Sunday, August 16, 2009

Medical Futiliy: Aiming for a ‘Hole-in-One’


Consider this hypothetical vignette. Tiger Woods accepts my challenge to play 18 holes. Obviously, the gallery would be packed with golf enthusiasts who would cancel job interviews, vacations and even worship services in order to witness this historic competition. Spectators would be permitted to place bets at even money. Perhaps, my mother would bet on me, but no other sane person would. They would properly conclude that even my best performance against Tiger’s worst would be inadequate. There is nothing I could do to change the outcome. All of my efforts would be futile.

Futility cannot be proved with mathematical certainly. After all, Tiger could develop acute appendicitis on the fairway and have to forfeit. He could be arrested. Lightning could strike. Killer bees could take him down. Nevertheless, the overwhelming odds are that I would be vanquished and humiliated.

Medical futility is a more serious issue that exists in every physician’s office and hospital in the country. Examples can be mundane such as a physician prescribing (or a patient demanding) antibiotics for the sniffles or a viral infection. This treatment is futile; it does no good. Medical futility is usually a controversy that involves end of life care when treatments are initiated or continued that won’t change the outcome. Many of these patients may have already ascended a few rungs up the ladder to the next world.

While physicians must not hasten death, we should not provide futile care. This expends resources, generates unrealistic hopes and demoralizes the medical professionals who are caring for the patient. Why is it done? It is often demanded by families who insist on more medical care and consultations. Sometimes, this is a guilt reaction. Often, they simply cannot accept the outcome. They deny. Or, they may think that the doctors are wrong. These families all know the rare anecdotes of folks who awaken from long comas ready to play chess. Since doctors cannot be 100% sure of anything, they press on hoping for a miracle. Finally, since hospital bills are usually paid by third parties, patients and families have every reason to pursue medical care against all odds.

Medicine is an imperfect discipline. If a patient or a family expect an inviolable guarantee that our advice is correct, then we can never satisfy them. Our job, as physicians, is to empathize and to guide them toward a rational plan. While the views of the family are important, our professional obligation is to serve as the patient’s advocate. When our medical judgment and experience convince us that surgery, a respirator, antibiotics or a colonoscopy are futile, we shouldn’t permit them. Patients should not receive treatments that medical professionals overwhelmingly feel would offer no benefit. In addition, is it fair for others to pay for futile care?

Of course, physicians should approach these issues delicately, but patients and families must be discouraged from pursuing a futile path. These bedside discussions can be difficult and consensus is not guaranteed. But, the goal is worth the effort.

Golfers, have you ever hit a hole-in-one? While this outcome is never impossible, would you bet large sums of money on it? If so, then you might also bet on me in my imaginary contest against Tiger. If you did, all your prayers for my victory would be futile. We can’t win at golf or practice medicine when our only hope for success is divine intervention.

9 comments:

Evinx said...

Well said and well written.

Maurice Bernstein, M.D. said...

Your analogy may have failed since today Sunday August 16 2009 a remarkable event occurred.

A "virtual unknown", Y.E. Yang, won the PGA Championship winning over Tiger Woods by 5 strokes despite the 5 stroke lead Woods had entered to the final round. Thus a point to remember: what seems futile at first may not eventually turn out to be. On the other hand, don't alway count on it. ..Maurice.

Michael Kirsch, M.D. said...

Quite a victory, I agree, but no hole-in-one here. Woods just wasn't up to par.

Club 166 said...
This comment has been removed by the author.
Club 166 said...

You are right, in that we (both the public and the physicians) should not pursue medical futility.

The problem becomes when one allows those whose only "skin in the game" is that more care costs them money (the hospital, the govt., insurers) be the final arbiters of such decisons.

Ideally, difficult conversations between physicians and family should result in agreement on the right decision. Failing that, there needs to be some sort of independent analysis available (such as a truly independent ethics committee) to assist in these matters.

Joe

Stephen Drake said...

One problem I have with these rationally presented arguments is that I'm expected to "play" with a deck that has been stacked. Like the term "end of life," "medical futility" is a very flexible and even expansive term. This is especially true when the "futility" judgments are *value* judgments - based on the idea that the belief that the life of the person saved is not one worth saving.

Recently, Laura Hershey wrote about this in US News and World Report (http://www.usnews.com/articles/opinion/2009/08/10/handicap-is-not-a-death-sentence-and-should-not-be-treated-as-one.html). She described, among other things, how the Univ. of Wisc Hospital is being sued for the denial of antibiotics to two people with developmental disabilities who had pneumonia.

She also gave an abbreviated version of the story of my coworker Terrie Lincoln, whose family had to fight the medical staff to continue treatment after Terrie broke her neck 12 years ago. Had the medical people succeeded in pressuring the family, I'm sure it would have been looked back on as an "end of life" decision that saved Terrie from burdensome "futile" care.

Her full story can be found here:

http://notdeadyetnewscommentary.blogspot.com/2009/06/terrie-lincoln-how-i-didnt-die-part-1.html

And if you read the story, I doubt that an ethics committee (not even a non-rubber-stamp one) would have made a difference. In Terrie's case - and in most of the similar stories we hear - none of this ever gets near an ethics committee.

How do you rein in this type of behavior? How do you actually enforce the ideal that medical professionals distinguish between their professional judgments and personal biases?

Anonymous said...

I love the last line in this blog, I think I will Tweet it! Lynn

Michael J. McFadden said...

Dr. Kirsch, just so you know in case you're using a cut 'n paste: your media and democracy link was spelled mdwhistle*L*blower

Excellent post there by the way!

:)
Michael J. McFadden
Author of "Dissecting Antismokers' Brains"

Glenda said...

Doctor, you said, it isn't fair for other to pay for futlie care. But--we are--the federal gov't is forcing ALL taxpayers to pay for futlile care. I am a retired RN. My hubby and I own and operate a small grocery store in upstate NY since 1978. ALL day long for all these years I witness our food stamp customers purchase candies, chips, dips, sodas, ice creams and confections. No toilet paper--but all the candy bars they can eat. Oh--in the past several years--these kids waddle up to the register with arm fulls. It IS allowed. Junk--junk--junk. I was told back in '78 when I questioned this--it was so these kids would not feel different than cash paying people. Back then--the kids were skinnier. It's just not the same today. These kids are getting so fat. It breaks my heart.

I rather think it would be a huge money savings to us all if we would require all cashiers to have nursing degrees--so while they check out these junk foods they can give insulin injections at the same time--bill the feds in one swoop. Maybe eliminate an agency.

Seriously, doctor--it is getting bad. NOBODY is talking about this. It is the 800 pound elephant in the room. (I think some of these kids are getting close to that, any ways.)

This is tax dollars blowing it in one way and out the other. Going at both ends. So damn dumb.

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