Termination process and procedures

Termination Process

When there are patients receiving treatments or interventions that keep them alive, one may face the decision of whether to discontinue treatment. The example is an adult male patient at the HIV Treatment Center on dialysis for acute renal failure and mechanical ventilation for respiratory failure. In this circumstance, the total parenteral nutrition (TPN) treatments are no longer of benefit, even though the patient's family wants them continued.

If the patient had the ability to make decisions, fully understood the consequences of his decision, and stated he no longer want treatment, it would be justifiable to withdraw the treatment. However, treatment withdrawal is also justifiable if the treatment no longer offers benefit to the patient (Braddock 1).

In this case, the treatment is "futile" and may no longer fulfill any of the goals of medicine. "Medical futility" refers to interventions unlikely to produce any significant benefit to the patient. There are two kinds of medical futility: quantitative futility (likelihood that intervention will benefit the patient would be exceedingly poor) and qualitative futility (quality of life that an intervention will produce would be exceedingly poor). "Both quantitative and qualitative futility refer to the prospect of benefiting the patient. A treatment that merely produces a physiological effect on a patient's body does not necessarily confer any benefit that the patient can appreciate" (Braddock 2).

The goal of medicine is to help the sick. The clinician does not have any obligations to apply treatments that do not benefit the patient. Futile interventions often increase a patient's pain and discomfort in their final days and weeks of life. They can also use up finite medical and financial resources on the part of the hospital and family of the patient.

Terminally ill patients provide challenges to ethics in other than cancer cases. In one study, the records of a large urban emergency medical services system were reviewed to identify consecutive patients with cardiac arrest over the 10-month period November 1996 to August 1997. All data were abstracted from the paramedics' ambulance call reports. Terminal illness was determined by proportion, as was the proportion of terminally ill patients with a DNR request. Resuscitative efforts of paramedics were compared for patients with and without a DNR request (Guru, et al. 1251).

In this study, of the 1534 cardiac arrests, 144 (9.4%) involved patients described as having a terminal illness. The mean age of the patients was 72.2 (standard deviation 14.8) years. Paramedics encountered a DNR request in 90 (62.5%) of these cases. Current regulations governing paramedic practice were not followed in 34 (23.6%) of the cases. There was no difference in the likelihood that cardiopulmonary resuscitation (CPR) would be initiated between patients with and those without a DNR request (73% v. 83%; p = 0.17). In patients for whom CPR was initiated, paramedics were much more likely to withhold full advanced cardiac life support if there was a DNR request than if there was not (22% v. 68%; p < 0.001) (Guru, et al. 1251).

Paramedics, as well as nurses, clinicians and physicians are frequently asked to attend terminally ill patients and make abrupt decisions. Often current regulations create conflict between the clinician's duty to treat and the patient's right's to resuscitative efforts at the time of death (Guru, et al. 1251).

The obligations of physicians are limited to offering treatments that are consistent with professional standards of care, although ethical requirement to respect patient autonomy entitles a patient to choose from among medically acceptable treatment options (or to reject all options). It does not entitle patients to receive whatever treatments they ask for.

Transference and Countertransference:

Transference and countertransference are both normal phenomena that may arise during the course of the therapeutic relationship. Transference is the tendency on the part of the patient to "transfer" past feelings, conflicts, and attitudes into situations, circumstances and present relationships. According to psychoanalytic theory, transference evolves from unresolved or unsatisfactory childhood experiences in relationships with parents or other important figures. From a behavioral orientation, patients may have developed habit-forming patterns in how they relate and interact with others. These habits involve development of attitudes and ideas based on the learning and retention of information from past relationships. The habits learned from past relationships may create behavioral and thought patterns in subsequent relationships, even though the actions and attitudes may be inappropriate for the current relationship (Strayhorn, 1982). As caregivers have frequent contact with patients, the potential for caregivers to be objects of transference is significant (Hilz 2).

Countertransference involves the same dynamic, except the direction of the transference is reversed. Countertransference is a normal occurrence as well, involving the clinician's reactions, behaviors, thoughts, and feelings toward the patient. Unresolved conflicts from the past may be involved in this countertransference. A patient who displays childlike dependency toward caregivers may evoke a parental attitude from that person, depending on the iimportance and meaning that he or she assigns to the relationship with the patient. If past conflicts are significant to the present situation, this will interfere with proper care, as well. Caregivers may be completely unaware or only minimally aware of the countertransference as it is occurring (Hilz 6).

There are management strategies for clinicians to deal with this phenomenon, including formulating and using interpretations in ways that do not threaten clients. Not only patients and clinicians but staff members can have problems with transference and countertransference. Communication between staff members in a psychotherapeutic community is very important to the functioning of the team itself, to the community as a whole, and to the treatment of the patients. Transference and countertransference are linked with two levels of communication within a team surface and in the deep structure. Awareness of concepts and strategies to deal with it may be applied in such a way that, what is happening within the team is clear to the team members and the team can function effectively.

Futility Judgments

The ethical authority to render futility judgments rests with the medical profession as a whole, not with the individual physician at the bedside. Futility termination decisions should conform to general professional standards of care (Braddock 2).

Even though a patient may not feel that a particular outcome is worth striving for and reject a treatment, this decision should be based on personal preferences and not necessarily on futility. In such situations, the physician has a duty to communicate openly with the family members and patient about any interventions being withdrawn or withheld and explain the rationale for such decisions. It is important to approach such conversations with compassion, saying to a patient or family, "everything possible will be done to ensure the patient's comfort and dignity" rather than "there is nothing I can do for you" (Braddock 3).

Sometimes, as in the case of the adult male in the HIV treatment center, it may necessary to continue to make a futile intervention available to assist the patient and family in coming to terms with how grave the situation is, in order to allow time for a loved one arriving from another state to see the patient for the last time and have time to reach a point of personal closure. The word "futility" here refers to the benefit of a particular intervention for a particular patient. With futility, the central question is not, "How much money does this treatment cost?" Or "Who else might benefit from it?" But instead, "Does the intervention have any reasonable prospect of helping this patient?" (Braddock 2).

Making a judgment in such grave matters requires empirical evidence and documentation of the outcome of the intervention for other groups of patients. Futility confirms the determination that evidence can show no significant likelihood of conferring any significant benefit. In contrast, it is considered an experimental treatment when empirical evidence is lacking and the outcome of an intervention is unknown. As always, the goal is to cure if possible, or, lacking that, to palliate symptoms, prevent disease or disease complications, or improve functional status (Braddock 2).

Many clinicians feel that it is easier to withhold a treatment, such as mechanical ventilation, than to withdraw it. While some tend to believe this, there is no physical evidence or ethical distinction between the not starting and the stopping of treatment. In numerous legal cases, courts have found that it equally justifiable to withdraw as to withhold life-sustaining treatments. Most bioethicists, including the President's Commission, are of the same opinion. The patient does not have to be "terminally ill" in order for treatment to be withdrawn or withheld, though withholding or withdrawing treatment is done to a patient who has a serious illness with limited life expectancy, in most cases.

Some states have laws that guarantee the right to refuse treatment to terminally ill patients, who are usually defined as those having less than 6 months to live, and have laws that allow other patients to exercise the same right. Many court cases have affirmed the right of competent patient to refuse medical treatments (Braddock 2).

Debating Cardiopulmonary Arrest and Resuscitation

As with our example patient, some patients have a "Do-Not-Resuscitate" order on their chart. But there will also be situations where clinicians are asked to discuss with a patient whether they want to or should have resuscitation if they have had a cardiac arrest or life-threatening arrhythmia. The potential likelihood for clinical benefit in accordance with the patient's preferences for intervention and its likely outcome, involves careful consideration, as with many other medical decisions, in deciding whether or not to resuscitate a patient who suffers a cardiopulmonary arrest. Therefore, decisions to forego cardiac resuscitation are often difficult.

Cardiopulmonary resuscitation (CPR) is a set of specific medical procedures designed to establish circulation and breathing in a patient who's suffered an arrest of both. CPR is a supportive therapy, designed to maintain perfusion to vital organs while attempts are made to restore spontaneous breathing and cardiac rhythm (Braddock 2).

The standard of care is to perform CPR in the absence of a valid physician's order to withhold it, if a patient stops breathing or their heart stops beating in the hospital. Paramedics responding to an arrest in the field are required to administer CPR. Some patients, however, may wear a bracelet that tells a responding paramedic to honor a physician's order to withhold CPR.

There are two general situations which may arise that justify withholding CPR: when CPR is judged to be of no medical benefit, also known as "medical futility," and when the patient with intact decision making capacity or someone designated to make decisions for them clearly indicates that, should the need arise, he or she does not want CPR. Virtually all hospitals have policies which describe circumstances under which CPR can be withheld. (Braddock 4).

When a resuscitation treatment offers no benefit, the physician is ethically justified in withholding resuscitation. It is important to define what it means to "be of benefit." The probability of an intervention leading to a desirable outcome is one way to define benefit. CPR, for instance, has been prospectively evaluated in a wide variety of clinical situations, yet the probability of success with CPR may be used to determine its futility. CPR has been shown to be have a 0% probability of success in circumstances such as septic shock, acute stroke, metastatic cancer or severe pneumonia. And survival from CPR is extremely limited in other circumstances such as in hypotension (2% survival), renal failure (3%), AIDS (2%), homebound lifestyle (4%), and age greater than 70 (4% survival to discharge from hospital) (Braddock 4).

Judging "quality of life" tempts prejudicial statements about patients with chronic illness or disability. CPR lacks benefit when the patient's quality of life is so poor no meaningful survival is expected, even if CPR could restore circulatory stability. There is probably consensus that patients in a permanently unconscious state possess a quality of life that few would accept, so CPR is usually considered "futile" for patients in a persistent vegetative state.

When a treatment is judged to be medically futile, the physician is under no obligation to provide it. But the patient and/or the patient's family should have a role in making the decision whether a DNR order is to be followed. This stems from respect for all people who take part in important life decisions. This is also commonly referred to as respect for autonomy or respect for person (Braddock 5).

If the family disagrees, ethicists and physicians are divided over how to proceed. If there is disagreement, every reasonable effort should be made to communicate the futility to the patient or the patient's family. Sometimes this will lead to a resolution. In difficult cases, however, an ethics consultant can prove helpful in the form of a meeting with the doctors, or with a religious minister. Nevertheless, resuscitation treatments should still be provided to these patients, even if judged futile.

Slow-codes," are a half-hearted effort at resuscitation is made, and are not ethically justified. These undermine the right patients have to be involved in inpatient clinical decisions, and violate the trust patients have in their physicians to give full effort. In some cases, the patient is clearly unable to voice a wish to have treatment withheld or withdrawn. As with DNR orders, there are two general approaches to this dilemma:

Advance Directives and surrogate decision makers (Braddock 5).

Advance directives are usually written documents designed to allow competent patients the opportunity to guide future health care decisions in the event that they are unable to participate directly in medical decision making." (Frequently 1).

Living Wills and Durable Power of Attorney: in some cases, a Living Will may spell out specific decisions while in the Power of Attorney it will designate a specific person to make health care decisions for them. There is some controversy over how literally Living Wills should be interpreted. In some cases, the document may have been drafted in the distant past, and the patient's views may have changed. Similarly, some patients do change their minds about end-of-life decisions when actually faced. In general, when they reflect long held, consistently stable views of the patient, preferences expressed in a Living Will are most compelling. Conversations with family members, close friends, or health care providers with long-term relationships with the patient may determine the patient's views.

Surrogate decision makers: In the absence of a written document, those familiar with the patient's wishes may be very helpful, such as people close to the patient and family. Though all close family members and significant others should be involved and reach consensus, the law recognizes the hierarchy of family relationships in determining which family member should be the official "spokesperson." The hierarchy is as follows: