Medical Futility in LTC

To the Editor:

The article “Medical Futility: Ethical, Legal, and Policy Issues”¹ is a timely review of a very complex topic and very relevant to physicians who take care of the elderly in the long-term care setting. I, as an intensivist, encounter this dilemma when patients who are mentally/decisionally incapacitated are hospitalized in the Intensive Care Unit with life-threatening illnesses. Often, these patients have many chronic comorbid conditions with a very limited life expectancy. Many have not expressed their wishes and have not discussed advance directives with their next of kin. Some have not designated healthcare proxies. As a result, family members are reluctant to make difficult decisions of limiting care. In such situations, a palliative care team can discuss with the family the benefits and burdens of care, and the family can make informed decisions based on patient values. Although the article placed great emphasis on withdrawal of life support, the same considerations apply to withholding life support. Medically, ethically/morally, and legally these are no different. Many physicians do not want to withdraw life support, such as mechanical ventilation, against the wishes of healthcare proxies or next of kin, but feel comfortable in withholding other life support modalities such as hemodialysis, based on medical futility. The question many physicians would have liked to have been addressed in the article is: “In the absence of a Do-Not Resuscitate order, do physicians have a legal obligation to provide cardiopulmonary resuscitation (CPR) after death, knowing full well that CPR would be more burdensome and not beneficial?” As per the American Medical Association, we as physicians are not obligated to provide medically futile care.

Viswanath Vasudevan, MD Director, Medical ICU, The Brooklyn Hospital Center Associate Professor of Clinical Medicine New York Medical College Valhalla, NY

Reference

1. Eskildsen MA. Medical futility: Ethical, legal, and policy issues. Annals of Long-Term Care: Clinical Care and Aging 2010;18(3):35-38.

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Response from Dr. Eskildsen:

The letter writer accurately describes the ethical and moral differences between withdrawing and withholding futile treatments. When a life-sustaining treatment is withdrawn, this action is more likely to be seen by patients, family members—and possibly, the legal system—as actively causing a patient’s death. On the other hand, withholding such treatment may be perceived as less controversial because it does not generate an action that actively ends a person’s life. As the writer mentioned, cardiopulmonary resuscitation (CPR) is an intervention that may indeed be futile, especially in older, chronically ill patients. The AMA’s Code of Medical Ethics, in its Opinion 2.035 (“Futile Care”), states¹: “Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients.” However, at the end of the paragraph, the opinion gives the following caveat: “Denial of treatment should be justified by reliance on openly stated ethical principles and acceptable standards of care…not on the concept of ‘futility,’ which cannot be meaningfully defined.” This last statement should be interpreted as meaning that resuscitation can be withheld by physicians when they think that resuscitation itself has a negligible probability of success in restoring breathing, a pulse, and a normal cardiac rhythm. The opinion does not give physicians license to withhold CPR solely because the physician subjectively believes that resuscitating the patient will result in poor quality of life. This distinction is important, because we as physicians may sometimes impose our value judgments on our patients regarding what is considered an “acceptable” quality of life. Injecting those judgments into a decision on whether or not to apply CPR may put a physician in an ethically, or even legally, precarious situation. The last note of caution I would give is that the AMA’s ethics guidelines are not legally binding, and, according to my research, there is no specific statutory or case law giving physicians direct guidelines as to how to act in the situations described above.

Sincerely, Manuel A. Eskildsen, MD, MPH, CMD Division of Geriatric Medicine and Gerontology Department of Medicine Emory University School of Medicine Atlanta, GA

Reference

1. American Medical Association. Code of Medical Ethics. Opinion 2.035 - Futile Care. Chicago, IL: American Medical Association; 2008.