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This morning, I am posting a series of topics from the Medical Futility blog of Professor Thaddeus Pope...

Thanks, Leslie.

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Minneapolis oncologist Stuart Bloom has a short piece in the July 1, 2008 Journal of Clinical Oncology titled "In Defense of Futile Gestures."

He describes a patient for whom, after her fourth try at remission, he recommended "supportive care alone." While the patient initially agreed with this plan, she later decided that she wanted to "fight her cancer" even though "the chance of any intervention was vanishingly low."

Bloom agrees that "continuing toxic therapy in hope of some response is inadequate medicine." But he also concedes that "our prognostic acumen is often insufficient to predict which patient will defy statistical odds and improve." His patient, of course, ended up being that rare patient who improved dramatically.

It is important to remember the limits of prognostication. In several studies (e.g. Smith et al., Critical Care Med. May 2007) of the Texas Advance Directives Act, some patients made substantial recoveries even after the treating team, the ethics committee, and potential transferee facilities all judged that further treatment was medically inappropriate.

Posted by Thaddeus Mason Pope at 9:12 AM

Defending Futile Treatment

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More on Professor Pope's blog...

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Barbara Daly, an oncology nursing professor at Case Western, has a short piece in the July 2008 American Journal of Critical Care arguing for a reversal of the current norm which presumes that every patient gets CPR unless there is a specific physician order to the contrary.

This argument has been pushed for many years and I am pretty sympathetic to it. But Daly's argument is not terribly persuasive. She raises and cogently responds to some important objections. But she leaves a rather central issue untouched.

Daly wants to "restrict use of CPR to those patients who provide adequately informed consent and for whom CPR has a reasonable chance of success (discharge from the hospital without significant impairment in cognitive status.)" But why is "discharge from the hospital without significant impairment" the right measure of success? What is a reasonable chance? Clinicians cannot agree on these thresholds. And patients and surrogates certainly cannot agree.

Posted by Thaddeus Mason Pope at 9:33 AM

An Indecent Proposal: Withholding CPR

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