The effect on survival of continuing chemotherapy to near deat

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

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

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

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