Nursing: Ethics of Medical Futility - Term Paper Example

Withdrawal And Withholding Care For Critically Ill Patients Health Care Ethics Final Paper April 13th, 2009 Karanja Kabuga MGH Institute of Health Professions The recent advances in medical technology have changed the management of terminally ill patients and death. The growing medicalization of death has resulted in human acts of interventions nearly totally replacing the natural processes of death and dying. With the almost daily discoveries of drugs that can do wonders and the perfection of medical procedures, critical illness as such can no longer be thought as having a natural progression towards a definite solution. Today, death is no longer a domestic family occurrence. Rather, end of life care involves decisions as to whether to do more tests perform procedures or begin or withdraw medication. There is broad general social consensus that treatment too burdensome for the benefits it promises may be withheld or withdrawn (Monagle and Thomasma, 2009). Such decisions are solely based on the principle of patient autonomy; which is the moral claim that people enjoy moral of sovereignty over themselves, while balanced by the larger societys goal of preserving life. At what point during caring for people do we, as a society decide that enough has already been done and time for the natural process to take place? With the ever increasing cost of health care, that question has never been more relevant. There are several high profile cases that serve to highlight the complexities of these issues and I will highlight a couple of cases. I work in a long-term healthcare facility where decisions are made almost daily on how aggressively to treat patients with poor prognosis. Often, family members make decisions which are consistent with the best interest of the patient. On many occasions, decisions are made (usually by the responsible persons) to continue aggressive treatment even when the outcome is hardly in doubt, and usually contrary to advice from nurses and doctors. The following is one of the well publicized cases which focus our attention on this issue. In mid May of 1989, Catherine Gilgunn, a 71 year-old resident of Charlestown, Massachusetts, fell in her home and injured her left hip. She had been hospitalized three times before to repair a broken hip, and was reluctant to go to the hospital one more time. She had been in generally poor health for many years, with diabetes, heart disease, and chronic urinary tract infections. She was recently diagnosed with Parkinson’s disease, and also recently received a mastectomy for breast cancer. Moreover, she had suffered a stroke the year before, from which she never fully recovered. Catherine’s 30 year-old daughter Joan, her primary caregiver, took her mother to Massachusetts General Hospital (MGH) on June 7, 1989 several weeks after the fall. Nine days later, before surgery could be performed, Catherine suffered two grandmal seizures, followed by repeat seizures that could not be controlled until June 29th. Before the seizures could be brought under control, she suffered extensive brain damage, resulting in a coma. Joan, who was the surrogate, informed the physicians (with the approval of Mr. Gilgunn and the other five children) that Catherine always said she “-wanted everything done-” that was medically possible. The hospital went ahead and made her a DNR against the familys expressed wishes citing that CPR was not a genuine therapeutic option , and that the familys inability to prepare for the inevitable did not justify mistreating the patient. (Carpon, 1995). The attending physician also began to wean Catherine from the ventilator, since he regarded her as imminently dying. Her blood gases were not monitored during the weaning, because Dr. Dec did not expect her to survive on her own. Three days later, on August 10, 1989, Catherine Gilgunn died. When a patient or the familys wishes conflict with the medical team and common sense takes precedence above patient rights, then a conflict is created. As an article in the New York Times put it “We now have the idea that not only does patients rights mean that I can turn down any treatment but we have the idea that patients and their surrogates can demand treatment and physicians are obligated to provide it.” One of the first principles of healthcare is that of nonmaleficence; to do no harm and only benefit. The hospital in this case took the view that continued provision of care, was “futile” and would amount to doing more harm than good. The patient was comatose and could not experience pain, however, doing anything that would prolong suffering without providing sufficient benefit would be considered harm. The family could argue that harm has been inflicted on the patient because there has been a violation of autonomy when care is not provided. The principle of beneficence, states that we are morally obligated to engage in altruistic or beneficent acts. Healthcare workers must take positive and direct steps to help patients; hence it could be argued that the physician based his decision on the beneficence principle, since he felt that there was no therapeutic reason to continue treatment. The final principle is autonomy; For instance in this case, the patients family clearly has made the choice to continue with treatment irrespective of the doctors opinion. The conflict emerges because the decisions are inconsistent in the eyes of the healthcare providers. Current emphasis on patient autonomy in medical decision making has been stimulated by societys increasing divergent moral views and an attempt to protect and respect personal values (Klienman and Khan, 2009). It has lead to the unintended consequence “of neglecting an earlier valid maxim that long defined physician obligations to patients: namely, that futile treatment are not obligatory”. Further, acting autonomously requires that individuals be aware of their limitations. (Clarke, 2000). In summary, it is difficult for a health care provider to work knowing that in their professional judgment, there will be no positive outcome; hence, the healthcare provider is not required to provide treatment simply because it is demanded by patients or their surrogates. (Kolata, 1995) The futility concept was at the center of this decision, and can be defined as actions that do not provide therapeutic benefit to the patient (Terra, 2006). Schneiderman, one of the pioneers of the futility movement, argues that the goal of medical treatments is to provide a benefit, not just an effect. (Schneiderman, 1996). Healthcare workers are not obligated to start interventions just because they are demanded by the patient or surrogate. The other closely related issue which is hidden beneath these ethics arguments is the question of expense. In these times of cost containment, can hospitals afford to provide care that doctors say is futile? From societys point of view, it is clear that we cannot continue to pour money and resources into care for a patient who cannot possibly benefit. One has to consider societys needs as well as individual patients requirements in determining the type and amount of medical care to deliver. The principle of distributive justice and proportional advocacy in decision-making is useful as a guide. As a society, we have to prioritize our care appropriately with limited resources (Zajac, 1996). Economic theory is often based upon the philosophy of utilitarianism. The foundation of utilitarian philosophy is "the greatest good for the greatest number." In other words, utilitarian philosophy suggests that decisions be made with the ultimate objective of maximizing societal welfare. Sometimes this choice is easy, but it can also be very difficult when it comes to placing a value on an individual human life and health. The decision is arrived at after consultation between the patient and the healthcare team based on the patient’s values about life and the way it should be lived, as well as and the patient’s attitudes towards sickness, suffering, medical procedures, and death. Technological advances in our ability to keep patients alive have outpaced our ability to help them return to a reasonable quality of life. The challenge here is to help families make this decision in the most humane way possible. These decisions are not limited to ICUs or hospitals. One of the patients I had been taking care of for a long time was a dialysis patient from the time I met him. He had been admitted to the rehab center after a cerebral vascular accident that left him with right sided weakness, and he also had chronic back pain. Initially he was able to express his needs, was self directed and seemed to enjoy the company of his family whenever they came to visit. Over the course of several years, his health continued to decline: he was mostly confined to bed, he became incontinent, he was more confused and his pain management was more difficult. He would on many occasions refuse his medication while crying out loudly in pain the next minute. Other times, he would refuse to go for his dialysis treatment which was at outside location requiring ambulance transfer three times a week. He was sent to the hospital on many occasions. For health insurance, he had Medicaid. Many meetings were held with the family to evaluate his plan of care and the family insisted on continuing the current level of treatment. This is one of many instances where patients autonomy conflicts with the principle of utility. The patient or in this case the surrogate has the right to determine what is best for him or her. This principle would function well if the patient were using private resources assuming they have the means to do so. Anyone could spend whatever amount they wished on their health if they privately paid for it without affecting anyone elses care. But currently, one persons choice of what resources to use affects the availability of resources to everyone else in the system. We agree that healthcare resources are fixed and the needs and demands for health resources are not, allocating resources to one patient means less is available to others. (Cook and Gioacomini, 1999). As society promotes the patients freedom to request whatever medical interventions available, it has to be balanced with cost and the likelihood of benefit. (Morrison & Mongale, 2008) There have been instances during my clinical rotation where families make choices to continue treatment of their loved ones even as when it is very evident that there is minimal gain to the welfare of the patient. Viewed through the lens of utilitarianism, the expenditure of large amounts of scarce resources for what in most cases is minimal gain or to satisfy the familys/surrogates feeling of having done “everything” is not desirable. Would we expect the same response from the family if they knew the real cost of their decisions? Our healthcare system currently insulates financial concerns from health decision in most cases. But that has lead some people to completely disregard the financial implications of their decisions, and how those decisions affect the care of others within the system. As one the administrators dealing with Mrs. Gilgunns case said “when inappropriate denial on the part of families cannot be broken through, its very hard to spend ones time adjusting ventilators, adjusting medications, to no positive end. It becomes disabling for the health care team”. (Kolata, 1995). Hence the doctors decision is the only choice left. In conclusion, the heathcare team does not have a responsibility to provide futile or unreasonable care to an insistent patient or family. Society, and not the individual provider, must make the decision and create guidelines limiting the availability of life-sustaining treatments. References Cook, D., & Giacomini, M. (1999). The sound of silence: rationing resources for critically ill patients. Critical Care forum, 3(1), R1-R3. Kleinman, I., & Khan, P. (2009). Relative treatment futility. Journal Of The Arts And Science In Medicine, 10 (2). Retrieved from http://www.humanehealthcare.com/Article.asp?art_id=508. Kolata, G. (1995, April 3). Withholding Care From Patients: Boston Case Asks, Who Decides? The New York Times. Retrieved from http://www.nytimes.com/1995/04/03/us/withholding-care-from-patients-boston-case-asks-who-decides.html Monagle, J. & Thomasma, D. (2004). Health care ethics: Critical Issues for the 21st Century, (2nd ed.). Sudbury, MS: Jones and Bartlett Publishers. Morrison, E. E. & Monagle, J. F. (2008). Health care ethics: critical issues for the 21st century. Sudbury, MA: Jones and Bartlett Publishers. Schneiderman, L, Jecker, S., Jonsen, A. (1996). Medical Futility: Response to critiques, Annals of Internal Medicine. 125(8), 669-674. Terra, S. (2006). Approach to Medical Futility in a Community Hospital: Is Use of a Prognostic Scoring System Applicable. The Internet Journal of Allied Health Sciences And Practice, 4 (4). Wanzer, S., Fedeman, D., & Adelstein, S. et al. (1989). The physician’s responsibility toward hopelessly ill patients. A second look. New England Journal of Medicine. 320 (13), 844-849. Zajac, Edward. (1996). Political Economy of Fairness. Cambridge, MA: MIT Press. (Carpon, 1995) (Clarke, 2000) Read More