Posted on 10/20/2003 9:03:08 PM PDT by Chancellor Palpatine
FAMILIES WHO DEMAND INAPPROPRIATE MEDICAL TREATMENT FOR MORIBUND PATIENTS
Editorial Comment: Pittsburgh Post- Gazette, Sunday, October 30, 1994. Reprinted by permission.
David Crippen, MD, FCCM, Director, Surgical Critical care, St. Francis Medical Center, 45th Street off Penn Ave, Pittsburgh, PA,(412) 622-4210.
Recent times have witnessed much discussion regarding the "life is sacred at any cost" philosophy. Current technology is capable of indiscriminately maintaining some of the vital functions of the body, but the same technology does not necessarily allow us to heal underlying disease processes. An unintended side effect of modern technological advances has been the plausibility of maintaining moribund patients in a state of suspended animation for prolonged and sometimes indefinite periods. Unfortunately, we are beginning to see patients stalled in suspended animation; not alive in the sense we enjoy life but not able to die because technology has temporarily arrested the disease but not the disease process. In many cases, reanimation of such patients is clearly impossible even with the advanced medical technology available to us.
In most acute illnesses, time is needed to see if aggressive treatment will improve the patient's condition. As physicians, we are prepared to apply life sustaining technology to patients when the benefit seems to outweigh the risk and when there is a reasonable chance for an outcome that the patient would desire. Decisions to place patients on life support are usually hastened by expectations embellished by the emergent nature of the proceedings. It frequently seems reasonable to buy sufficient time to see if the disease will respond to aggressive treatment by instituting the most invasive life support technology. If, however, organ system failure is not reversible, the reasoning behind life support technology becomes moot, and they serve no further useful function. We must then be prepared to remove supportive technology when it appears in our best judgment that inevitable death is being prolonged rather than meaningful life.
The courts have repeatedly affirmed competent a patient's authority to regulate their medical treatment, regardless of their reasoning. However, when the patient becomes incapacitated, family surrogates are granted virtually unlimited power to dictate treatment options because of their proximate knowledge of what the patient would have wanted before they became incompetent. This position is based on the postulation that any attempt to interject physician paternalism into the surrogate decision making equation is ethically unacceptable. Rational patients and their families are only rarely willing to continue life support after a reasonable trial has demonstrated their benefit has passed the point of diminishing returns. However, we are beginning to see a trend of family surrogates increasingly demanding moribund patients be kept on futile life support after prevailing medical opinions concur that there is no chance of reanimation.
In the best of circumstances, families of moribund patients have difficulty making critical decisions regarding life support systems based on the complex information necessary to assimilate and comprehend. Families frequently cannot understand the qualitative difference between allowing patients to die of untreatable disease processes and hastening death by some therapeutic or anti-therapeutic maneuver. Life support technology can give the appearance of viability when, in reality, there is none once the machines are removed. Under the current rules, surrogates do not have to proffer any reasoning or rationale for demanding futile life support. Some families feel that if life support systems can maintain vital signs for a day or a week, "suspended animation" should be possible indefinitely. These opinions are frequently supported by anecdotal articles in the popular press attesting to patients who have awakened after years of coma. The only test of utility is: "will this treatment result in sustained life?" If the answer is yes, virtually any treatment is fair game, even if it will do nothing to revitalize the patient.
A line of reasoning stating: "we don't want grandma to actually die because we find it emotionally disquieting, therefore, we are willing to allow the taxpayers to alleviate our suffering by avoiding the moment of truth indefinitely," is perfectly acceptable under the current health care system. Like tort liability laws, there is simply a strong incentive to give the great lottery wheel a spin and try your luck. If you lose, you get nothing but you don't lose anything either. If you win, your moribund relative gets a free ICU nursing home. If they (or the patient) desire it, that seems to be good enough reason for taxpayers to support it. Maintaining a moribund patient on mechanical ventilation in an ICU setting can be phenomenally expensive, as much as $2000.00 per day. Under Medicare law, it is illegal for families to be billed for any of this care. Therefore, since they don't have to assume any financial responsibility, families have little incentive to authorize withdrawal as long as the patient does not look uncomfortable and there is the slightest possibility of eventual success.
This notion of futility only as an end stage process where vital signs cannot be supported further is proving to be unworkable. Moribund patients supported by life sustaining machinery in an ICU are different from persistently vegetative patients supported by a feeding tube in nursing homes. It is possible to give them a thin veneer of life, but underneath there is only paper mache.' The cost to support them is disproportionally high, and unfairly borne by the tax base. We need a new definition that takes into account realistic assessments of viability under sophisticated life support systems that render a fallacious appearance of viability. Instead of "futile", we need the option of saying "not medically indicated" because under the current futility rules, false expectations are financed by taxpayers. Patients and families have too strong an incentive to use societal resources for their own ends and too little liability if they persist against expert advice. There is no balance of power between these forces and those who have to pay the bill for their decisions. We need to define futility in terms of numbers of organ systems failed, length of time failed and number of life support machines needed to maintain viability. Dismal predictions of future viability for these kinds of patients are very accurate in the peer-reviewed medical literature.
Should a health care system already strapped with exploding costs force physicians to go against their expert judgment when families insist on maintaining prolonged coma for reasons that are defensible only in emotional terms. Unlike most physician-patient relationships, It seems that we cannot exercise any clinical judgment in futility issues if it differs from judgments of the family. If we allow patients and their surrogates unlimited authority, we must accept the inevitable fact that such a decision will use scarce resources to warehouse increasing numbers of warm cadavers. In an economy seeking to maximize use of scarce resources, how far should we support the autonomy of groups who have an incentive to maximize expenditures of others to support their own ends? How much is society willing to pay for unlimited patient autonomy? The traditional case for avoiding paternalism is weakening with increasing numbers of unrealistic relatives taking the bit in their teeth and running amok in a high tech medical playpen, simply because they are told prospectively they have the authority to do so.
Neither faction, physicians nor family, in themselves, should necessarily have an inside track in decisions involving futility. Squabbles at the bedside between physicians and family surrogates over futility issues do not promote global decisions regarding the equitable use of scarce resources. We, as a society, need to get together and craft effective rules for the use of expensive, high technology medical resources. It seems to me that a consensus is a reflection of the communities affected by these ideas getting together and forging a policy that no one may like, but with which everyone can live. That is the nature of political process. The community that has to pay for these decisions should have the power to decide what they are willing to live with from both factions, physicians and family. If we have a consensus of what all agree on, we then have controls on the unrestrained action of all interested parties.
That's encouraging since the culture of death is winning. I wish they had said something when abortion was legalized, what 25 years ago? What's their excuse for allowing that to continue? It only follows that the disabled will be targtted next.
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