Texans debate Futile Care Law,

Kabin · Apr 17, 2009

The futile care law is a great idea. Most of the time drs and hospitals churn and burn healthcare dollars like a fox guarding the henhouse. There needs to be healthcare resource oversight. Also, in this way, the futile care law makes healthcare for all a more realistic proposition. Healthcare resources are limited and too much is wasted in heroic procedures within the last 2 years of life. If this became mainstream there'd be less demand for specialized docs and more primary care docs for preventive medicine.

Straydandelion · Apr 17, 2009

The futile care law is a great idea. Most of the time drs and hospitals churn and burn healthcare dollars like a fox guarding the henhouse. There needs to be healthcare resource oversight. Also, in this way, the futile care law makes healthcare for all a more realistic proposition. Healthcare resources are limited and too much is wasted in heroic procedures within the last 2 years of life. If this became mainstream there'd be less demand for specialized docs and more primary care docs for preventive medicine.

I thoroughly disagree.. this is the Doc or facillity playing god. who is to decide what care is futile?

UM Review RN, ASN, RN · Apr 17, 2009

Comletely unethical, downright Kevorkian-ish. These things need to be decided on a case-by-case basis with all the family involved.

elkpark · Apr 17, 2009

I was under the impression (thought I knew) that no state requires physicians or hospitals to provide futile care now. I agree that far too much of our limited healthcare resources are spent on futile care, with no real hope of improvement/benefit, but hospitals and physicians often go along with the family's wishes in order to avoid potential lawsuits.

I don't understand why so many people automatically start hollering "euthanasia" and "unethical" whenever someone tries to have a realistic discussion of what modern medicine can and can't do. There are an awful lot of people out there we just can't fix. Instead of running up a huge bill for the family to forestall the inevitable for a short time, how about putting the effort into helping families (and clients) accept reality and prepare for their loved one's death.

As for physicians and hospitals "playing God," we are talking, in these situations, about people who would already be dead if they weren't receiving massive, intensive medical intervention. God is clearly calling these people home, folks, and it is the continuing medical intervention/treatment that is "playing God" and thwarting God's will for these folks ... :)

lamazeteacher · Apr 17, 2009

The futile care law is a great idea. Most of the time drs and hospitals churn and burn healthcare dollars like a fox guarding the henhouse. There needs to be healthcare resource oversight. Also, in this way, the futile care law makes healthcare for all a more realistic proposition. Healthcare resources are limited and too much is wasted in heroic procedures within the last 2 years of life. If this became mainstream there'd be less demand for specialized docs and more primary care docs for preventive medicine.

I can't believe what I'm reading, here!

Are you saying that others can make life and death decisions, possibly against a patient's choice, because money might be "wasted", if they have a fatal disease, and are kept alive longer than a particular healthcare provider believes is necessary?

Now I'm all for "advance directives", and realize that many people haven't done their part of it, before they're hospitalized and in dire condition.........which could make one believe that completion of that should be mandatory, at least in regard to the appointment of medical durable attorney. We need more preparation for the inevitable, and our responsibilities for planning our demise, than has been available. I've been saying that since 1968, when I took a course in "thanatology" (the euphamistic label for "death and dying").

Perhaps a condition for admission could be the legal appointment of durable medical attorney; and if the patient has no idea who they want in that role, an interim one from hospice could be suggested. However for doctors to decide what they want a patient to want, is inexcusable! Some of them still think they're God, but must be disabused of that - perhaps by being told that a family could sue, and if untimely death was decided in court, penalties (monetary) would be paid.

Wise use of taxpayer money is essential in healthcare, but let's save it in the realm of preventive care and appropriate patient education, for heaven's sake. No civilized country has a regulation that provides that decisions regarding life and death can be made by anyone other than the person whose life or death is involved, unless of course, that person was sentenced to death by a court of law.

When we employ doctors to care for us, or hospitals with qualified nurses to be our caregivers, there is a tacit agreement that everything will be done to preserve our lives, hence the oath to "first do no harm".

To people in the prime of their lives, 2 years more or less of life may seem adequate, but that vantage point is considerable for anyone approaching the end of their days.

Pediatric Critical Care Columnist · Apr 17, 2009

I was under the impression (thought I knew) that no state requires physicians or hospitals to provide futile care now. I agree that far too much of our limited healthcare resources are spent on futile care, with no real hope of improvement/benefit, but hospitals and physicians often go along with the family's wishes in order to avoid potential lawsuits.
I don't understand why so many people automatically start hollering "euthanasia" and "unethical" whenever someone tries to have a realistic discussion of what modern medicine can and can't do. There are an awful lot of people out there we just can't fix. Instead of running up a huge bill for the family to forestall the inevitable for a short time, how about putting the effort into helping families (and clients) accept reality and prepare for their loved one's death.

Change the venue to Canada where we already have universal health care and there is no bill presented to the family at the end of it all... In every ICU in the country there are patients at this very moment who have no possibility of recovering in any way, not just in a "meaningful" way. Patients who have no awareness of their surroundings, who have no awareness of the passage of time, no awareness of whose hands are turning, diapering, suctioning them or in many cases that these events are even happening. Their families have insisted they be kept "alive" for as long as science will allow, for reasons they aren't always willing to share. And the hospital staff provide mechanical ventilation, vasopressor support, artificial nutrition, dialysis, and any other litle thing that will keep the heart beating until it stops, then performs CPR for as long as physically possible before ceding the field to the opposition. Where is the dignity in that?

As for physicians and hospitals "playing God," we are talking, in these situations, about people who would already be dead if they weren't receiving massive, intensive medical intervention. God is clearly calling these people home, folks, and it is the continuing medical intervention/treatment that is "playing God" and thwarting God's will for these folks ... :)

But you will never convince a certain portion of the population of that. One family member told me that if God had really wanted his son, then He wouldn't have allowed science to develop all the life-sustaining therapies we have today. And if we have all these wonderful tools at our disposal we darned well better use them on his son! The son has had more than a dozen prolonged cardiac arrests, numerous pneumonias and bouts of sepsis, prolonged apnea, decubitus ulcers, UTIs, diaper rashes, the whole gamut. He shows no evidence of being aware anyone is in the room with him. He used to cry when he was suctioned or had chest physio, though he hasn't been doing that any more for about 5 years. But he still has a heart beat.

I can't believe what I'm reading, here!
Are you saying that others can make life and death decisions, possibly against a patient's choice, because money might be "wasted", if they have a fatal disease, and are kept alive longer than a particular healthcare provider believes is necessary? When we employ doctors to care for us, or hospitals with qualified nurses to be our caregivers, there is a tacit agreement that everything will be done to preserve our lives, hence the oath to "first do no harm".

I would argue that when you go beyond what is reasonable, into the realm of advanced intensive care, for a patient who will inevitably succumb to their illness, that we're in fact doing them a disservice. I can think of no worse torture than to be trached, ventilated, GT fed, turned, bathed and diapered by strangers, dialysed when my kidneys fail, my decubiti debrided daily causing great pain, sedated anytime I show any measure of displeasure at my plight. Especially if there's a part of me that knows I will die anyway.

Perhaps a condition for admission could be the legal appointment of durable medical attorney.

In my world we already have that for every patient... they're called parents. But they are also not completely objective and will only hear what suits their construct of the situation.

Wise use of taxpayer money is essential in healthcare, but let's save it in the realm of preventive care and appropriate patient education, for heaven's sake.

Those are certainly worthy endeavors, but the largest portion of the health care dollar is spent in the first and last year of life... for advanced intensive care. An indefinable cost of this is the significant moral distress suffered by those who provide this care and the burnout that inexorably follows the demise of these patients. It might be difficult for those who do not work with this population to grasp that degree of distress, but I can tell you that a single recent patient situation on our unit caused six very experienced ICU nurses to leave for units where they would be insulated from having to live through anything like it again.

No civilized country has a regulation that provides that decisions regarding life and death can be made by anyone other than the person whose life or death is involved, unless of course, that person was sentenced to death by a court of law.

If you're excluding the Netherlands, Belgium, Switzerland and the state of Oregon from the list of civilized countires, then this statement is true. The Netherlands and Belgium allow euthanasia, while Switzerland and Oregon allow physician-assisted suicide. Despite the legality of euthanasia in Belgium, a recently published study suggests that it's used only very infrequently. The paper makes interesting reading. http://www.biomedcentral.com/1471-2458/9/79

lamazeteacher · Apr 18, 2009

Janfrn:

Thank you for such a thought provoking, thorough response. I read the Belgian,Dutch study and found it interesting that no mention of patients' religions was mentioned, as that would be quite influential in the USA.

It also didn't differentiate between which patients had Hospice Care. That could have been similar to the situation here, as many families and parents reject hospice, saying it can't be time for that. Being a patient receiving care in that program, is a definite indication/admission that the end is near, and earlier requirements of hospice that prohibited treatment, linger.

I worked for a short time with a Hospice organization, and was impressed with the rapidity of death following commencement of that type of care. I did think that earlier death meant less healthcare dollars spent at that time, although clearly patients having hospice care were far more comfortable and their families prepared for its eventuality, than those who did not have it.

What puzzles me, is why patients who are moribund and require less active treatment are ensconced in ICUs, with nurses burning out around them. My recall of the long ago days I spent around that unit, is that only acutely ill patients were admitted there, whose death was unexpected, or might occur if they weren't there.

The issue I have with the potential Texas "futile" care law, is what the definition of those whose conditions which warrant end of life support, rather than heroic measures is? A patient with a diagnosis of cancer, wherein aggressive chemotherapy caused heart disease that could be reversed or treated sufficiently, who might have a few good years of quality life left, differs from a patient whose bone cancer has shown no signs of remission with aggressive multitherapies and he/she is racked with pain, begging to die. Those issues need to be outlined in any law wherein one physician makes the decision to have no CPR performed, and a copy of the signed order and patient's or POA's signed agreement for that need to be in the chart.

I'll never forget a patient with stomach cancer I had who was in his early 70s, at home ( a lavish spread in the wealthiest area of the city), whose son was his doctor; and I worked as his private duty nurse. He was ambulatory, eating a regular diet without problems and conversed well, the first day I was there. Not much for me to do, and I wondered why I was there, in the winter of 1964. While I was off that night the doctor/son wrote orders for NPO, and sedation; and he had placed a foley catheter and started an IV (nurses didn't do those things, then) which was to be TKO. The patient was non communicative and remained in bed, refusing any hygienic care. I called the doctor/son to report that change of status, and was told by him that it was quite all right. By the next day, the patient was unconscious with labored breathing (in those days, nurses didn't listen to lungs). I gave him a bed bath (finally, something to do). The fourth day, he was Cheyne- Stoking upon my arrival and died in the late afternoon. The son was at his bedside, pronounced his father dead and said he'd take care of all the matters that needed to be done, and I left after charting my observations.

My new husband listened as I poured out my suspicions of muder to him, and my desire to report that to the authorities. I was young and hadn't done much bedside nursing and he started his first job as an associate attorney. He suggested that I call the agency that sent me out on the case, which I did. I was told by them that the son/doctor must have had good reasons for the treatment he gave his father, and said they'd "handle it". I was "out of the loop." It was a dilemma I pondered for many years; and when hospice began a decade later, I figured that I had functioned as a hospice nurse, but wished that I could have been in on the plan........:vlin:

So I have been fascinated with end of life decisions, care, and the ethics surrounding that ever since. One of the earlier educational programs I presented when I worked as an "Inservice Coordinator" was prompted by nurses refusing to enter a dying doctor's room at the hospital where I worked 5 years later. It was called "Thanatology", and represented the thinking of the time (pre Kubler Ross); and solicited the participants' feelings about death. We discussed how it would be if more of them did things for their favorite doctor, and they agreed to go into the room twice an hour, and if no nursing tasks were needed, just talk to him for at least 10 minutes, unless he was asleep. It's amazing to think back to those days and realize how much has been accompolished since then, for dying patients and their families. It is no less sad an experience, but certainly the care given is more appropriate.

:prdnrs:

Kabin · Apr 18, 2009

I thoroughly disagree.. this is the Doc or facillity playing god. who is to decide what care is futile?

It happens all the time. We've all seen it in hospitals and asked ourselves why would patients put themselves through it. It has nothing to do with playing god and many times has everything to do about poor education of the family and patient. Kudos to Texas for making a brave stand!

Kabin · Apr 18, 2009

I was under the impression (thought I knew) that no state requires physicians or hospitals to provide futile care now. I agree that far too much of our limited healthcare resources are spent on futile care, with no real hope of improvement/benefit, but hospitals and physicians often go along with the family's wishes in order to avoid potential lawsuits.:)

Many times they do it one their own. Hospitals and drs waste money like drunken sailors.

Kabin · Apr 18, 2009

I can't believe what I'm reading, here!
Are you saying that others can make life and death decisions, possibly against a patient's choice, because money might be "wasted", if they have a fatal disease, and are kept alive longer than a particular healthcare provider believes is necessary?
Perhaps a condition for admission could be the legal appointment of durable medical attorney; and if the patient has no idea who they want in that role, an interim one from hospice could be suggested. However for doctors to decide what they want a patient to want, is inexcusable! Some of them still think they're God, but must be disabused of that - perhaps by being told that a family could sue, and if untimely death was decided in court, penalties (monetary) would be paid.
Wise use of taxpayer money is essential in healthcare, but let's save it in the realm of preventive care and appropriate patient education, for heaven's sake. No civilized country has a regulation that provides that decisions regarding life and death can be made by anyone other than the person whose life or death is involved, unless of course, that person was sentenced to death by a court of law.
When we employ doctors to care for us, or hospitals with qualified nurses to be our caregivers, there is a tacit agreement that everything will be done to preserve our lives, hence the oath to "first do no harm"..

Only the rich are entitled to full treatment without regard to limited resources. Your tacit agreement is pie in the sky.

It's tough when you can can't have it both ways but that's the real world. US doctors are employed in about a 30/70 ratio of primary care/specialization. How can that ever support preventive care today let alone expanding to healthcare for all? It can't!

VICEDRN, BSN, RN · Apr 18, 2009

I can't believe what I'm reading, here!
Wise use of taxpayer money is essential in healthcare, but let's save it in the realm of preventive care and appropriate patient education, for heaven's sake. No civilized country has a regulation that provides that decisions regarding life and death can be made by anyone other than the person whose life or death is involved, unless of course, that person was when we sentenced a person to death by a court of law.

I kind of disagree here. My mother is a British citizen and I distinctly remember her telling me that they don't do dialysis on patients with renal failure after a certain age or a certain point (can't remember which) and if I remember correctly, UK also has policies that limit surgical interventions for certain conditions depending on your age.

Also, don't insurance companies indirectly do just this when they deny care that they have determined is futile and that the patient could never afford on his or her own? Isn't that a death sentence? I remember seeing an article about a woman dying of lung cancer who received a letter from her insurance company stating her drug would not be covered because the drug had a less than 5% chance of curing her cancer. It was expensive and she felt this was heartless.

I think its a cultural issue. We don't regard health care as a resource and the reflection of this is that we believe we have the right to care even when it is clearly futile and not the best use of our dollars. Before you waggle your finger at me, yes, I know that I am talking about people and sick people at that.

:twocents: