“Third Generation” Futile Care Theory

They keep wanting to force very sick patients off of wanted life-extending treatment.  Known as futile care theory, medical futility, “inappropriate care,” and a few other names, the idea is to withdraw wanted life-sustaining and other potentially efficacious treatments based on the suffering caused to the patient, quality of life, money—or all of the above. Please note that we are not talking about treatment that doesn’t work, which should be denied. Rather, we are talking about withdrawing treatment precisely—at least sometimes—because it does work and that is an undesired result. In those cases, in essence and to put it bluntly, it is the patient who is being declared futile.

This movement has been led by some within the Catholic healthcare community.  Now, two bioethicist, including one at the Catholic SSM Healthcare in St. Louis, and one from the Catholic Health Association , have published a “third generation” futile care policy by which hospitals are empowered to refuse treatment.

There is very much to applaud in this document.  For example, urging doctors to be more honest and blunt with patients about prospects and beginning to discuss the seriousness of a serious situation sooner rather than later. No question: Better communication usually results in better decisions.

But at the end of the day, after all the compassionate and caring communication, the hospital reserves to itself the right to refuse treatment the patient or family want.  From “Enhancing Communication and Coordination of Care: A “Third Generation” Approach to Medical Futility,” published by Health Care Ethics:

G. Lack of agreement. If agreement cannot be reached about withholding or withdrawing treatment, an ethics consult should be called and the hospital president or administrator on-call should be notified of the situation. Additionally, attention should now focus on restricting treatment options in light of the patient’s best interests, with no treatment options being offered to the family that will extend or increase the patient’s suffering (e.g., amputation of a limb for a patient with end-stage illness) or are medically contraindicated because they will be ineffective (e.g., advanced cardiac life-support for a frail, elderly patient with multiple chronic conditions).

G1. Offer time-limited trial. If the treatment in question does not extend or increase the patient’s suffering and could perhaps achieve its physiological end, the attending/primary treating physician could offer the option of providing the treatment for a time-limited trial. The attending/primary treating physician must delineate the therapeutic goals and the length of time the treatment will be provided to assess the effects of the treatment in light of the goals. In no uncertain terms, the attending/primary treating physician should point out that the treatment will be withdrawn if the patient does not achieve the therapeutic goals in the designated time.

G2. Discuss alternate care options. If, after the time-limited trial, the treatment is still considered unreasonable or inappropriate, it could be withdrawn provided there is wide agreement among the attending/primary treating physician, other caregivers, hospital president, ethics committee and so on. If the decision is made to withdraw the treatment, the family should be notified promptly and given an appropriate amount of time to reconcile with the situation or make alternative plans.

Bottom line: WE decide.

It is worth nothing that the SSM hospitals have this mission statement as their guiding light:

“Through our exceptional health care services, we reveal the healing presence of God.” Accompanying that mission are five values the organization holds dear: Compassion, Respect, Excellence, Stewardship, Community.”

That’s very nice. But apparently, if a patient’s life is deemed to undermine “stewardship” or “community,” the meaning of “compassion” is to refuse to extend your life—a core purpose of medicine—even if that is what you and your family desire.  That doesn’t seem very “respectful” to me.

HT: Medical Futility Blog