- It’s paradoxical that the idea of living a long life appeals to everyone, but the idea of getting old doesn’t appeal to anyone. Andy Rooney
- Health nuts are going to feel stupid someday, lying in a hospital dying of absolutely nothing. Redd Foxx
- I am prepared to meet my Maker. Whether my Maker is prepared for the ordeal of meeting me is another matter. Winston Churchill
While Winston Churchill may have been prepared to meet his maker, many others are not. Despite the prominence of Advanced Directives, Durable Powers of Attorney, Living Wills, DNR status forms, No Code orders and POLST forms, far too little communication takes place regarding the second most important event of our lives: our death.
In my many years of emergency medicine practice, some of my most difficult experiences have been those in which patients, more often their families, have come to that point in their life woefully ill-prepared. One would think that death is an event most people would prepare for, but both physicians and attorneys see the sad outcomes of a lack of preparation far too often. Many individuals, even those of very advanced age, blissfully go onward hoping to avoid confronting the fact that none of us are leaving here alive. Many think that the miraculous resuscitations seen in the medical shows on TV are the norm. Few realize that eventually, at some point, all treatment is futile. Like taxes, death is certain.
But what constitutes futility? When is a physician obligated to offer a treatment to a patient, knowing that it will most likely do no good, or at best do some good for a meaningless period of time?
The key words here are “most likely” and “meaningless.” A recent article in Medical Economics by Steven Kern JD reviews the concept of futility rather succinctly. Mr. Kern argues that “citing alternatives that are likely futile provides no benefit to the patient and can result in accusations of offering false hope. What’s more, providing such treatment can lead to complaints of overutilization and even quackery.” In his opinion, no one would opt for a futile course of treatment or tests under either the “reasonable physician standard” or the “reasonable patient standard.”
That said, some patients and their families are unreasonable. In those situations, it may be necessary for the ethical physician to transfer care of the patient to someone else, explaining that he/she cannot rightfully expend resources on something for which there is no return.
However, in order to become truly “informed,” a patient should be told of anything that has even a small chance of being useful, with the “chance” being qualified by such things as statistical efficacy, side effects, cost, etc. Once informed, the patient (or his/her legal surrogate) can then make a decision.
Most of us, given the option, wish to die a natural death. All the buzz words for resuscitation aside, the best one currently available is “AND” which stands for “Allow Natural Death.” The more often that patients, their families and advisers acknowledge that surviving life itself is futile, the sooner these important and necessary conversations will occur. Both physicians and attorneys are in a position to make those conversations happen. In Washington and Oregon, the POLST form (Physicians Orders for Life-Sustaining Treatment) is extremely useful in facilitating those discussions.
Bottom line: a treatment/test that is truly worthless need not be disclosed. Anything else should be discussed with the patient.
(For further information on this topic, you may wish to review this presentation from the University of Washington, which includes case studies.)