Medical Futility

1. Medical Futility Jeff Kaufhold, MD FACP 2013 Daniel P Sulmasy, OFM, MD, PhD Director, The Bioethics Institute New York Medical Center July 17, 2004

2. Case • 76 y.o. female with Multiple Myeloma admitted with Sepsis. • Heavily pretreated, no further chemo available • On vent, Pressors • Daughter wants everything done.

3. The Basis for Medical Futility • History of Futility • State law on Futility • Religious Principles • Moral Principles • Probability • Dealing with the case.

4. Futility, a History • Smith Papyrus, 1700 B.C. • Entreaty to not intervene if spinal cord is transected • This Egyptian papyrus, found in 1900’s, references a much older text.

5. Futility, a History • Smith Papyrus, 1700 B.C. • Entreaty to not intervene if spinal cord is transected • Hippocrates, 460 – 377 B.C. • “On The Art” – the physician should refuse to treat in cases where medicine is powerless

6. Social norms regarding cancer • 1950’s – call it something else. • 1960’s – Inform pt of diagnosis • 1970’s – Informed consent • 1990’s - Informed Demand

7. Evolution of Futility In the 1970’s, doctors would not remove life support even if the family ASKED for it. You didn’t die in a hospital without getting CPR first. Once there was a safe harbor for withdrawal of care, doctors became comfortable with it. The safe harbor came after Quinlan 1976. Now called inappropriate care or Nonbeneficial care.

8. States with statutes regarding physician refusal of nonbeneficial care. • California • Texas • Maine • Delaware • Hawaii • Alaska • All use the Uniform health Care Benefits act as a guide.

9. Texas Statute • “I don’t want people to like Texas. I prefer if they hate and FEAR it.” • H Tristan Englehart, PhD.

10. Texas Statute • A patient may be removed from life support and a doctor may refuse to provide inappropriate treatment to a patient if • The doctor believes it is non beneficial • Must be confirmed by the hospitals ethics committee. • Surrogate has 10 days to try to find another provider. • On the 11th day, facility may withdraw treatment even against the surrogates wishes. • Doctor has immunity if process is followed.

11. Texas Statute • Three components: • 1. Process • 2. Competencies of Doctor and ethics committee members. • 3. Cultural Norms • Has everything been done? • Are ethics comm members biased / acting in the interest of the institution or the patient?

12. Religious Principles • Intrinsic Dignity • Made in the image of God • Alien Dignity • Relationships define our being. • Also a fact that we are Finite

13. Religious Principles • Life is a gift, and we are its stewards • Limits to stewardship • Illness is a burden • Costs and burden to family/caregivers • Futile care need not be given.

14. Moral Principles • No moral obligation to provide futile Tx. • What is Futile Treatment? • Non-beneficial • Inappropriate treatment at the end of life • What is the real goal? • Free of pain and suffering

15. Moral Principles • What is Futile Treatment? • Subjective Futility • Patient won’t be able to appreciate benefit • This is not sufficient moral argument to withhold therapy • Objective Futility (biomedical use) • No objective benefit to any observer

16. Moral Principles • Medical Realism • There are facts • Trained people can make judgements • But we are fallible • We have to relate the data to the patient • This is the tricky part of the art. • Requires use of probability.

17. Probability • Is this patient going to die? • Probably. • Even with treatment? • Probably. • Can you be more specific? • Probably.

18. Probability • Prognosis is the probability that a patient will respond to tx, plus the probability that the disease will kill them. • Probability that we use in individual cases comes from objective data about the particulars of the case, plus experience, plus common sense. • This process is fallible, but we do the best we can.

19. Probability • Three factors: • Frequency: • Prediction: • Strength of belief • Lets apply to the case:

20. Probability Myeloma with sepsis • Frequency: (80% of myeloma pts do not wean from vent) • Based on studies • Prediction: (1% likelihood of survival for this pt) • Based on Karnovsky score in Onc literature • Based on APACHE score in ICU literature • Strength of belief • P value • “Reasonable degree of medical certitude”

21. “Ultimately, Ethics is about What to Do” Aristotle, 384 – 322 B.C.

22. Morality of Futility • Judgment enters Morality when decision is made about taking action. • Actions: • Wean from vent? • Wean from pressors? • Stop Antibiotics? • Stop tube feedings/ IV fluids?

23. Morality of Futility • Judgment enters Morality when decision is made about taking action. • Approaches: • Pragmatic – does this help the patient? • Remember, removing pt from life support may kill them, but might it also stop their suffering? • Moral (prudential) – is this the right thing to do?

24. Back to the CaseMyeloma with sepsis • Frequency: • (80% of myeloma pts do not wean from vent) • Prediction: • (1% likelihood of survival for this pt) • Strength of belief • “Reasonable degree of medical certitude” • Pragmatic approach • CPR will not help pt get better • Prudential approach • Morally wrong to provide inappropriate treatment.

25. Back to the CaseMyeloma with sepsis • Pragmatic approach • CPR will not help pt get better • Prudential approach • Morally wrong to provide inappropriate treatment. • Recommendation: • Make the pt DNR – CC arrest • Consider withdrawal of life support • How do we proceed with the family?

26. Back to the CaseMyeloma with sepsis • The family in town wants to keep Mom comfortable, and see she is suffering on life support. • However, the out of town daughter is “in charge” and insists everything be done. • Cultural barriers arise. • Tilden. Nurs Res: 2001, 50;105-115. • Its Stressful to be the surrogate • Guilt, Ambivalence, Depression, Anger.

27. How to proceed Clinically • Establish relationship with family • Review case (how did she get here) • Describe level of illness • Lay out options • Establish goals • keep her alive until son gets here • Maintain comfort no matter what. • Establish Limits • will not resuscitate her if heart stops.

28. Praying for a Miracle • Affirm that this is OK • Bear witness in faith, resurrection • God is present and answering all our prayers, even if a miracle doesn’t come • Recognize the miracles that have already taken place in the patient’s life or the patient’s care.

29. Praying for a Miracle • A man is in his house in New Orleans before Hurricane Katrina. • The city sent around a bus before the storm to take residents to a safe place, but he refused, saying “God will protect me”.

30. Praying for a Miracle • The national guard sent around a boat during the storm to rescue the man, but he refused, saying “God will look after me”. • When he was on the roof of his house, the Coast Guard sent a helicopter to rescue him, but he refused, saying “God will save me”.

31. Praying for a Miracle Finally, he finds himself in front of heaven, and sees God. He asks God “why didn’t you save me?” And God said, “ I sent you a bus, I sent you a boat, I sent you a helicopter! How do you think they found you?”