國(guó)家職業(yè)資格考試培訓(xùn)小型鉆井工程

1、Medical Futility: clarity or confusion?Jay M. Baruch, MDChairman, Ethics CommitteeMemorial Hospital of Rhode IslandFaculty, Center for Biomedical EthicsBrown Medical School祛痘 /ObjectivesExamine the various definitions of medical futility Consider whats at the heart of disagreements involving futilit

2、y judgmentsAddress moral positions of stakeholders, and common pitfalls in “futility” discussions Explore strategies HECs can use to facilitate medically and ethically sound solutionsCase 186-year-old woman in PVS requiring ventilator support, repeated courses of antibiotics, frequent airway suction

3、ing, tube feedings, air flotation bed and biochemical monitoringMedical team suggested to family that treatment be withdrawn because not benefiting the patient.Husband, son, and daughter insist txmt continue.Patients treatment preferences unknown.Helga Wanglie caseHusband said physicians should not

4、play G-dHelga would not be better off deadRemoving life-support evidence of moral decay in our civilizationMiracle could occurHospital went to court to get permission to withdraw treatmentHusbands role as surrogate and his judgment took precedent over teams view of “nonbeneficial” txmt. Angell M.The

5、 case of Helga Wanglie. NEJM 1991;325: 511-512.Miles SH. Informed demand for “nonbeneficial treatment. NEJM 1991;325:512-515.Case 272-year-old with past medical history of DM, anemia, renal insufficiency, CVA, CAD, PVD, Parkinsons, heal ulcers, three hip replacements fell and broke her hip in May 19

6、89.Prior to surgery, experienced multiple grand mal seizures.Afterwards, was posturing, rigid, unresponsive to noise or pain. Per neurology, chance functional recovery dismal.Family refused DNRTracheostomy and gastrostomy tube placedMore seizures, arrhythmias, GI bleeding, DIC, muscle wasting. Chanc

7、e neurological recovery nil.Gilgunn v. MGHICU attending-after multiple meetings with family, ethics consults, and involvement with hospital attorney-weaned patient off ventilator. She died shortly after.1st case in which jury asked to consider legitimacy of values involved in physicians refusal to a

8、ttempt CPR in comatose patient with multiple medical problems out of belief in would be ineffective.Daughter wanted everything done regardless of cost“The familys opinion is relevant only when there is a genuine therapeutic option. For this patient, CPR is not one of them”P(pán)aris JJ, Cassem EH, Dec GW

9、, et al. Use of DNR order over family objections: The Case of Gilgunn v. MGH. J Intensive Care Med 1999;14:41-45.Medical Futilitymoral perspectiveAre the benefits of certain treatments or interventionsusually at the end of life- so remote or limited that physicians may unilaterally decide not to off

10、er them as feasible options, or refuse to consider them despite the patients or surrogates request?Clinical scenariosLife-sustaining interventions for patients in persistent vegetative state ( ie,Helga Wangle)CPR in terminally illDNR without consent“Slow code”Tube feedingOrgan transplantation The fu

11、tility debate Problems with definitionWho defines the terms; who decides that treatment is futile?Ethical implicationsProblems of meaningProfessional standards vs. patients rightsHow is conflict resolved?FutilityDefinition: inadequacy to produce a result or bring about a required end; ineffectivenes

12、s, uselessnessEtymology: futtilisthat easily pours out, leaky, hence untrustworthy, vain, uselessOxford English DictionaryFutility-DefinitionsIntervention has no pathophysiologic benefit* Uncertain or controversial benefitsBurdens/harms/cost benefits Intervention has already failed in the patientMax

13、imal treatment is failingDefinitionsFutility: Objective StandardsLess than 1% likelihood of successTreatment preserves permanent unconsciousness or cannot end dependence on ICU“No survivors after CPR have been reported under the circumstances in well-designed studies.”“Highly unlikely to result in m

14、eaningful survival”Certain medical conditions (ie, met CA, cirrhosis) with poor prognosisSchneiderman LJ et al. Medical Futility: Its Meanings and Ethical Implications. Ann Intern Med 1990;112:949-954. AHA, Emergency Cardiac Care Committee JAMA 1992; 268: 2282-2288.American Thoracic Society Ann Inte

15、rn Med 1991;115: 478-485.Statistical uncertaintyEstimates of probability prone to errorClinical assessment often imprecise tools to determine diagnosis and prognosisApplying empirical data to the particular patientHeuristic strategiesExceptions to the ruleFutility-DefinitionsTreatment(s) will not ac

16、complish intended goalConflicts arise when disagreement about intended goals of treatment:Appropriateness of goals (ie, pulse and respiration if PVS)Qualitative goals: poor likelihood of benefitQuantitative goals: low grade outcome virtually certainConflicts of values, rather than factsEthics Commit

17、tee of the Society of Critical Care Medicine. Consensus statement of the Society of Critical Care Medicines Ethics Committee regarding futile and other possibly inadvisable treatments Crit Care Med 25;1997:887-891Futility and Ambiguity“Hides many deep and serious ambiguities that threaten its legiti

18、macy as a rationale for limiting treatment.”P(pán)lurality of valuesagreement difficultThat goals are not worth pursuing is a conflict of values, not a question of futility.Truog RD, Brett AS, Frader J. The Problem with Futility NEJM 326;1992:1560-1564Are any “futile” treatments futile?Treatments that of

19、fer no pathophysiologic benefit are considered futileCPR for patient with ruptured aortaTreatments where the benefit is uncertain, unlikely, or controversial, should not be considered futile.Address sources of conflict, including goals of treatment, POV about “success”, problems in doctor/patient re

20、lationshipEthical considerationsLanguage and Meaning“part of their physicians angst comes not simply from the pressure to provide burdensome treatment, but also from in inability to find the right language and conceptual framework for talking about the problem with patients and families.” The word “

21、futility” used in multiple and contradictory waysDouble meaningEvaluative judgment (Quality of life assessment) Medical judgment on efficacy of treatmentSolomon MZ. How physicians talk about futility: making words mean too many things. Journal of Law, Medicine, and Ethics 1993;21:231-237.Sources of

22、conflictPatients right to be autonomous and self-determining, to make a plan that reflects his/her own values, interests, goals for futureRespect for diverse values Different interpretations of goods and harmsTreatments that prolong deathIncrease sufferingWorthy optionTime with familyChance of survi

23、valReligious/cultural beliefsPVSDifferent perceptions of personhoodDilemma not simply a result of miscommunication or misunderstanding between involved parties. But a real, substantive difference of values regarding the meaning of life, death, disability, family obligation, etc.Ethical arguments in

24、favor of futilityProfessional integrityPhysicians as moral agents Patients cant make unrestricted demands for certain treatmentsProfessional expertiseBased on scientific evidence, not opinion or biasThe physician isnt morally required to offer non-beneficial treatment.Must the physician even discuss

25、 “futile” treatment with patients or surrogates?Stewardship of scarce resourcesGuardian of ICUEthical considerations against futilityPatient autonomyInformed consentPrognostic uncertaintyCompeting valuesPatient or surrogate in best position to decide on questionably beneficial treatment optionsLast

26、vestiges of paternalismUndermines pluralistic societySocial consensusPitfalls in discussionDefinition slipperyMisuse of empirical dataOpinions disguised as dataDecision-making reduced to struggle between patient autonomy and autonomy of clinicianGoals not clarified: what parties believe will be achi

27、eved by treatment or intervention.Subjective perceptions of quality of this lifeNo established transparent process to resolve disputes Helft PR, Siegler M, Lantos J. The Rise and Fall of the Futility Movement. NEJM 343;2000;293-296.Presidents Commission on Biomedical EthicsRejected position that a p

28、hysician could withhold futile CPR without patients consentFound “it necessary for the patient or surrogate to have given valid consent to any plan of treatment, whether involving omissions or actions.”Deciding to Forego Life-Sustaining Treatment. Washington, DC:Presidents Commission for the Study o

29、f Ethical Problems in Medicine and Biomedical and Behavioral Research.1983:240-241.“The health care professionals value judgment that although a treatment will produce physiologic benefit, the benefit is not sufficient to warrant the treatment, should not be used as a basis for determining a treatme

30、nt to be futile.”Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying: A Report of the Hastings Center. Briarcliff Manor, NY:Hastings Center; 1987:32.“The physicians obligation to respect a patients decisiondoes not require a physician to provide a treatment that is n

31、otmedically soundSound medical treatment is defined as theuse of medical knowledge or means to cure or prevent amedical disorder, preserve life, or relieve distressingsymptoms.”Council on Ethical and Judicial Affairs, American Medical Association. Decisionnear the end of life. JAMA 1992;267: 2229-22

32、33.Which value judgments are reasonable?Societal consensus Professional integrityPhysicians as moral agentsDo no harmRole of profession in assessing the “good”P(pán)rotection of patient autonomyIllusion of choice Working through family/physician conflictPhysician-family conflicts with life-sustaining tre

33、atments: family issuesDont understand medical situationDenialcant recognize facts because of unacceptable psychological consequences (ie, grief or guilt)May lead to focus on trivial but controllable mattersDenial may be “misdiagnosed” as misunderstandingBad news poorly processed and not remembered w

34、ellPhysicians communication styles misunderstandingJargon: “usually” “most of the time” “cannot rule out” “futile”Semantics: “death with dignity” “everything done” “vegetable”Multiple sourcesTV, internet, friends, relativesMultiple voices of heath care teamGoold SD, Williams B, Arnold RM. Conflicts

35、regarding decisions to limit treatment. JAMA 2000; 283:909-914.Physician-family conflicts with life-sustaining treatments: family issues (cont)Guilt of family members“I cannot do this” “I wont be able to live with myself”P(pán)hysicians require they take responsibility for medical decisionsFear of abando

36、nment“withdrawing care” “CMO” “Stopping care.”Intrinsic family issuesConflict of interestValuesImproving family understandingAsk family to verbalize the patients history, what other providers have told them, and their understanding of clinical situation.Help identify gaps or incorrect informationSli

37、ce in a larger storyAsk family to explain choicesassess reasoning skills and competenceEducational appropriate languageOpen-ended listening and validating familys emotionsPrimary communicatorImproving family understanding (cont)Explore cause of denialRepeat key conceptsVerbal and written information

38、Encourage questions“Can you tell me your understanding of the situation?”Family guilttake responsibility off surrogateSubstituted judgmentAddress abandonment- set positive goals and recommend means to achieve them. (ie, maximum comfort)Physician limitationsUncomfortable with prognostic uncertaintyUn

39、comfortable with death and medical failureRespond defensivelyUnderestimate quality of life of chronically illDont pay attention toReligious beliefs of family especially regarding sanctity of lifeHow cultural differences impact medical decisionsInsecurity about skills in end of life care Misunderstan

40、ding ethics/law Fatigue, frustration, stress Development of a futility policyFutility policy-purposeTo promote appropriate treatment in those clinical situations where patients/surrogates request treatment that physician believes isnt medically indicated.Establish standard transparent process to res

41、olve disagreements.Establish mechanisms that recognize and clarify values and goals of the involved parties with aim of establishing richer understanding of treatment options.Define termsFutilityTreatment goalsDecision-making capacityLife-sustaining treatmentComfort care/palliative care“Futility” po

42、licy developmentDefinitional policiesProbability of success or quality of outcomeIdentify specific conditions with extremely poor prognosisHowever, insensitive to values of individual patientsProcedural policiesConflict resolution: spells clear process for judgmentAccounts for beliefs, values and pr

43、eferences of patientPrognosis relevant, not necessarily determinative Review cases-inquiryWhy wouldnt treatment achieve intended goalsIf txmt has clinical effects, why would it fail to benefit patientWhy did patient/surrogate disagree with team?Effect of conflict on patient/family?Effect on treatmen

44、t team (nursing*)What efforts attempted to resolve issueSecond opinionClergy, social workEthics committeeProcedural responseDocument carefully why treatment considered “futile”Second opinion from physician not part of txmt teamInform patient/family of decision and explain whyShould patient/proxy obj

45、ectGood faith communicationSocial work/clergy/psychiatristRole of hospital ethics committeeInvolve familyDocumentation in medical recordFollow upThird party-hospital staff involvement-legalNotification of decisions to patient/familyAppellate mechanismsCriteria for transfer to another institutionElements of futility policyAll health care institutions should adopt a futility policyD