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Medical Futility--- If A Treatment Is Medically Futile- Should Doctors Respect The Sdm Decisions?


End Poverty

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Everybody has an SDM somewhere.  In Ontario if no friends or family, it becomes the Public Guardian.  You phone or fax their office with the information and they ask any questions they have and give consent (or withhold it, but in my limited experience if you give them a good rationale they'll consent).

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In theory, if a treatment is truly medically futile, it shouldn't even be offered to the patient or their SDM. For example, if a cancer is non-operable, the patient or their SDM can demand surgical removal as much as they want, no surgeon will offer an operation, much less consent to doing it. Ostensibly, that should be the case for all futile actions.

 

In practice though, the definition of "futile" is vague enough that it's hard to demonstrate definitively and, in many cases, exists along a spectrum. I would consider an action that extends life by 1 day for a patient in the ICU to be futile in most cases (with possible exceptions for those waiting on a loved one to arrive), but a patient and their SDM might disagree if they value any extension of life. Additionally, from a practical perspective, taking a hard line on futility puts a physician in a difficult legal position. Futility is hard to prove and refusal to provide services perceived as necessary by an SDM means lawsuits can come pretty quickly. In a longer-term treatment situation, where there's time to consider options, we do have a legal process to resolve such disputes between SDMs and physicians. Physicians have protections if they go through that system, cumbersome as it is. In more acute settings, that process takes far too long and SDMs can stall it for quite some time if they want to. So, it's often easier to just adhere to the SDM's wishes. Truly futile acute treatment situations resolve themselves, unfortunately, though often not without substantial cost to the system (and physician morale).

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As above mentioned, it is difficult to assess for and determine fultility. Clinical ethicists see this as two distinct types of futility. Qualitative vs quantitative fultility. For example. It is quantitatively fultilile to treat a viral infection with antibiotics. Therefor practitioners can refuse to administer that type of treatment. Qualitative futility would be when the practitioner (or others) think that there is no reasonable hope of restoring a livable life to a person. For example, in a severe tramautic brain injury, where a person has remained unresponsive for a month. It might seem futile to provide a tracheostomy, knowing this person will remain in a persistent vegetative state. However, it is not unreasonable treatment to provide a tracheostomy to a brain injured patient. In fact it is consistent care that is often provided for this type of injury. So its difficult to say that it is quantitatively futile care. For example, if this person has a respiratory drive, and might foreseeably be liberated from the ventilator, then the trach is a reasonable intermediate step to ventilatory liberation. The family then might advocate that this is a desirable procedure. Ethically, it's not obviously wrong to provide this treatment, and therefor the team might be compelled to provide it, even though they deem it "futile". The end result is a person off of the ventilator, in a persistent vegetative state. This is obviously undesirable for most people, but that is a qualitative measure of desirabliltiy.

 

In the end, its about respecting and upholding the ability of SDM's to make ethically, and morally difficult decisions. When quantitatively futile, practitioners are able to refuse care, but even this is difficult to do, and is often a process that involves time and several conversations (think brain death). When it is qualitatively fultile (think brain injury), then often it becomes an imperative to uphold the decisions of the SDM, even if it places the care providers into moral distress (as it often does).

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  • 3 weeks later...

In practice though, the definition of "futile" is vague enough that it's hard to demonstrate definitively and, in many cases, exists along a spectrum. I would consider an action that extends life by 1 day for a patient in the ICU to be futile in most cases (with possible exceptions for those waiting on a loved one to arrive), but a patient and their SDM might disagree if they value any extension of life. Additionally, from a practical perspective, taking a hard line on futility puts a physician in a difficult legal position. Futility is hard to prove and refusal to provide services perceived as necessary by an SDM means lawsuits can come pretty quickly. In a longer-term treatment situation, where there's time to consider options, we do have a legal process to resolve such disputes between SDMs and physicians. Physicians have protections if they go through that system, cumbersome as it is. In more acute settings, that process takes far too long and SDMs can stall it for quite some time if they want to. So, it's often easier to just adhere to the SDM's wishes. Truly futile acute treatment situations resolve themselves, unfortunately, though often not without substantial cost to the system (and physician morale).

 

"Futility" implies that an intervention will not benefit or even cause net harm to the patient. It can be very difficult to determine what this means in the ICU but oftentimes we can keep people "alive" for a while barring catastrophe. 

 

Otherwise there are quite variable policies across the country re: disputes. The Consent and Capacity Board in Ontario process has essentially been entrenched in the wake of the Rasouli decision, while the CPSO has (not without considerable controversy) made it policy to require consent for a "no code" designation. That is, however, policy, not law, and there is no legal (let alone moral) obligation to run a code in any arbitrary situation. 

 

As above mentioned, it is difficult to assess for and determine fultility. Clinical ethicists see this as two distinct types of futility. Qualitative vs quantitative fultility. For example. It is quantitatively fultilile to treat a viral infection with antibiotics. Therefor practitioners can refuse to administer that type of treatment. Qualitative futility would be when the practitioner (or others) think that there is no reasonable hope of restoring a livable life to a person. For example, in a severe tramautic brain injury, where a person has remained unresponsive for a month. It might seem futile to provide a tracheostomy, knowing this person will remain in a persistent vegetative state. However, it is not unreasonable treatment to provide a tracheostomy to a brain injured patient. In fact it is consistent care that is often provided for this type of injury. So its difficult to say that it is quantitatively futile care. For example, if this person has a respiratory drive, and might foreseeably be liberated from the ventilator, then the trach is a reasonable intermediate step to ventilatory liberation. The family then might advocate that this is a desirable procedure. Ethically, it's not obviously wrong to provide this treatment, and therefor the team might be compelled to provide it, even though they deem it "futile". The end result is a person off of the ventilator, in a persistent vegetative state. This is obviously undesirable for most people, but that is a qualitative measure of desirabliltiy.

 

 

Treating a viral infection with antibiotics is like treating an MI with a Tylenol and pat on the back. It's simply inappropriate and otherwise not indicated. I suppose this could be termed "futile" but I don't think this is a meaningful term in that situation. 

 

Similarly your example of a trach doesn't quite ring true. The "futility" questions tends to come into play where weaning is considered unlikely or impossible, and when continuation of "life-sustaining" care is thought not to be beneficial. Most of the time, families come round themselves to withdrawal of care, but in less common circumstances there is a breakdown of communication and/or (usually "and") strong convictions (religious or otherwise) against withdrawal on the parts of family members. 

 

 

 

In the end, its about respecting and upholding the ability of SDM's to make ethically, and morally difficult decisions. When quantitatively futile, practitioners are able to refuse care, but even this is difficult to do, and is often a process that involves time and several conversations (think brain death). When it is qualitatively fultile (think brain injury), then often it becomes an imperative to uphold the decisions of the SDM, even if it places the care providers into moral distress (as it often does).

 

Brain death is legal death and declaration thereof does not require any kind of consent of SDMs. 

 

In any event, I feel the initial question here is a bit unclear. In cases of medical futility, physicians should discuss and counsel families regarding palliative measures and all alternatives. Futile care should not be offered, e.g. initiation of dialysis in a demented 85 year old with end-stage heart failure and dementia who had arrested earlier that day. Families do not generally want to make decisions about withdrawal of care, and it is the wrong approach to make this about simply "respecting" their decisions. 

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