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Transcript of Medical Futility
1. Summarize definitions of
II. Analyze ethical, economical,
and political issues related to
III.Formulate possible solutions Carey Heck, Danielle Kohler, & Christina Whitehouse Case Study Ethical Principles The Belmont Report (1978)
Ethical principles in evaluating issues concerning research using human subjects Utilitarianism
no one principle could over-rule any of the others Greatest benefit to most people
Actions right or wrong based on consequences (consequentialism)
Do what “is right”
Regardless of personal feelings or societal constraints
Concerned with fairness UTILITARIANISM Nonmaleficence
Primum non nocere (first do no harm)
Doing good PRINCIPLISM Autonomy
right to make own decision
Actions should be fair to those involved
Extenuating circumstances may affect principle
“An injustice occurs when some benefit to which a person is entitled is denied without good reason or when some burden is imposed unduly” (Belmont Report) ETHICAL CONFLICTS Disagreement about issue
Perception of unfairness in the process
Emotional response to the situation Moral Distress Classic definition
“psychological disequilibrium and a negative feeling state experienced when a person makes a moral decision but does not follow through by performing the moral behavior indicated in that decision” (Wilkinson, 1987)
Newer research advocates including unresolved or unsettling conflict in the definition (Pavlish et al., 2011) Consequences Cost
Unhealthy work environment
Impact on quality outcomes
Regulatory reporting Futility THE PROBLEM There is a general agreement that physicians are not required to provide futile care.
Who defines what futile care is? DEBATES Cost Payment for futile treatment usually comes from private or public collective resources or from a social insurance program such as Medicare or Medicaid.
The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006. The Congressional Budget Office estimated, prior to the 2010 health carereform, that total U.S. spending on health care would reach:
25% of the gross domestic product (GDP) in 2025
37% in 2050, and 49% in 2082. Resource Allocation Resources are scarce, so limits are necessary in a health care system.
Rationing refers to the withholding of effective treatments which cannot be afforded. ARE WE RATIONING CARE? Solutions & Tools AMA Opinion for End of Life Care
Advanced Directives Discuss in advance.
Attempt to negotiate disagreements.
Involvement of an institutional committee such as the ethics committee if warranted.
Can transfer care to another physician.
Can transfer care to another institution.
If transfer is not possible, the intervention need not be offered. American Medical AssociationOpinion 2.037 - Medical Futility in End-of-Life Care AMA ADVANCED DIRECTIVES Living Will
Is a document where an individual communicates specific wishes about life support and other medical treatments.
Basic or Fundamental
Durable Power of Attorney for Healthcare (DPAH)
Names someone who would be responsible for healthcare decisions if the individual is unable to do so.
An individual can direct how an agent will make choices for them and when the agent is authorized to make choices for them. DISADVANTAGES/BARRIERS TO LIVING WILLS
Individual may not fully comprehend the clinical treatments required in a life-threatening situation.
Individual may not have clear treatment preferences.
Reluctance to commit preferences in writing.
Limited influence on end-of-life care.
Family/Care provider beliefs. Advantages/Barriers Barries to completing advanced directives:
Barriers to completing the form itself:
Layout Implementation problems of advanced directives
Poor proxy representation
Care provider adherence
Individual factors Regulation/Legal The Joint Commission (TJC)
Patient Self-Determination Act (PSDA)
Passed in 1991
Pennsylvania Act 169 Patient admitted to the Trauma Intensive Care Unit at a large academic medical hospital s/p MVA
Prolonged extrication with report of anoxia prior to intubation
GCS = 5 (1+1+3)
Worsening pulmonary status ARDS Maximal support is being provided
Multiple vasoactive gtts to support BP
Full code per family’s request Medical futility defined...
Patient has a lethal or imminent prognosis
Evidence exists that suggests therapies cannot/will not
achieve a physiologic goal
extend the patient’s lifespan
increase the patient’s quality of life Futility debates begin when healthcare provider assessments of the benefits and burdens of treatment differ from the assessments of patients, families or other members of the healthcare team Aren’t we entitled to the best healthcare whenever it’s available?
What are the unintended consequences? Ethics, Cost, and Policy Patient is 22 years old Patient is 92 years old In summary... References Baily, M., Ann. (2011). Futility, autonomy, and cost in end-of-life care. Journal of Law, Medicine & Ethics, 39(2), 172-182. doi:10.1111/j.1748-720X.2011.00586.x
Baumrucker, S.J. (2007). Durable power of attorney versus the advanced directive: Who wins, who suffers? American Journal of Hospice & Palliative Medicine, 24 (1), 68-73.
Donley, G., & Danis, M. (2011). Making the case for talking to patients about the costs of end-of-life care. Journal of Law, Medicine & Ethics, 39(2), 183-193. doi:10.1111/j.1748-720X.2011.00587.x
Gilmer, T., Schneiderman, L. J., Teetzel, H., Blustein, J., Briggs, K., Cohn, F., & Young, E. (2005). The costs of nonbeneficial treatment in the intensive care setting. Health Affairs, 24(4), 961-971. Heron, M. (2010) Centers for Disease Control. Deaths: Leading Causes for 2006. National Vital Statistics Report, 58 (14).
Jezewski, M.A., Meeker, M.A., Sessanna, L., and Finnell, D.S. (2007). The effectiveness of interventions to increase advanced directive completion rates. Journal of Aging and Health 19 (3), 519-536.
Koch, T. (2011). Care, compassion, or cost: Redefining the basis of treatment in ethics and law. Journal of Law, Medicine & Ethics, 39(2), 130-139. doi:10.1111/j.1748-720X.2011.00583.x
Martinez, L. G., Pope, T. M., Day, L., & Sherman, D. A. (2009). Controversies abound in end-of-life decisions... day L. medical futility, personal goods, and social responsibility. am J crit care. 2009 may;18(3):279-82. American Journal of Critical Care, 18(5), 401-403. doi:10.4037/ajcc2009413 Medicine & Ethics, 39(2), 172-182. doi:10.1111/j.1748-720X.2011.00586.x
Niederman, M. S., & Berger, J. T. (2010). The delivery of futile care is harmful to other patients. Critical Care Medicine, 38(10), S518-S522.
Pavlish C, Brown-Saltzman K, Hersh M, Shirk M, Nudelman O. (2011). Early indicators and risk factors for ethical issues in clinical practice. Journal of Nursing Scholarship, 43(1), 13-21. doi: 10.1111/j.1547-5069.2010.01380
Roessel, L.L. (2007). Protect your patients’ rights with advanced directives. The Nurse Practitioner, 32 (8), 38-43