Wednesday, March 16, 2011

Autonomy versus Bureaucracy

I came across this at Secondhand Smoke and believe it is a must read for anyone interested in bioethics, managed care, hospice/palliative care or "death panels. It is a brief review of a paper that is to be published in The Journal of Law and Medicine that proposes a futile care hospital policy that requires that decision making responsibility is ultimately in the hand of the hospitals ethics committee and not the patient or their surrogate.

To provide for substantive reform, any proposed public policy or internal health

care entity effort should address how best to:

1. Facilitate meaningful communication between patients/surrogates and the

patient’s medical team;

2. Facilitate patient education about advance directives, what they mean, when

they come into play and how they would apply;

3. Ensure the patient or his/her surrogate understands the patient’s rights either to

consent to treatment or consent to withhold or withdraw treatment;

4. Ensure that the patient or their surrogate understands the physician and health

care facility have decision-making options regarding continuation of treatment;

5. Facilitate understanding, either through ethics committees, or special

communication teams, between the patient/surrogate and the physician/health care

facility regarding how the patient’s treatment decisions are made and how the health care

facility manages patients in end-of-life-care situations.

Numbers 4 and 5 really spell it all out. When push comes to shove the hospital and it's Ethics Committee has the ultimate decision making ability to terminate life sustaining treatment deemed to be futile. Quoting from the review, "The risk manager explained that when end-of-life conflicts arise, hospital staff and physicians are forced to continue treatments, e.g. dialysis, that they believe have no benefit for the patient." Sure treatment of end stage renal disease is a futile endeavor and patients will ultimately die from it, but to argue that this treatment is of no benefit to the patient is absurd, unless of course it is your contention that life is futile.

Regardless, nearly everything we do in medicine is futile. Tell me the last time you have heard a doctor say that they have cured anything? Other than a few infectious diseases all we do is treat chronic illness that will eventually cause the death of the patient. We talk about cancer in terms of treatment and remission, not cure. If hypertension, diabetes, hyperlipidemia or congestive heart failure is curable why do you have to take medications to treat these ailments for ever? The truth is, nearly everything that I do in the hospital is futile care. The argument in the referenced policy proposal is not about whether a particular treatment option is futile, they all are, it's not even about costs or availability (at least in the short term), it is about patient autonomy. The right of the patient to make decisions about medical care without undue influence by the caregiver. When that is lost the game is over. You will suddenly become a disease and cease to be human.

"Care isn't deemed futile because it doesn't work, but because it does. Hence, it is the patient being declared futile."

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