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On Being a Doctor |

Futility

Samir K. Shah, MD
[+] Article and Author Information

From The Cleveland Clinic Foundation, Cleveland, Ohio.

Requests for Single Reprints: Samir K. Shah, MD, Department of General Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk A100, Cleveland, OH 44195; e-mail, samirkshah.0@gmail.com.


Ann Intern Med. 2014;160(2):138-139. doi:10.7326/M13-1050
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In this era of increasingly cost-conscious health care, end-of-life care has been the focus of much discussion. Although this analysis has provided insight into the problem, it neglects to take into account an essential barrier for avoiding unnecessary care: humans.

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Another Pathway when Asked for Futile Interventions
Posted on January 27, 2014
Joanne Lynn, MD
Director, Center for Elder Care and Advanced Illness, Altarum Institute
Conflict of Interest: None Declared
Dr. Shah might do well to consider a different approach that has often worked well in my interactions with frantic family members. First, the physician needs to be clear that adding more interventions is not likely to change the outcome. In the case described, the additional "treatment" might change how Ms. K died, but it is not likely to improve her odds (which were not 0% without the added treatment - just similarly very, very small). The daughter is probably in her 20's or 30's and moved with the expectation of becoming friends with her mother - who is now suddenly dying. The daughter's pain certainly needs to be addressed, but I would recommend working with her to set out the plan for the most likely course - that her mother would die soon. If the mother might be able to communicate or at least to hear, the daughter needs the opportunity to thank her for being her mother and to say some last words that matter. She needs the opportunity to say prayers or just to sit with her mother and hold her hand. The daughter needs help to make some plans for what will happen when her mother dies - who needs to be notified, what sort of memorial and burial to plan, and so forth. Even if she really cannot do these things at this time, the fact that the doctor brings them up has a remarkable way of making the situation real and confrontable, rather than something so frightening that the only response is to run. There will be a time after the death, and she will get through it. Perhaps there is a friend or another family member who can come to help - or a chaplain or sympathetic mature volunteer. The daughter was begging for something magical to make the situation different from what it was. The physician probably does not help her in the long run by taking on the magician role.
Comment
Posted on January 28, 2014
Keyvan Ravakhah, MD, MBA, FACP
St. Vincent's
Conflict of Interest: None Declared
To the editor: In his nicely written story on futility, Dr. Shah misleads readers to believe surrendering to a dying patient’s daughter’s unreasonable request under the cover-up of “giving hope” is acceptable. It seemed that he forgot whose physician he was, subjecting a terminally ill patient to an extensive surgery, bowel resection and open abdomen only to die a few days later. His responsibility would have been to help his dying patient and not a family member in desperate need of a support that apparently could not be provided by Dr. Shah. It is also painfully surprising to see that the person communicating these complex and difficult decisions with the family is a surgical resident and not an experienced medical or surgical attending who could have assisted this desperate daughter to understand the appropriate decision for her ailing mother. The end of life discussions have been the Achilles heel of healthcare in US [1]. Physicians are not trained to do so; it is discomforting and not good for marketing or for the pocket. Because of this, a practicing physician frequently hides behind terms like “giving hope, miracles happen, everybody has a chance” or overestimating the prognosis [2] and proceeds with painful, invasive and expensive treatments. Dr. Shah should have called his favorite palliative care physician together with a spiritual member of their hospital to discuss the treatment plan for this patient. The reality is that this decision made Dr. Shah feel better about himself while his patient suffered more. The cost was shared among all of us who pay for healthcare in US; another unfair consequence of such decisions which are made in our hospitals continuously. I agree that we are pressured by illusions of cure created by our beliefs, media and lack of knowledge. However, physicians, who are aware of futility of these fallacies should lead this war and not surrender.

1. Clayton JM, Butow PN, Arnold RM, Tattersall MH. Discussing life expectancy with terminally ill cancer patients and their carers: a qualitative study. Support Care Cancer. 2005 Sep;13(9):733-42. Epub 2005 Mar 11.
2. Nicholas A Christakis, Elizabeth B Lamont, Extent and determinants of error in doctors' prognoses in terminally ill patients: prospective cohort study BMJ. 2000 February 19; 320(7233): 469–473.
We need a different set of tools
Posted on January 27, 2014
Steven Radwany, MD
Summa Health System, Akron, Ohio
Conflict of Interest: None Declared
To the Editor:

I was touched by Dr. Shah’s essay on ‘Futility’ (1). It points to how unprepared we are as physicians to address what is essentially an emotional crisis in response to an irreversible medical situation. My read of this story is that a daughter’s grief and sense of isolation were treated with repeated invasive surgical procedures. Please believe me that I do not say this to criticize Dr. Shah. He was put in an untenable position as a surgical resident to try to address someone in severe emotional distress on first acquaintance, likely without the training or tools needed to help begin to relieve the daughter’s suffering.

That we, as a health care system, put a surgical resident in this position at night while on call is sad but all too typical. I was left with many more questions than answers in the end:

• Was Palliative Care involved at any time before or after the transfer to the receiving hospital?
• Was Pastoral Care or a psychologist involved to provide spiritual and emotional support?
• Did any of the physicians involved receive practical training in addressing grief and bereavement, or for that matter, addressing acute severe emotional distress in a bereaved family?

These questions reflect systematic deficiencies in the healthcare system and in our system of medical education.

A long look in the mirror tells us that we have much to do.

Sincerely,

Steven M. Radwany, M.D., FACP, FAAHPM

Reference
1. Shah SK. Futility. Ann Intern Med 2014;160:138-139.
Treatment of Futility as Palliative Care
Posted on February 11, 2014
Simon Kassabian, MD
VA Hudson Valley Health Care System
Conflict of Interest: None Declared
TO THE EDITOR: Dr. Shah's case presentation of 'Futility' (1) is an eloquent and poignant example many clinicians may identify with, at least in an analogous manner. Some might reject such care, on the basis of 'moral distress', as both improper and unnecessary. While details involve an extreme of surgical intervention, at great cost, its specifics do not differ conceptually from a simpler situation like keeping intravenous hydration maintained in a terminal case, for an out-of-state relative to visit or other similar reason. This is often considered, and done.

Palliative Care is a team-based approach directed toward the care of both patient and family. Treatment of 'Futility' in this case provided that, albeit by extreme example.

On the other hand, many palliative clinicians in this case may have adopted a nonsurgical course as the sole option, while supportive of family and with compassionate resolve. For surgery to be negated only if it had ‘0% chance of survival’, with ‘absolute certainty’ as a possible outcome, is an extreme standard not reasonably supported in our profession.

The bereavement of relatives and their psychological closure, either with terminal surgery or with intravenous hydration, are individualized decisions. Thankfully the art of medicine provides for that, when science may necessarily have to be set aside.


Simon Kassabian, MD
VA Hudson Valley Health Care System
Montrose, New York


Reference:
1. Shah SK. Futility. Ann Intern Med. 2014;160:138-9
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