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Please stop “futile” care

An article in a recent JAMA Internal Medicine Journal http://bit.ly/16sptD0no reports on the frequency and cost of futile treatment at one academic medical center. Over 3 months in 5 ICUs, the research team found 6.7% of patient days involved futile care. The cost was estimated at $2.6 million.

 

Futility is something I’m unfortunately familiar with. As a palliative care nurse practitioner in a large urban academic medical center, these are often the cases my team is consulted on.  Here are my observations:

 

  1. Futility is in the eye of the beholder- The study defines futility as “sustaining life under circumstances that will not achieve an outcome that patients can meaningfully appreciate”. This definition can be problematic as none of us can really determine what someone could “meaningfully appreciate”. Although most, but not all, critical care clinicians know futility when they see it, that is not the case for patients or families.
  2. Language matters- My experience is that the term “futility” is off-putting to families. If your loved one is critically ill and you want them to survive, nothing the medical team could do would ever be “futile”. And, when we use this term with families, there is a good chance they will be suspicious that our priority is money, rather than their loved one.
  3. Positioning- Framing futility as treatment that won’t achieve the patient or family’s goals is potentially better. It’s important in these situations to determine what families are hoping for. If it’s recovery to the pre-hospital baseline or full functionality, then evidence, including some from this study, suggests that is unlikely. However, even that is hard for families to accept.
  4. It takes time- As with all difficult ICU situations, it’s important to view interaction with families as a process. Which is another argument for starting that process early. When we wait until ICU day 20 to meet with the family, the ICU team is already 3 weeks ahead of them in concluding things are becoming futile. Families need time to catch up and support to do so.

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  • Anonymous

    Medical futility has to be defined very narrowly under the law, when defined at all, because of the propensity to mix up “medical futility” with “fiscal futility” that results often in the inappropriate shortening of life of elderly Medicare/Medicaid patients and charity patients without the informed consent of the patient or the legal surrogate as a matter of fiscal expediency for the hospitals who are l not reimbursed for treatments by Medicare and its private partners, Big Insurance, that is deemed to be over treatment, mistake/error, or a complication thereof. .
    Obviously, the 1991 Patient Self Determination Act intended that elderly Medicare/Medicaid patients with life-threatening cancers/other diseases, etc.. be permitted under Federal Law to determine themselves if life-saving/life-extending treatments or any treatments at all were in their best interests and to refuse medical treatment and shorten their lives to shorten their suffering —-even if the medical treatment refused was not deemed by the physician to be medically futile under some due process of law procedure.
    In order to make this most important decision of one’s life, however, elderly very ill patients have to be educated by their treating physician in terms of the physician’s educated diagnosis and educated prognosis for the cancer/disease being treated.
    Treating physicians (especially the oncologists) were not covered under the provisions of the 1991 PSDA (The AMA lobbied against it —the physicians wanted nothing to do with voluntary patient rationing of care) and believe that they have no legal obligation to SEEK informed consent for one or the other of the two legal standards of care created and reimbursed by the government out of the people’s Medicare purse. There is no money to be made by the treating specialist physicians if educated patients elect to nothing and transition to palliative care/transition to Hospice, as and when necessary.
    If, however, physicians were mandated by The Congress or the Executive to SEEK informed consent for one or the other of the two legal standards of care created and reimbursed under Medicare law and the 1991 PSDA, the problem of defining “futility” in end of life care would be lessened because of the self rationing of educated patients and educated surrogates.
    Wouldn’t it? . .

Can We Talk?
Watch and share this five minute video about the need for prophylactic end-of-life conversations. Laura Heldebrand, an ICU nurse tells her mother's story.
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