In a forthcoming article in HEC Forum, Colleen Gallagher and Ryan Holmes describe how medical futility cases are handled at the University of Texas MD Anderson Cancer Center
The authors note that they rarely use the formal TADA mechanism. That is fine. Other Texas
In July, I wrote about "illusory consensus." I think that concept applies here. Following Gallagher and Ryan may avoid conflict. There may be agreement and consensus. But it is conditioned on deception.
I agree that providers should not offer false hope. But preventing or resolving conflict by withholding options and information is very dangerous. It is especially dangerous because there are few lines (medical or ethical) that clearly separate the medically appropriate options from the medically inappropriate options. That lack of definition is a constitutive feature of medical futility. Gallagher and Ryan propose dealing with medical futility situations by pretending that there is literally nothing more that can be done. This gets too close to constituting a hard paternalistic abandonment of informed consent.
2 comments:
It does sound like they're too paternalistic and perhaps at times misleading the patient and family. It would be interesting to see some specific examples and the opinions of the patients/families involved when they find out there may not have been full disclosure.
On the other hand, many oncologists offer too much and end up prolonging the agony before death. This is noted in your more recent post about a hospice going broke because they were getting patients so sick and so late from oncologists.
I think the balance is to be as open and transparent as possible. After discussing the "slim chance treatment" along with the serious side effects and suffering involved, I would cite my experience in a similar case in story format, then most often recommend against the particular treatment.
There is always "something more" that can be done, the art is in letting go at the end by the patient, family, and physician.
Thank you.
For years, the first best offered solution is "better communication." And this is probably right.
But "better communication" has been interpreted as "not offering slim chance options." A key problem is that there is no consensus on the thresholds. Consequently, there is too much variability in what is disclosed.
Better to disclose all options but to advocate for the one the physician thinks appropriate.
If the doc were working off a blank slate, then maybe disclosure of dialysis to the surrogate of the PVS patient might not be necessary. But the physician is working in a world where this has been and is done.
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