Medical Futility in the ICUMedical Futility in the ICU

Michael W. Rabow, MDMichael W. Rabow, MDDirector, Symptom Management ServiceDirector, Symptom Management Service

Helen Helen Diller Diller Family Comprehensive Cancer CenterFamily Comprehensive Cancer CenterProfessor of Clinical MedicineProfessor of Clinical Medicine

UCSFUCSF

June 3, 2010June 3, 2010

...not for the good it will do, but that nothing may be left undone on the margin of the impossible.

T.S. Eliot

OutlineOutlineI. Background on FutilityII. The Challenges of FutilityIII. Practical Recommendations

I. Ethics, History &I. Ethics, History & the Lawthe Law

•• PatientPatient’’s right to decide about s right to decide about withdrawing/withholding treatmentwithdrawing/withholding treatment

•• SurrogateSurrogate’’s right tos right to decidedecide if necessaryif necessary•• PhysicianPhysician’’s professional, legal, ethical s professional, legal, ethical

right to withhold/withdraw futile right to withhold/withdraw futile treatmenttreatment

Luce JM, White DB. Crit Care Clin. 2009 Jan;25(1):221-37American Medical Association Code of Ethics, June 1994

Ethics of FutilityEthics of Futility

• Oldest principles (fiduciary relationship)– Beneficence– Non-maleficence

• Newer principles– Autonomy– Justice

History of Patient AutonomyHistory of Patient Autonomy

1976: Quinlan decision (right to die,refuse LSMT)

1990: Cruzan decision reaffirms1990: Patient Self-Determination Act1990: 50% of ICU deaths involve wd/wh (Smedira)

1997: 77% (Prendergast)

1997: AMA, SCCM, ATS, ACCP– ethical and legal propriety of limiting unwanted

treatment, necessity of pall care

History of FutilityHistory of Futility• 430s BC: Hippocrates “refusal to treat those

who are overmastered by their diseases, realizing that in such cases medicine is powerless”

• 1976: CPR policies “out of the closet”Fried. N Engl J Med. 1976 Aug 12;295(7):390-1.

• 1980s: Futility to justify unilateral decisions• 1987: Blackhall: CPR not universal

Blackhall LJ. N Engl J Med. 1987 Nov 12;317(20):1281-5.

• 1990: Futility defined as none in the last 100Schneiderman LJ et al. Ann Intern Med. 1990 Jun 15;112(12):949-54.

Futility as PracticedFutility as Practiced

Commonly used– 34% MDs continue treatment against

patient/surrogate wishes– 83% withhold, 82% withdraw

unilaterally interventions judged to be futile

Asch DA et al. Am J Respir Crit Care Med. 1995 Feb;151(2 Pt 1):288-92.

Definitions of FutilityDefinitions of Futility

•• Physiologic futilityPhysiologic futility•• Quantitative futilityQuantitative futility•• Qualitative futilityQualitative futility

II. The Challenges of FutilityII. The Challenges of Futility

• Achieving consensus• Determining & Following patient preferences• Estimating prognosis• Evaluating benefit• Physician fears• Balancing individuals & society: resource

allocation

Achieving ConsensusAchieving Consensus

• Cannot agree on the definition• In the eye of the beholder,

subjective/personal:a) is unlikely to be of any benefit to a

particular patient in a particular medical situation

b) will not achieve the patient’s intended goals

Helft. N Engl J Med. 2000;343:293-296.

Determining & FollowingDetermining & Following Patient PreferencePatient Preference

• AD may not be present• AD may not be specific enough• Surrogates may be unrealistic

– No improved mortality– Increased cost

KH Berge et al. Mayo Clin Proc. 2005;80:166-173.

Patient Preferences cont.Patient Preferences cont.

AD may not influence careSupport TrialDanis M, et al. Crit Care Med. 1996 Nov;24(11):1811-7.

But… may be that is changingSilveira MJ, et al. N Engl J Med. 2010 Apr 1;362(13):1211-8.Detering KM, et al. BMJ 2010;340:c1345.

Estimating PrognosisEstimating Prognosis• We’re poor at prognosticating• RNs and MDs don’t agree on futility

– Docs and RNs not agree in 63% of dying– Cannot predict QOL– RNs more pessimistic, more correct

Frick S et al. Crit Care Med. 2003 Feb;31(2):456-61.

• APACHE less effective at individual level

Zimmerman JE et al. Crit Care Med. 1998 Aug;26(8):1317-26.

Evaluating BenefitEvaluating Benefit

• May be unexpected– 47% hospital survival for >70yo >30 day in ICU

Montuclard L et al. Crit Care Med. 2000 Oct;28(10):3389-95.

• Cannot figure out others’ quality of life• Experiences change patient’s preferences

– eg CPR

3%

42%

55%

Ambivalent Not Want CPR AgainWant CPR Again

Experience Changes PreferencesAssessment of CPR by Survivors

Physician Fears of LitigationPhysician Fears of Litigation

• Generally, courts don’t want to be involved• Only 11 states have laws requiring

treatment with no time limit to allow transfer

• Almost always support physician decisions– Especially Ex Post (duty, breach, direct

causation, damages)– Ex Ante sometimes injunctions are ordered to

allow transfer

Individual and Society: Individual and Society: Resource AllocationResource Allocation

• Public policy should not be determined at the bedside

• However, when will rationing of health care enter the debate?

Teres D. Civilian triage in the intensive care unit: the ritual of the last bed. Crit Care Med. 1993 Apr;21(4):598-606.

III. Practical RecommendationsIII. Practical Recommendations

1.1. DonDon’’t talk about futilityt talk about futility2.2. Give it timeGive it time3.3. Focus on the relationshipFocus on the relationship4.4. Offer excellent communicationOffer excellent communication5.5. Rely on policiesRely on policies6.6. Call in helpCall in help7.7. Support each otherSupport each other

1. Don1. Don’’t Talk about Futilityt Talk about Futility

• We don’t agree on what it is• We don’t agree on how to evaluate the benefit

of interventions• We can misuse the futility argument

• 33% used the argument of Quantitative Futility but estimated the chance of survival to be 0-75%

• 18% used the argument of Qualitative Futility, but only 1/3 discussed QOL

Curtis, JAMA, 1995American Medical Association Code of Ethics, June 1994

Focus on goals of careFocus on goals of care––specificspecific––achievableachievable––benefits and burdensbenefits and burdens

Siegel MD. Clin Chest Med. 2009 Mar;30(1):181-94.

2. Give it Time2. Give it Time

•• Talk AND listen moreTalk AND listen more•• Allows for conflict resolutionAllows for conflict resolution

– 57% of patients and surrogates agreed immediately to a physician's recommendation to limit intensive care

– 90% agreed within 5 daysPrendergast TJ. New Horiz. 1997 Feb;5(1):62-71.

•• Therapeutic trialsTherapeutic trials

3. Focus on the Relationship3. Focus on the Relationship

•• FiduciaryFiduciary“Physician commits himself to the patient's best interests but retains a role in defining those interests.”

TJ Prendergast•• ““AssentAssent”” rather than consentrather than consent

Enhanced Models of theEnhanced Models of the PatientPatient-- Physician RelationshipPhysician Relationship

Type of Automony Goals PlanNone (Parentalism) MD MDSimple (Consumerism) Patient PatientEnhanced (Professionalism) Patient MD

Types of Patient-Physician RelationshipsPaternalisticDeliberative (includes shared decision-making)

“All medical care flows through the relationship between physician and patient, and the spoken word is the most important tool in medicine.”

Eric Eric CassellCassell

4. Offer Excellent Communication4. Offer Excellent Communication• Communication… not Criteria or Committees

Burns J and Truog R. Chest, 2007; 132(6):1987-93.

• Communication as a skill– “Effective communication about end-of-life care

requires training, practice, and supervision, as well as planning and preparation”

Curtis JR. Crit Care Clin. 2004 Jul;20(3):363-80, viii.

• Communication improves outcomes– Family meeting and EOLC as opportunities for

improved careCurtis JR et al. Crit Care Med. 2001;29(2, suppl):N26-N33.Prendergast TJ, Puntillo KA. JAMA. 2002 Dec

4;288(21):2732-40.

Family Communication Needs

(1) A clinician willing to talk

(2) Timely and clear information– Information needs are paramount

• Prognostic information > decision-making• Control over timing

Steinhauser, J Pain Sx Mgmt. 2001;22:727

Butow, Support Care Cancer, 2002

(3) A clinician able to listen

Listening Outcomes• Seattle ICU study

– 51 family meetings– Average length 32 minutes (7-74minute range)– 29% vs 71%

• Increased proportion of family speech associated with– Increased satisfaction– Less reported conflict

McDonagh, Crit Care Med, 2004

Evidence for Family MeetingEvidence for Family MeetingBereavement brochure and

communication guidelines (VALUE)• Valuing what the family members said• Acknowledging their emotions• Listening• Understanding the patient as a person through asking

questions• Eliciting questions from the family members.

– 30 vs 20 min meetings: 14 vs 5 min family talk

– Decreased caregiver depression, anxiety and PTSD at 2 months

Lautrette, NEJM, 2007

5. Rely on Policies if Necessary5. Rely on Policies if Necessary

• Community-based consensus standards• Hospital futility policies

– Due process: negotiation, shared decision- making, ethics committee

– Transfer to another MD (if institutional review supports proxy) or another institution (if supports MD)

– If no transfer possible, no interventionLuce JM. Am J Respir Crit Care Med. 1997 Dec;156(6):1715-8.AMA Code of Ethics, 1994

6. Get Help: 6. Get Help: Ethics Committees & Palliative Care ServicesEthics Committees & Palliative Care Services

• Help is usually… Communication• Proven benefits to Ethics Committee

– No difference in mortality– Decreased ICU/hospital LOS among dying

Schneiderman LJ et al. JAMA. 2003 Sep 3;290(9):1166-72.

• Proven benefits to Palliative Care Consultation– No difference in mortality– Pain & Non-pain symptoms– Patient/family satisfaction – ICU length of stay & Cost

Jordhay et al Lancet 2000; Higginson et al, JPSM, 2003; Finlay et al, Ann Oncol 2002; Higginson et al, JPSM 2002, Zimmerrman, JAMA 2008

7. Support Each Other7. Support Each Other• Crisis of conscience: Adults

– 47% of MDs and RNs– 70% of house officers

Solomon MZ et al. Am J Public Health. 1993 Jan;83(1):14-23.

• Crises of conscience: Peds– 54% of house officers– 48% of critical care nurses– 38% of critical care attending physicians

Solomon MZ et al. Pediatrics 2005 116: 872 - 883.

• Spend the time to achieve consensus, or at least offer support and mutual respect