It goes against the grain for everyone involved: doctor, patient, family. But for physicians especially, talking about when further treatment is futile conflicts with everything they do every day. But when an end-stage patient presents in the ED, the doctor must don a different hat and lead the patient and his family to the correct course of action.
The session, “Compassionate Care or Death Panel: The Dilemma of Futile Treatment in the ED,” presented at the American College of Emergency Physicians Scientific Assembly in October, explored the futility quandary.
Jerome R. Hoffman, MD, one of the panelists and a professor of emergency medicine at the University of California, Los Angeles, said the problem stems from patients believing that doctors can fix everything.
“In America we seem to have the sense that we can do anything,” said Dr. Hoffman. “The ultimate is the notion that we can live forever because of technology. These are crazy notions.”
But where medicine and technology fall short, candid conversations fill the gap, said Dr. Hoffman, Jean T. Abbott, MD, the moderator of the session, and Arthur R. Derse, MD, JD, a second panelist. Talking to the patient and family is essential to solving the futility dilemma. If a patient is dying, the patient and his family need to understand that, even if such conversations are uncomfortable.
“We need to use the word dead or dying,” said Dr. Abbott, faculty at the University of Colorado. “We must be frank and start the conversation. The patients and families are experts at goals. We are experts of whether procedures would be effective and reach goals,” she said. “We can't provide a Chinese menu inquiring about what treatments they would want. We need to talk to them of what the values are. We need to then give our advice.”
Physicians have to be sensitive to the difficulties patients face in making these decisions and the helplessness that often accompanies them. When a patient rejects a treatment, the doctor must respect that decision, the panelists said. But when the doctor decides that measures to prolong the life of an end-stage patient are ineffective, the patient must confront the mortality inherent in that choice, and often has no option to obtain further treatment. The challenge is helping family members accept the death of a loved one, they said.
Physicians meanwhile constantly fear litigation, according to Dr. Derse, a professor of emergency medicine and bioethics and medical humanities at the Medical College of Wisconsin, and may approve futile procedures to avoid being sued. “Litigated futility patients usually concern [are those] who want to stop treatment, not patients who died after a physician's decision to withhold or withdraw treatment on the basis of lack of efficacy,” he said. “Of those cases that go to court because of physician's decision to not give treatment, physicians almost always win. And while one may say that it is easy for us to do actions to avoid court, aren't we just abdicating professional responsibility?”
The cost debate is very real, Dr. Hoffman said, noting that physicians must discuss cost in life-or-death situations even if it seems infelicitous.
“Take this scenario,” he said. “A race car driver dies. That is so rare, right? If we were driving at those speeds, and we crashed we would be dead instantaneously. Why is a race car driver death an anomaly? They spend millions of dollars on safety. We have hundreds of thousands of deaths from auto accidents, and we don't pay the money to make highways much safer. Why? Because of money. So when we discuss life or death, money is an object.”
The same holds true in medicine, Dr. Hoffman said, where it is just as important to to discuss what the system can afford.
“We in medicine are used to allocating scarce resources when we can't buy more, so we have to make decisions on allocating those resources, and some people die because of our decisions,” Dr. Derse said. “We are spending so much money, and we can't spend more. We are going to need to allocate.”
Drs. Derse and Hoffman agreed that these decisions must be made because funds are limited, especially for end-of-life care. “The process of watching a loved one die is a hard thing,” Dr. Hoffman said. “They have feelings, and we shouldn't make less of any of this.” But, he said, “that doesn't mean that people get to demand everything forever.”
Patients and families, Drs. Abbott and Hoffman said, need to think about treatment options and death, and doctors need to start the conversation, continue [it], and ultimately see the conversation through to the end.
“We need to plant the seed, and warn people that this conversation is going to occur,” Dr. Abbott said. “We need to get people to start thinking about this.”
Dr. Hoffman agreed. “This is the type of talking we have to do not just among ourselves but in our communities,” he said. “We really need to talk about these things, and I hope that we will do much more of this.”
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