The Limits of Medical Futility: Craniectomy & ECMO

Why are there not more disputes where surrogates demand decompressive craniectomies and ECMO?

In many situations these medical interventions could postpone the moment of death. Take the case of Motl Brody, for example. The sect of Orthodox Judaism to which the patient's parents belong apparently requires that patients be maintained on maximum life support until brain death. But then why did they not demand a craniectomy? That might have delayed brain death and prolonged life as long as possible.

Are these far more radical procedures not the subject of futility disputes just because they are so radical? Is the mere visual image of these procedures enough to deter even the most adamant surrogate? Perhaps it does not seem so unusual to demand continued use of ventilators, dialysis, or ANH for the chronically critically ill. After all, these have been regularly used for over three decades.

Continuation of Treatment in Chronic Critical Illness

Sharon Camhi and colleagues at the VA Pittsburgh Health Care System had an article in the March Critical Care Medicine, titled “Deciding in the Dark: Advance Directives and Continuation of Treatment in Chronic Critical Illness.”

First, “chronic critical illness” is a great term that I am not sure I’ve heard before. Camhi et al. explain: “Chronic critical illness is a devastating syndrome for which treatment offers limited clinical benefit but imposes heavy burdens on patients, families, clinicians, and the health care system. We studied the availability of advance directives and appropriate surrogates to guide decisions about life-sustaining treatment for the chronically critically ill and the extent and timing of treatment limitation.”

Camhi et al found” “most chronically critically ill patients fail to designate a surrogate decision-maker or express preferences regarding life-sustaining treatments. Despite burdensome symptoms and poor outcomes, limitation of such treatments was rare and occurred late, when patients were near death.”

“More and more patients survive acute critical illness only to remain dependent on life-sustaining therapies on a chronic basis. . . . [F]ew of these patients achieve functional recovery . . . . Treatment is prolonged, expensive, and burdensome . . . .” Camhi et al agree that might be appropriate to continue but argue that “continuation of treatment in the chronic phase of critical illness should never be driven by default . . . .”

Avoiding and Resolving EOL Conflict

Tidbits from a recent presentation:

Add life to the patient's years

Not years to the patient's life

Physicians, hope is good.

• Say, "I too hope for a miracle."
• Say, "What else do you hope for?"

Start communicating early.

• Have shorter, more frequent meetings.
• Let the families talk more.

Show empathy, honesty.

• Say, "I'm worried."
• Say, "I wish there had been improvement."
• Do not say, "I'm sorry."

Lauren Richardson -- The Wrong Result for Lauren and for Vulnerable Patients in Delaware

Matt Bowman at the Alliance Defense Fund posted a lengthy response to my criticism (expanded upon here) of the result in the Lauren Richardson case. I am not sure that I ever responded. Here goes.

I never said that Lauren or any person with disabilities was "subhuman." I never said "some human beings are less valuable than others." Nor am I part of a "pro-death movement."

Matt writes that Lauren's mother had a "conversion of heart." This implies that the result turned on the mother's preferences, emotions, or feelings. This is wrong. When deciding on medical treatment for an incapacitated individual, the focus should be on that individual's (Lauren's) preferences, values, and wishes. The Master, an experienced and neutral fact finder, found that there was clear and convincing evidence (a high standard) that Lauren would not want ventilator and other technological support in her current circumstances. The Chancery Court never rejected the Master's findings. They were the only findings ever made. The only reason the Master's findings have no legal status is because, as Matt explains, the case was settled.

To be clear, this case entails no controversial value judgments about whether it is worthwhile to live in a state like Lauren's. Rather, it is about Lauren's autonomy, about Lauren's own right to determine what happens to her body. Solid evidence indicates (and a judicial finding confirmed) that Lauren did not want her current treatment.

That there is no ongoing dispute hardly means that the correct result was reached. It means only that there is a conspiracy to exploit and take advantage of the vulnerable (Lauren) for selfish reasons.

Inappropriate Treatment - More Providers' Fault than Surrogates'

Medical futility disputes are often described as being the "fault" of surrogates. They demand continued treatment that providers think is inappropriate. But the issue of ineffective treatment goes far beyond medical futility disputes. Far more often, ineffective treatment is provided and there is no dispute. The provider offers it (perhaps culpably) and the patient or surrogate accepts.

Boston Doctor has a recent post on this titled "Our Fault."

CMS Proposes to De-Incentivize Aggressive End-of-Life Interventions

In a proposed rule published this week, Medicare Program; Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2010, CMS identifies priorities as:

prevention; chronic conditions; high cost and high volume conditions; elimination of health disparities; healthcare-associated infections and other conditions; improved care coordination; improved efficiency; improved patient and family experience of care; improved end-of-life/palliative care; effective management of acute and chronic episodes of care; reduced unwarranted geographic variation in quality and efficiency; and adoption and use of interoperable HIT

Accordingly, the rule proposes to change physician reimbursement rates (RVU). Seriously negatively impacted are (among others) radiation oncology, cardiology, nuclear medicine and radiology. It would increase rates to (among others) geriatrics, pain management, and family medicine.

Ineffective CPR on the Rise

Today's issue of the New England Journal of Medicine includes this article by William Ehlenbach and colleagues at the University of Washington-Seattle: "Epidemiologic Study of In-Hospital Cardiopulmonary Resuscitation in the Elderly."

The authors identified 433,985 patients (Medicare beneficiaries 65 years of age or older) who underwent in-hospital CPR and found:

• Only 18% of these patient survived to discharge -- a rate that did not change substantially during the period from 1992 through 2005
• The proportion of in-hospital deaths preceded by CPR increased, whereas the proportion of survivors discharged home after undergoing CPR decreased
• The overall incidence of CPR was higher among black and other nonwhite patients

The authors rightly express concern that "the proportion of patients who died in the hospital after having previously undergone in-hospital CPR has increased during a time of more education and awareness about the limits of CPR in patients with advanced chronic illness and life-threatening acute disease."

Multi-Institutional Healthcare Ethics Committees: the Procedurally Fair Internal Dispute Resolution Mechanism

My article attacking healthcare ethics committees and defending multi-institutional ethics committees was finally published.

"Multi-Institutional Healthcare Ethics Committees: the Procedurally Fair Internal Dispute Resolution Mechanism" is now available:

• In 31 Campbell Law Review 257-331 (hard copy, Westlaw LEXIS)
• SSRN
• BePress
• ThaddeusPope.com

End-of-Life Care: Top Priority for Comparative Effectiveness Research

Comparative effectiveness research (CER) is a way to identify what works for which patients under what circumstances. Congress, in the American Recovery and Reinvestment Act (ARRA) of 2009, appropriated $1.1 billion to jump-start the nation’s efforts to accelerate CER. ARRA tasked the Institute of Medicine (IOM) to recommend national priorities for research questions to be addressed by CER and supported by ARRA funds.

In a report released yesterday, the IOM identified in its second and fourth quartile lists of research priorities:

• Compare the effectiveness of coordinated care (supported by reimbursement innovations) and usual care in long-term and end-of-life care of the elderly.
• Compare the effectiveness of hospital-based palliative care and usual care on patient-reported outcomes and cost.

Palliative Care Grand Rounds Vol 1, Issue 6

Now up at Palliative Care Success -- the sixth edition of Palliative Care Grand Rounds, a monthly (appearing the first Wednesday of each month) summary of interesting, thought-provoking, timely, relevant, humane, and exceptionally well-written postings from the blogosphere.