Life, Death, and Heartache: Ethical Dilemmas Get Tougher

|Disclosures|November 15, 2012
 

Giving "Futile" Treatment

Some of the intriguing findings from Medscape's 2012 Ethics survey report include:

Would you ever give life-sustaining therapy if you believed it to be futile?

About one third (35%) of physicians would continue treatment; 24% would not, and 41% said it depends.

Those who said "yes" gave poignant examples: "I've seen a patient recover after a prolonged comatose state post-cardiac resuscitation, which went on for 30 minutes; his therapy was thought to be futile." Several respondents noted that "miracles do happen" and that "physicians don't always know what's futile, no matter what they think."

Kenneth Prager, MD

Others said that keeping a patient on life support for a limited time is helpful for the family: "I'd do this on a short-term basis to allow family members time to arrive and/or come to terms with the finality of the situation," said one physician. "Yes, sometimes you're giving time for a family member to say goodbye and have time to grieve," said one doctor.

Others maintained that "futility" was not the key issue. "Maybe the treatment won't cure the patient or won't put them into remission, but if it gives them more time to live, with an acceptable quality of life, why shouldn't I do that?" Many respondents commented that this is why advance directives are so important. Some noted that they try to change the family's mind if family members are pushing for continued treatment: "In situations such as this, I have a conversation with the family and encourage them not to continue treatment," said a physician.

Dr. Prager says he avoids the word "futility" in favor of a very narrow definition: "If someone is in the hospital and on life support, and every doctor believes that patient is going to die in the hospital no matter what you do -- for example, the patient is in multiorgan failure with no chance -- in that situation, the doctor is not really keeping the patient alive," said Dr. Prager. "What the doctor is doing is what I call 'prolonging the dying process.'"

"It's not the medical futility care that's breaking the healthcare budget," said Dr. Prager. "Often, it's the family that is being very unrealistically blind to the suffering of the patient with all the invasive treatments he's being given, and the pain he's experiencing as he's being cared for."

Save a Younger Patient or an Older Patient?

Would you ever decide to devote scarce or costly resources to a younger patient rather than to one who was older but not facing imminent death?

Some politicians have tried to whip up fear by conjuring up nonexistent "death panels" to decide who was worthy of medical care. No such panel exists, but the emotional intensity of the responses showed this is still a hot issue. Many physicians said they needed specific details in order to give an answer; however, more than one quarter (27%) of respondents said yes, over one third (39%) said no, and another one third (35%) said it depends. This issue may well heat up again as pressure on costs grows.

"If the patients are equally sick and have the same chance of survival, and both were my patients, I would consider allocating more resources for the management of the younger patient," said one doctor. "This is a reality that we will have to face in society and in medicine -- just because costly technology is available does not necessarily mean that we should feel obliged to use it in every situation," said another.

Yet, many other respondents were reluctant to make a decision on the basis of age. "I would choose an older patient contributing to society over a young psychopathic mass murderer, for example," said a respondent. "There is no guarantee the younger person will live longer or be 'more valuable,' as if we could make that determination," said another physician.

Although the issue is clearly difficult, "doctors should not be in the business of deciding which life has a quality worth sustaining or not," said Dr. Prager. He also noted that younger physicians are more apt to feel that aged patients have already had their shot at life. "Older doctors are more likely to say 'no' to this question," said Dr. Prager. "They're thinking, 'We're not ready to check out. I'm 85, and I don't want anybody pulling the plug on me.'"

 
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Authors and Disclosures

Author

Leslie Kane, MA

Executive Editor, Medscape Business of Medicine

Disclosure: Leslie Kane, MA, has disclosed no relevant financial relationships.

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