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Chapter Nine: Futility
of Care
David Simpson never knew what hit him. Jogging along the sidewalk
in his suburban neighborhood, he thought nothing of the blue sedan
that drove slowly past him. Neighbors, sitting on their porches
heard a muffled gunshot and the sound of the car as it sped away.
When they looked up, David was lying in a pool of blood.
By the time Janet got to the hospital, David was intubated, and
in the Surgical Intensive Care Unit Dr. Braun, the neurosurgeon
had already examined David, and told her there was nothing he could
do. The bullet fragments had exploded inside his head, and the brain
was a swollen, bloody mass. Much of it had been extruded through
the exit wound of the bullet.
"Can't you do something?" wailed Janet. "He can't
die like this. We have three children, and I am six months pregnant
again. Do something! Take him to surgery! Transfer him to a bigger
hospital!"
"I wish we could help," said Dr. Braun, "but all
further intervention at this point would be useless. We could call
your pastor or your family for you, but there is nothing else to
be done medically."
Felipe Jimenez was eighty-two years old, moderately demented, and
had widely-spread metastatic lung cancer. The oncologists told him
and his family that he likely had less than six months to live.
He also had heart disease. On Thursday evening he was admitted to
St. Luke's hospital with crushing mid-sternal chest pain.
As Dr. Jim Garcia filled out the admitting paperwork, he paused
and spoke with Felipe's daughter Juanita. "Since Felipe has
the widely-spread cancer, we need to discuss some treatment decisions.
If your Dad should go into an acute cardiac arrest, we should probably
not intervene and do Cardio-Pulmonary Resuscitation, electrical
shock, or put him on artificial respiration. Don't you think this
is what he would want?"
"I thought that everyone was entitled to those basic things,"
said Juanita. "Are you giving us bad treatment just because
he is on Medicare and can't pay as much as those other people?"
"No, of course not," said Dr. Garcia. "If we thought
that this would help your dad in the long run we would not hesitate
to do everything. But in light of his cancer and his Alzheimer's
disease I just don't think it would be helpful for him."
"I thought that since you were 'Mexicano' we could trust you!
But now I see, us poor folks don't get the regular care all the
rich people get!" seethed Juanita. "We want everything
done for my father, and we want another doctor, too. Don't you touch
him again or we will sue you!"
"I know this is tough to hear," said Lucinda White,
advanced nurse practitioner, "but the test results, your exam,
and your complaints all seem to indicate that despite our best efforts
the Lou Gehrig's disease has continued to progress. We have tried
all the available medications, and nothing seems to be slowing things
down like we had hoped."
Danny Ferguson snorted. "Well, I read on the internet that
there is a great new treatment that they are using in Kentucky that
has worked wonders on three patients. I know it would work for me
too, if you would just try it."
Lucinda refused to take offense at Danny's tone of voice, and stayed
calm as she gently continued. "If you mean the chelation therapy
that the Jonesboro group have touted lately, I hate to tell you,
but two major trials proved that chelation is of no use in Amyotrophic
Lateral Sclerosis. If I thought it would help I would be glad to
arrange for the therapy."
Luella, Danny's wife cut in: "If he were your husband you
would do everything that you could to help. Since he's just another
patient to you, you are too lazy to fill out the paperwork to arrange
for the second opinion! You probably get some kickback from the
HMO for not sending patients off to outside doctors."
Dr. William May, in his book Testing the Medical Covenant, states
"The concept of 'medical futility' has emerged in the middle
1990s as a way of placing a limit on the physician's and the health
care organization's medical covenant with a gravely ill patient."
He then goes on to elaborate that since the providers receive fixed
annual payments from the insurer, instead of the older model of
fee for service, it is in the provider's best interest to deny full
service to patients in need of care. They then disguise this fact
by describing full service as unnecessary and futile. Godly physicians
involved in the delivery of medical care via organized medicine
may find Dr. May unnecessarily cynical.
While the term "medical futility" may be relatively new,
the concept itself was conceived long before managed care. Triage,
established just after World War I, is the placement of wounded
soldiers into three classes:
1) salvageable if acute care is given,
2) salvageable even if treatment is delayed, and
3) unsalvageable despite any efforts. This third group was not
to be treated. If time and resources were wasted on these patients,
they would still die, and so would the patients from the first
category. Thus, a functional definition of futility has been employed
for over seventy years.
Even though futility may be hard to define absolutely, the idea
is rather straightforward. Physicians are not ethically obligated
to provide care that in their best judgment will not have a reasonable
chance of benefiting their patient. The sticking points are:
1) In whose best judgment?
2) What is a reasonable chance? And
3) What does "benefiting the patient" mean?
As one may readily see, each of these benchmarks is somewhat open
to interpretation.
While futility has been variably defined over the years, Dr. May
highlights several points that should be employed in addressing
this question: "Would the proposed course of treatment provide
a reasonable chance of benefiting the patient?" These are:
1) The process should involve medical and patient or proxy input.
2) Unreasonable requests need not be uncritically fulfilled, and
no doctor need provide care contrary to conscience.
3) Consensus should be achieved, if possible.
4) Fidelity to the doctor-patient relationship is paramount, but
concurrent responsibilities to all persons involved may be considered.
5) In situations of insurmountable disagreement between the medical
team and the patient or proxy, assistance in process may be sought
from independent sources, such as an ethics consult team, an arbitration
panel, or as a last resort, the judiciary system.
The Bible addresses medical futility only indirectly. Let's look
and see.
Scripture and Discussion Questions
Genesis 18:20-33
2 Samuel 12:13-23
Joshua 7:1-15; 8:1,2
Deuteronomy 34:1-6
Hebrews 6:4-6
Acts 18:5,6 and 19:8,9
Romans 1:24,26,28
Luke 19:11-27
1) In Genesis 18, God tells Abraham of his plans to destroy Sodom
and Gomorrah. Abraham postulates that there might be a few righteous
people left. God seems to be saying that further postponement of
punishment for these evil cities is futile. God, infinitely wise,
is in a position to make these judgments. Does this underscore one
of our problems in establishing futility?
2) Nathan predicts the baby's demise, but David fasts and prays
for his salvation. God decides not to affirmatively answer David's
prayers. When David realizes that the child is dead, he gets up,
bathes, and eats. He has realized that God has answered his prayers
"No." Have there been any times in your life, when you
realized that further prayers or efforts were futile? How did you
respond to this realization?
3) Achan disobeyed God and Joshua. As a result of his sin, the efforts
of the Israelites were futile. Can you think of times in your life
or the lives of loved ones when further actions were futile because
of previous irrevocable sins?
4) Though Moses was a powerful prophet and leader of Israel, he
disobeyed God in the wilderness, and God refused to allow him to
enter Canaan. Can you think of times in your life when irrevocable
acts reaped painful consequences? Was God still able to work things
out to his glory and your growth?
5) Hebrews 6:4-6 talks about believers who knowingly step away from
God. While there has always been some debate about "eternal
security" versus the ongoing work of the Holy Spirit in the
life of the believer, this passage would seem to indicate that we
can choose to irrevocably distance ourselves from God. In this case
further preaching to us would appear to be futile. How would you
interpret this passage? What bearing does that have on this discussion
of futility?
6) The two passages in Acts depict instances where Paul chose to
no longer pursue evangelistic outreach to the Jews in question.
Does this imply that he deemed further evangelistic efforts futile?
How do we know which limited resources to apply to needs at hand,
and which to save for more likely return on investment?
7) In Romans 1 it mentions that God "gave them over" to
sinful desires, shameful lusts and a depraved mind. Does this mean
that he quit wooing them to himself? Does there ever come a time
when we are to quit sharing Christ with our friends and neighbors?
8) In Luke 19 the three servants are held responsible for the way
that they deal with the talents the king gave them. Does this accountability
principle apply to arguments regarding futility? If so, how? Please
elaborate.
9) Have you seen instances when you felt racism played a role in
medical decision-making? In surveys taken across racial and ethnic
lines, members of minority groups answer this question affirmatively
much more frequently than do whites.
10) Very few patients with A. L. S. (Amyotrophic Lateral Sclerosis,
Lou Gehrig's Disease) are placed on artificial ventilation and feeding
at the end of life. The patient's mind remains lucid. In light of
the patient's prognosis, though, most doctors, families and patients
do not choose to do so. How is this different from Christopher Reeves?
If we justify it for him, why don't we justify it and encourage
it for all A. L. S. patients?
11) "With God, all things are possible." Does this imply
that no action on the part of the medical team should be deemed
futile until God decides the patient should die?
12) Can you think of a situation where "concurrent responsibilities
to all persons involved" might dictate a different course of
action than solely stressing fidelity to the doctor-patient relationship?
Comments
1) Patient and family autonomy sometimes push physicians to do
more than they think is medically indicated. Physicians are not
compelled to perform medical therapies that they feel are not medically
indicated, but sometimes, the medical team, afraid of bad publicity
or malpractice lawsuits, give in, rather than argue. It might be
instructive to role-play a situation where you are a doctor asked
to perform futile surgery for a dying man.
2) Patients with commercial insurance sometimes abuse the system
by seeking a fourth or fifth medical opinion for what is essentially
an untreatable condition. Health Maintenance Organizations (HMOs)
have strict guidelines in place to prevent this waste. It is important
when thinking about medical decision-making to consider how incentives
are aligned. In the old fee-for-service model, incentives encouraged
doctors to order more tests than were needed. In the new HMO models
the opposite is often true.
3) Some people hold that the doctor not only has a responsibility
to his or her own patient, but to all society. From this perspective
the doctor would often not be the patient's advocate, but society's
advocate.
4) God doesn't answer all prayers the way we wish he would. It is
not always easy to reconcile this fact with passages like "Ask
and it shall be given to you, seek and you shall find, knock and
the door shall be opened unto you." We will never understand
some things till we see Christ face to face.
5) An interesting learning exercise for your group might be to role-play
a discussion in which a husband tries to tell his wife that he does
not wish futile care to be performed on his behalf. Have the wife
inquire very pointedly who, when, what, where, and why she should
decide that further treatment on her husband's behalf is futile.
6) Futility in medical therapy is often difficult to define. Some
physicians define it loosely as "I think that this is very
unlikely to help." Others look for a more rigorous standard,
such as "I have not seen anyone survive in this setting, of
the last 100 patients that I have seen."
PRAYER REQUESTS: As you close today's
lesson together, pray that God will help you know what needs in
your world he would have you spend your time and effort on. Ask
the Lord to reveal to you any areas where you should no longer invest
time or effort, and to guide your thoughts as you think about issues
of futility.
For Further Reading:
William F. May, Testing the Medical Covenant (Grand Rapids, MI:
Eerdmans Publishing, 1996). This book was supported in part by The
Institute of Religion, founded in 1954 in the Texas Medical Center.
It reflects the "intersection of healthcare and religious commitment."
Pages 85-99 are on futility of care.
A valuable journal article is in JAMA (Journal of the American Medical
Association), March 10, 1999, Volume 281, No. 10, pages 937-941,
entitled Medical Futility in End-of-Life Care, Report of the Council
on Ethical and Judicial Affairs.
Charles Junkerman, M.D., and David Schiedermayer, M.D., Practical
Ethics for Students, Interns, and Residents-a Short Reference Manual,
2d ed., (Frederick, Maryland: University Publishing Group, Inc.:
1998). True to its name, this concise manual nonetheless offers
some valuable reviews of selected clinical topics. The brief chapter
on futility/unreasonable patient requests covers these issues from
the perspective of a practicing physician.
Steven H. Miles, M.D., "Medical Futility," Law, Medicine
& Healthcare 1992; 20(4): 310-315. Dr. Miles argues that while
the concept of medical futility is useful and necessary, it is best
implemented on an institutional basis, as opposed to through legislative
channels.
The Hastings Center, Guidelines on the Termination of Life-Sustaining
Treatment and the Care of the Dying (Bloomington, Indiana: Indiana
University Press and the Hastings Center, 1987). On Pages 8 and
9 of this text, hammered out by an eminent group of physicians,
thinkers, administrators and lawyers between 1985 and 1987, the
health care provider is encouraged to help the patient discern what
is in their best interest regarding issues of futility.
Decisions Near the End of Life is an "institution-based, multi-disciplinary
continuing medical education program jointly sponsored by Education
Development Center, Inc. (EDC), The Hastings Center, The American
Medical Association, and the Hospital Research and Educational Trust,
an affiliate of the American Hospital Association." The Decisions
program is presented on a continuing basis in large metropolitan
centers throughout the United States. For information about upcoming
programs contact EDC, 55 Chapel Street, Newton, Massachusetts 02158.
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