Monday, November 01, 2004

When further treatment is futile....

"In many cases, when a patient is irreversibly ill and dying, resuscitation is simply not an option and is futile. For example, for a patient whose glioblastoma has advanced to the point at which the patient is semicomatose and he or she will die with or without treatment, CPR is not a medical option. Application of it is contrary to the standards of medical practice, unethical, and inhumane. The family who asks that CPR and all life-saving treatment be withheld or withdrawn from such a patient should be obeyed by the physician inclined to provide it. Likewise, in such a case, the physician does not have a duty to consult anyone before writing a DNR order. We recommend that the physician take the opportunity to remind the family just how severe the illness is and that appropriate attention is being given to the needs of the patient: "It is important for you to know that your father's condition has reached the point where he will die with treatment or without it. We will direct every effort to maintaining his comfort and dignity. Treatments like resuscitation or countershock would only brutalize him and he has been protected from them by specific written order."..."No physician is required to provide harmful treatments to a patient...No physician is required to provide useless treatments either." (from Mass General Hospital's Handbook of General Psychiatry, chap. 23, by Ned Cassem MD SJ and Rebecca Brendel, MD, JD)

Several weeks ago, NPR interviewed a med student who was disturbed by one of his cases. As I recall, his patient was terminally ill, and had demanded that the doctors "do everything." The patient was "full code." When the patient lapsed into an irreversible coma, the physicians and family quietly changed his care plan to "do not resuscitate." We don't know the source of this patient's desires for "everything" to be done, nor any discussions that may have laid out what "everything" means. But at some point, a doctor might have said, "When further treatment causes you nothing but suffering and is futile, then we will inform you and your family. There will be no breathing machine, no resuscitation, if those measures are futile, and if the only result is that you would suffer. At that point, all of our efforts will be focused on your comfort and dignity alone." I wonder how the patient would have responded...or how he did respond, when offered this information.

Update: I'm unhappy with the title of this post. I've renamed it, so Blogger has re-published it. One obvious unanswered question: at what point is care determined to be futile? Who decides? Can reasonable people disagree? Perhaps that's for another post.

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