Medical Futility Blog

The effect on survival of continuing chemotherapy to near deat

2012-01-27T19:29:00.000-05:00

Rarely, but sometimes, a medical intervention is not just qualitatively or quantitative futile but actually physiologically futile. In the latest issue of BMC Palliative Care, Akiko M Saito and colleagues found:

About one tenth (8.5%) of patients who had ever received chemotherapy were still receiving chemotherapy within 14 days of death; this population experienced no survival benefit as determined by three different statistical approaches. These patients were also much less likely to receive hospice care or and more likely to receive it for three or fewer days. These results suggest that patients receiving chemotherapy within 14 days of death do not benefit from this aggressive approach to treatment, and they may also be deprived of good palliative care provided by hospice.

The authors conclude:

We could not detect a benefit in survival from continuing chemotherapy close to death. Furthermore, this treatment was associated with substantially reduced use of palliative hospice care. The Health Services Research Committee of the American Society of Clinical Oncology (ASCO) agreed that treatment could still be recommended, even without an improvement in survival, if it improves the quality of life in the case of metastatic cancer. Our data suggest that an aggressive approach to continuing chemotherapy to very near death likely does not meet this test in that it may result in no survival benefit, and, in fact, in negative outcomes. It is imperative that physicians present honest, individualized, evidence-based information to patients making treatment decisions near the end of life about the expected risks and benefits of chemotherapy.

In re AK -- CCB Supports Physician over Surrogate

2012-01-27T01:00:00.001-05:00

In a futility case from last month, the CCB ruled that a surrogate's refusal to accept a physician's treatment recommendation was not in accordance with the principles for giving or refusing consent to treatment as set out in Ontario Health Care Consent Act.

Interestingly, while the patient's son and other family did produce evidence (including a letter from the patient's Rabbi) that the patient would have wanted to continue LSMT, the board did not not find that evidence credible. The board instead decided the case on an objective standard. "The issue of the best interests for AK and the quality of the patient’s life was subverted by the family’s actions. . . . PK put his own views ahead of the expert opinions of AK’s treating physicians. In our opinion, PK was totally wrong."

AK, A PATIENT OF YORK CENTRAL HOSPITAL RICHMOND HILL, ONTARIO, 2011 CanLII 82907 (ON CCB).

Futile Care Disputes Belong in Court

2012-01-25T23:50:00.000-05:00

I am just starting to emerge from a bog of exam grading and manuscript deadlines. So, blogging has been light. I did want to note Wesley Smith's blog post commenting on my and Doug White's recent JAMA article. Perhaps the final line is my favorite: "On that point, at least, White, Pope, and Smith agree."

The Unbefriended - Patients without Surrogates

2012-01-25T23:43:00.001-05:00

I just finished editing a comprehensive review of the various mechanisms by which treatment decisions are made for the unbefriended, patients without surrogates. Most authors addressing the strengths and weaknesses of existing decision-making mechanisms invoke the language of balance and equilibrium. Muriel Gillick, for example, writes that “a balance must be struck between the need to protect [the unbefriended] from caregiver bias and institutional self-interest, on the one hand, and a stranger’s excessive distance on the other.” Diane Meier writes that the decision-maker must be “responsive yet independent.”

This "balancing" is also a central issue in medical futility debates. On the one hand, we want a decision-making process that is accessible, quick, convenient, and cost-effective. Example: the Texas Advance Directive Act approach. But, on the other hand, we want a process that provides the important safeguards of expertise, neutrality, and careful deliberation.

Rivera v. Children's Hospital of Philadelphia

2012-01-17T20:57:00.001-05:00

Worse than Dead, His Brain is Gone

2012-01-13T23:32:00.000-05:00

The Long and Winding Road: The Unfaithful Proxy and the Protracted Death of Albert Barnes

2012-01-13T21:30:00.001-05:00

Next Friday, January 20, at 12:15 p.m., Mary Faith Marshall, PhD, FCCM (Interim Co-Director, Professor, Center for Bioethics) will present "The Long and Winding Road: The Unfaithful Proxy and the Protracted Death of Albert Barnes.” Seminars are held in 3-125 Mayo on the University of Minnesota campus, and are free and open to the public.

50th Anniversary of the Death Panel (1962-2012)

2012-01-13T20:53:00.000-05:00

It is 2012, 50 years since the original U.S. "death panel," Seattle Swedish Hospital's so-called 1962 "God committee."

This committee, formally known as the Admissions and Policy Committee of the Seattle Artificial Kidney Center, decided who got dialysis (and lived) and who did not get dialysis (and died). As I have argued in several articles and in recent presentations, this is one of the ancestors of today's hospital ethics committees.

Ethical Dilemmas in End of Life Care

2012-01-13T17:49:00.000-05:00

I listened to this story from a Florida NPR station on the way home: "Ethical Dilemmas in End of Life Care" with gerontology professor Ken Doka.

5% of Americans Account for 50% of Healthcare Spending

2012-01-13T11:20:00.001-05:00

New report from AHRQ shows:

5% of Americans account for 50% of healthcare spending
1% of Americans accounted for 20% of healthcare spending
30% of Americans account for 90% of healthcare spending

Minnesota End-of-Life Law & Policy Symposium (11-09-12)

2012-01-12T23:57:00.005-05:00

Save the date - Friday, November 9, 2012 - for the Minnesota End-of-Life Law and Policy Symposium at Hamline University School of Law in St. Paul

Jordan Allen - Patient in Futility Dispute Dies 6 Months Later

2012-01-12T11:46:00.001-05:00

In July I blogged about Jordan Allen, a patient who was the subject of a formal Texas H&S Code section 166.046 futility dispute process. Allen, a 14-year-old, had an inoperable brain tumor. After a cardiopulmonary arrest, his providers at Texas Children's Hospital determined that there was no chance of recovery or cure. They followed the formal section 166.046 procedure and planned to withdraw life support. But, just days before the Children's deadline, Jordan's family was able to find a LTC transfer facility for Jordan, after their insurance company reversed its earlier coverage denial decision.

Yesterday's Houston Chronicle reports that Allen was subsequently discharged to the care of his parents. His father said that "the months caring for him at home were important to us - they gave us time to recognize God's plan and accept it."

Hammond v. QEH - Family Recovers Damages for Unilateral DNR

2012-01-11T16:00:00.000-05:00

In 2007, providers at Queen Elizabeth Hospital in King’s Lynn put a Do Not Resuscitate order on Jean Hammond without her husband's knowledge. After taking his case to court, Bob Hammond has obtained an apology and £1,000 from the QEH.

Mrs Hammond, who had vascular dementia, died at the age of 76, on June 28, 2007, due to pneumonia and a congested lung, chronic anaemia and dementia. A Do Not Resuscitate (DNR) order was issued by a doctor, with the reason that “CPR would not result in a good quality of life” and she passed away before her husband could get to the hospital. Bob Hammond says he only found out doctors had issued the order for his wife Jean after he obtained her medical records almost a year after her death at the Queen Elizabeth Hospital in King’s Lynn. (EDP24)

The Courts, Futility, and the Ends of Medicine - in JAMA

2012-01-10T17:58:00.001-05:00

"The Courts, Futility, and the Ends of Medicine," a "Viewpoint" piece that I did with Douglas White has just been published in JAMA. There is another piece on the same topic by Allan Brett and Larry McCullough.

Choosing Wisely - Five Things Physicians and Patients Should Question

2012-01-10T13:59:00.000-05:00

The American Board of Internal Medicine and nine medical specialty boards have joined together for the “Choosing Wisely” initiative. By April, the partners will identify Five Things to Question — tests or procedures commonly used in their field whose necessity should be questioned and discussed. Consumer Reports is also working with the campaign to develop and disseminate materials to patients to help them engage their physicians in these conversations and ask questions about these test and procedures.

The objective of the “Choosing Wisely” initiative is to get physicians, patients and other health care stakeholders thinking and talking about the overuse or misuse of medical tests and procedures that provide little benefit, and in some instances harm.

Book Review of WRONG MEDICINE

2012-01-06T19:29:00.000-05:00

My book review of WRONG MEDICINE: DOCTORS, PATIENTS, AND FUTILE TREATMENT (Johns Hopkins 2011) has been published in the latest issue, 12(1), of the American Journal of Bioethics.

American College of Physicians on Medical Futility

2012-01-03T23:15:00.002-05:00

The American College of Physicians has just released the sixth edition of its Ethics Manual. Here is what it has to say about medical futility:

In the circumstance that no evidence shows that a specific treatment desired by the patient will provide any medical benefit, the physician is not ethically obliged to provide such treatment (although the physician should be aware of any relevant state law). The physician need not provide an effort at resuscitation that cannot conceivably restore circulation and breathing, but he or she should help the family to understand and accept this reality. The more common and much more difficult circumstance occurs when treatment offers some small prospect of benefit at a great burden of suffering (or financial cost—see “Resource Allocation” within in the Physician and Society section), but the patient or family nevertheless desires it. If the physician and patient (or appropriate surrogate) cannot agree on how to proceed, there is no easy, automatic solution. Consultation with learned colleagues or an ethics consultation may be helpful in ascertaining what interventions have a reasonable balance of burden and benefit. Timely transfer of care to another clinician who is willing to pursue the patient’s preference may resolve the problem. Infrequently, resort to the courts may be necessary. Some jurisdictions have specific processes and standards for allowing these unilateral decisions.

Some institutions allow physicians to unilaterally write a DNR order over patient or family objections when the patient may survive, at most, for only a brief time in the hospital. Empathy and thoughtful exploration of options for care with patients or surrogate decision makers should make such impasses rare. Full discussion about the issue should include the indications for and outcomes of cardiopulmonary resuscitation, the physical impact on the patient, the implications for clinicians, the impact (or lack thereof) of a DNR order on other care, the legal aspects of such orders, and the physician’s role as patient advocate. A physician who writes a unilateral DNR order must inform the patient or surrogate when doing so.

New Contact Information for Thaddeus Pope

2012-01-02T20:32:00.000-05:00

Tomorrow is my first day at a new law school. My contact information effective immediately is

Thaddeus M. Pope, J.D., Ph.D.

Director, Health Law Institute

Associate Professor of Law

Hamline University School of Law

MS-D2017, 1536 Hewitt Avenue

Saint Paul, MN 55104-1237

p: 651-523-2519

f: 901-202-7549

tpope01@hamline.edu

www.thaddeuspope.com

www.hamline.edu/law

Government Rationing vs. Self-Rationing

2012-01-02T17:49:00.000-05:00

Karen D. McKeown, a Graduate Fellow in the Center for Health Policy Studies at The Heritage Foundation, has just posted a very good 20-page primer on health care rationing and patient empowerment. Here is the abstract:

The current trend of rapidly rising health care costs is unsustainable. Many proposed reforms to curb spending rely on some type of rationing imposed by an unaccountable government body. A better alternative would be to allow individual consumers to make their own decisions about care, including the self-rationing of medical services, based on cost and their own desires. Such a policy is compatible with American values of limited government and individual liberty and responsibility. State and federal policymakers should adopt measures to facilitate personal control of health care decisions.

New Case - Puskar v. Riley Children's Hospital

2012-01-01T11:53:00.000-05:00

Parents of a South Bend, Indiana infant born with a slew of medical ailments are crying foul. This after Riley Children's Hospital released the eight-month-old earlier this month. Jeff and Tanisha Puskar say their fragile daughter Maci was in no shape to leave Riley.

Maci’s story dates back to May 6, 2011 when she was born at St. Joseph Regional Medical Center in Mishawaka - with a closed trachea, intestines outside of her body and irregular blood flow which was slowly killing her heart. Riley apparently rescued Maci with some $2 million worth of treatment. The Puskar family says it’s in touch with a local attorney and is preparing to take legal action against the hospital any day now.

Variations in End-of-Life Care across England

2011-12-29T09:00:00.000-05:00

I just noticed that England has a tool similar to the Dartmouth Atlas in the United States. The National End of Life Care Intelligence Network (NEoLCIN) aims to improve the collection and analysis of information related to the quality, volume and costs of care provided by the NHS, social services and the third sector, to adults approaching the end of life.

The Network's data and statistics “tool” allows the user to run various profiles. For example, a quick search shows that in Newham 74% of the very elderly die in hospital. In contrast, in Torbay, fewer than half of the very elderly (36%) die in hospital and fully one-half die at home -- where most people say they prefer to die. This gap reminds me of similar gaps in the United States between, for example, New Jersey and Utah.

Effective Advance Care Planning: Are Your Advance Directives Worth the Paper They Are Written On?

2011-12-28T09:31:00.003-05:00

| | |

Effective Advance Care Planning: Are Your Advance Directives Worth the Paper They Are Written On?

Live Webinar
Tuesday, January 31, 2012
Event Code: CET2EAC

This program will enhance practioners’ knowledge and skills with
respect to:

the evolving components of advance care planning and how the emerging “Physician (or Medical) Orders for Life-Sustaining Treatment” (POLST or MOLST) will affect the process as they
emerge in virtually every state,
effectively counseling clients and provide them with the tools they need for meaningful health decisions planning, and
drafting more practical and effective advance planning documents

Our Expert Faculty

Walter T. Burke, Esq. (Moderator)Attorney
Burke & Casserly PC
Albany, NY

Charles P. Sabatino, Esq.
Director
ABA Commission on Law and Aging
Washington, DC

Patricia Bomba, MD
Vice President and Medical Director, Geriatrics
Excellus BlueCross BlueShield, New York
Rochester, NY

David M. English
Professor of Law
University of Missouri Columbia Law School
Columbia, MO

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Program Time

1:00 PM - 2:30 PM ET

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Publish Ethics Committee Decisions pt III

2011-12-25T15:59:00.001-05:00

A few weeks ago, I argued that ethics committees should publish their recommendations when those recommendations operate as binding decisions. The complete argument for this position will appear in an article I have yet to write.

But I was encouraged to see this in the New York State Task Force on Life and the Law 1992 report When Others Must Choose (p169):

"The committee should issue a statement of reasons for its decision, and unlike cases where the committee acts in an advisory manner, committee records of decisions about life-sustaining treatment should be subject to review . . . . These procedures will afford openness and accountability . . . ."

Christmas Wish Granted: Woman on Organ Support Given 1 More Day

2011-12-25T08:27:00.002-05:00

Family Requests 1 More Day of LSMT for Brain Dead Patient

2011-12-24T08:06:00.000-05:00