOT of futile care.

[DusktilDawn]

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 agree with living wills and your situation is one of many reasons why. I've also seen too many situations where a living will has been ignored. What I have a problem with is when the patient either has a living will or has expressed that they wish to cease treatment and it has been ignored, you know the saying "the dead can't sue, but the living can".

After the death of a close friend my grandmother initiated a conversation with me about living wills and POA. Although it made me uncomfortable (I don't like the thought of losing someone I love), I did understand why she wanted to have this conversation. When the time comes for my grandmother to pass on, I think the last gift I could give her would be to respect her final wishes.

My condolences on your loss jsteine 1.

[julieK]

I haven't had a chance to read all responses on this thread, though I'm finding them fascinating. This is the real problem for me:

The article in the original post makes it seem like MD's across the country are going to be signing DNR orders left and right and not giving care to anyone. However, anyone who read a NY Times article within the last month regarding "The Good Death" will know that that article portrayed docs as being terrified to mention the word "death" to a patient - that they can't accept death since it means that they have been defeated. Seems like they can't win where this is concerned.

-Julie in NYC

[NurCrystal22]

First, it's obvious we have different definitions about "futile care" and I believe we were talking about different sets of populations. Perhaps, if these definitions and populations were talked about in earlier posts then I'm sure we would not be disagreeing. The PEOPLE you speak of "corpses", I mean what ELSE could be done? Nothing. You're right about that. But it cases like my aunt, the doctor did think it was futile, he really didn't think she had a chance, he actually told her she was going to die (period)... but went along with her wishes to keep trying things. And I'm glad for that. In cases like THAT I think people should get what they ask for, NOT if they are "corpses" like you say, I don't think people should be kept alive to suffer, they should be kept alive to LIVE. If it's possible for them to have a decent quality of life, they should. Other than that, I agree with you given this new information. Mmkay? Okay.

From Tweety "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? "

Well, if those are the patients wishes, say, in their advanced directives or living wills, but not if their is NO possible way they would live.

Second, yes there are homeless people and people without food... etc and so forth, and they are provided with a place to live and heat (shelters) food for their children (food-stamps or soup kitchens meal on wheels, should I go on?). The government provides that for those that apply. And yes they SHOULD have it too. Unfortunately, there are homeless people in the world and they are that way for different circumstances but their ARE opportunites available to them. Right? Right.

Third, congratulations on being past your "expiration date" but I think in some cases experimental does mean futile. An "experiment" is not guaranteed to work, hence WHY it is called an experiment, and if it doesn't.... then what was it for? It was futile. In my opinion...

And I keep saying in my opinion because it's just what I think, perhaps my views will change in the future. BUT NOT TODAY. So... thanks for offering me your opinion, but I'm about to keep arguing about it... i'm mean, it's just so futile to keep going...

~Crystal

[elthia]

I haven't had a chance to read all responses on this thread, though I'm finding them fascinating. This is the real problem for me:

The article in the original post makes it seem like MD's across the country are going to be signing DNR orders left and right and not giving care to anyone. However, anyone who read a NY Times article within the last month regarding "The Good Death" will know that that article portrayed docs as being terrified to mention the word "death" to a patient - that they can't accept death since it means that they have been defeated. Seems like they can't win where this is concerned.

-Julie in NYC

This is where nursing should step in. For one, people need to be educated. DNR does notmean DO NOT TREAT. But I have encountered many out of the medical field that believe that. Also, sometimes the nurses need to gently remind the MD's that maybe it's time to think about hospice. Also, we need to remember these families are in denial, and this is part of the grieving process. Maybe we should help them past this point and on to the other stages of grief.

[icu/don]

I think alot of our confusion in this discussion is that we each have different definitions of "futile care."

As an ICU nurse, running a full code on a patient that has already been in the unit for weeks, is on pressure control ventilation, is on CVVH (continuous dialysis), is on Epi and Levophed drips, and is in liver failure constitutes "futile care." In many cases that I have seen by the time the pts. heart actually stops there are very few drugs/interventions we can give because we have already been resuscitating the pt. for weeks. In some cases in ICU, I really feel that running a code and/or continuing treatment is like doing an appendectomy to cure an earache.

I blame alot of this on the doctors for not adequately educating the families involved. (The patient has been out of the decision making process for a long time.) As nurses in our facility, we have been warned by management that we are being too agressive in trying to convince families to become DNR's. Of course they received complaints from the surgeons who think can keep every pt. alive forever.

As far as the original article on "futile care," it sounded a little scary even to a seasoned ICU nurse. As a nurse, I would refuse to participate in an extubation that was definately not wanted by the family members. I would attempt education, but I would feel the need to abide by the family wishes.

I would only be able to follow a "futile care" policy as long as the decisions reached lined up with my experience and my personal ethics. I would then have to disregard my patients and families viewpoints and call their position ridiculous. This is no way to operate.

The writer of the original article sure does slant things their way with the statement that Ryan "is a living four-year old child." In my mind that leaves alot unsaid. In other words, maybe the family has now been trained in the technology needed to care for him at home. It says nothing of quality of life.