As the federal government becomes progressively more intertwined in the delivery and reimbursement of medical care, there are more discussions about ‘Death Panels’ and the denial of ‘futile’ care. Often, the two get conflated, but they are quite different. Commentators who clearly are well intentioned often get very confused when they talk about what medicine is supposed to do. Consider this view: Extending the life of a patient when that is what he wants is a quintessential purpose of medicine. This is a simplistic view of medicine’s goal. The purpose of medicine is straightforward – to prevent premature death and to relieve pain and suffering. Obviously we should respect the patient’s wishes whenever possible, but sometimes doing so is impossible because of circumstance, cost, demand, geography, or lack of resources. When the first of these two goals of medicine becomes impossible as it typically does when a patient survives to old age, the second goal become the single priority of the physician. When this end is no longer possible then we’ve reached the point of futile medical care.
How does a physician decide that further care is useless? Typically this decision is not difficult even if the patient is unable to express himself. At this point his family will collectively agree that medical care should be stopped. Trouble arises when the family doesn’t agree or when it wants medical care to be given that is without benefit. The article linked above cites a Texas law that allows care to be stopped when the patient or his family wishes it continued. I have seen this law invoked only once. I’ll get to that case in a moment. I cannot envision it being applied to a patient who is conscious and able to express his wishes which apparently is the case with the Texas patient for whom a hospital wishes to cease care – see link above.
The problem may not lie with the Texas law, but how hospitals apply it. I would never consent to taking a conscious patient off life support against his wishes. The relief of pain and suffering is always possible in a conscious patient. So to whom should the law apply? Here’s a real case the details of which I have changed or made vague so the patient cannot be identified.
She was young and had undergone a successful cadaveric kidney transplant two years earlier. Remember there would be no cadaveric kidney transplants if further medical care was not deemed futile for the donor. The cause of the patient’s last hospital admission was a massive cerebral hemorrhage which destroyed all higher brain functions. The patient was admitted to the intensive care unit, intubated, and placed on a ventilator. She was unresponsive on admission and remained so for the duration of her hospital stay. Numerous diagnostic studies were done which showed massive brain damage. Neurology was repeatedly consulted and always offered the same assessment: There was no hope of recovery of brain function. After a week she was placed on total parenteral hyperalimentation. The patient had left no instructions as to how she wished to be treated in the event that she could not express her wishes. Her family was unanimous that all possible care be given despite repeated explanations by a large number of physicians and nurses that recovery was impossible. Over the next few months the patient developed several serious infections that were all vigorously and successfully treated. About this time neurology signed off the case saying they had nothing to offer the patient reiterating their opinion that recovery of any brain function was impossible. Supportive care was continued for another two months at which time the patient’s transplanted kidney failed. Nephrology was of the opinion that hemodialysis was not indicated as there was no hope of recovery. The patient’s family wanted it started as well as any other care that would treat any other complications that might develop.The physicians taking care of the patient were were reluctant to keeping a patient on life support who met all the criteria for brain death. It was at this time that the Texas law regarding futile care was invoked. While the process was taking place the patient was started on hemodialysis. After a month or so the decision to stop life support was made; a court was involved in this decision. The patient’s family was bitterly unhappy with this outcome. But as they could not find another hospital willing to accept transfer of the patient, she was disconnected from all the various devices that were sustaining her and was shortly thereafter pronounced dead.
Was this the right decision? Certainly, the family thought it wasn’t. But if this patient doesn’t meet the criteria for futile care than there is no such thing. The decision to withdraw care wasn’t made because the patient lacked insurance. She was still covered by Medicare. The hospital put no pressure on the physicians to stop care. The decision was made because the attending physicians could see no possible benefit from continuing it.
Was the decision made by a ‘Death Panel’? I don’t think so. I think it was an extreme form of medical triage. Resources, expressed as both time and money, are not limitless. Spending them with no limit when there was no hope of a salubrious outcome was not wise. But carefully note the difference between the case I just described and the one linked above. Distinctions matter.
I remember when there really were ‘Death Panels’. Back in the sixties and early seventies before Medicare assumed financial responsibility for dialysis treatment, there were panels of laymen, ethicists, and physicians who decided who should be dialyzed and who should not based on the patient’s perceived (by the panels) value to society compared to others on the dialysis waiting list. There were a limited number of spaces for dialysis patients before federal funding for the treatment. It was a terrible system that had no alternative.
Many are convinced that we are about to ration medical care because of its ever increasing cost and that ‘Death Panels will be part of the rationing scheme imposed by financial constraints. Why medicine is so expensive has already been covered here. It didn’t have to be so costly, but our out of control system seems to have passed the point of no return.