Medical futility and treatment withdrawal in terminal illness

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).

Adult siblings of patient (all in agreement) (Braddock 5)

As long as a patient remains competent to participate in medical decisions, both Power of Attorney for Health Care documents and Living wills and are revocable. Decisions by competent patients supersede any written directive (Frequently 1). Sometimes the patient is awake, alert, and conversant, but their decisions seem questionable or irrational. First, it is important to distinguish an irrational decision from simple disagreement. If you feel strongly that a certain course of action is "what's best" for the patient, it can seem irrational for them to disagree. In these situations, it is critical to talk with the patient and find out why they disagree.

In general, the capacity to make treatment decisions, including to withhold or withdraw treatment, is considered intact if the patient:

understands the clinical information presented appreciates his/her situation, including consequences with treatment refusal is able to display reason in deliberating about their choices is able to clearly communicate their choice (Braddock 5).

If the patient does not meet these criteria, then their decision to refuse treatment should be questioned, and handled in much the same way as the clearly incompetent patient. When in doubt, an ethics consultation may prove helpful. A psychiatric consult may also be most helpful in these situations. Patients with active mental illness including depression should have their decision making capacity evaluated carefully. Depression and other mental disorders should prompt careful evaluation, which may often be helped by psychiatry consultation (Braddock 2).

The question of whether to withhold fluids underscores the importance of clarifying the goals of medical treatment. Any medical intervention can be withheld or withdrawn, including nutrition and IV fluids. At all times, patients must be given basic humane, compassionate care. They should be given a comfortable bed, human contact, warmth, and be kept as free from pain and suffering as possible. While some believe that food and fluids are part of the bare minimum of humane treatment, both are still considered medical treatments. Several court cases have established that it is justifiable to withhold or withdraw food and fluids.

It is rarely justifiable to discontinue life-sustaining treatment for cost reasons alone. There are rare situations in which costs expended on one terminally ill patient could be clearly better used on another, more viable patient. Even so, such decisions must be carefully considered, and made with the full knowledge of patients and their surrogate decision makers (Braddock 5).

The example patient is being treated at the HIV treatment center, and his cancer has metastasized. Patients with metastatic cancer often suffer from profound cachexia, attributable to their inability to get adequate caloric intake from eating alone and the metabolic effects of their cancer. total parenteral nutrition (TPN) is able to provide protein as well as nonprotein nutrients to reverse the catabolic effects of illness. TPN has a number of potential complications, such as those related to infection from the central line catheter site.

In this case, the goals of therapy must be carefully evaluated, as they relate to TPN. Is TPN likely to offer the patient any benefit? If life expectancy can be prolonged with additional chemotherapy, it may be reasonable to give TPN to allow the patient to enjoy that benefit. However, in this case, additional chemotherapy offers no substantial increase in quantity or quality of life. In actuality, TPN could become another burden for the patient without any meaningful benefit, and ought to be withheld.