Sunday, November 21, 2010

The Path of Aggressive, Futile Care

From Health Leader Media an article on what they call the elephant in the room, futile care, and what those of us watching the health care crisis unfold in the U.S. see as the number one issue, not only because of cost but because of violation of patient autonomy and well-being:

Once again, the folks at the Dartmouth Atlas Project have pointed to an elephant in the room. There the beast sits—the enormous amount of far too aggressive, painful, costly and often futile care, which too many doctors and hospitals provide during a Medicare patient's last 14 or 30 days of life.

The Dartmouth team's report, entitled Quality of End-of-Life Cancer Care for Medicare Beneficiaries: Regional and Hospital-Specific Analyses, shows the wide, and hard to explain, variation across the country in care provided in the last month or two weeks of a patients life. Its data tables look at cancer care practices within regional referral networks and specific hospitals for 235,821 end-stage cancer patients who died between 2003 and 2007.

The Atlas shows that this aggressive care was provided to patients whose type and stage of cancer predicted extremely poor prognosis, even for the short-term, and for whom such care is likely futile. Cancers like pancreatic, lung, and some types of leukemia and lymphoma were included in the analysis.

This is care that many patients would reject if they were told the truth: that there is very low probability their time spent in a hospital—often in an intensive care unit—will increase their number of days, the authors say.

In some cases, aggressive treatment with chemotherapy, endotracheal intubation, feeding tube placement and cardiopulmonary resuscitation, can hasten death, or at least severely weaken the patient and limit their ability to communicate with loved ones in the time when that's of greatest importance.

Is this what some might truly want? Some, perhaps. But for others, decidely not.

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The Doctor's Role in Patient Consent

More and more I encounter the meme that doctors should begin receiving spiritual sensitivity training, training that allows them to be more sensitive to a patient's moral and religious values. While the details of what this exactly means are vague, I'd rather my doctor tell me what is medically proven, not what he thinks his knowledge of my religious values dictates. From a recent post at Science + Religion:

... religion informs health values for many patient populations and, as such, deserves consideration within the clinical encounter. If a patient adheres to a religious worldview, then the physician should learn the skills to elicit these values (noting the patient to be the foremost interpreter of these values for themselves) and help the patient to make decisions consonant with their own value system.

We already have an environment where doctor-patient communication is in need of improvement. Asking doctors to tailor information for patients based on their assumptions of the patient's moral and religious values is far too near the paternalistic communication pattern well entrenched. Belief is never monolithic. While the Catholic church may oppose removal of some patients from artificial nutrition and hydration, it would be ethically wrong for a doctor to assume that a patient, because they define themselves as Catholic, would be as well. It seems to me that calls for greater religious sensitivity are misdirected and based on assumptions about moral and religious values, assumptions that are far too simplistic to capture and react to the plurality of many individual faith understandings.

The role of the doctor is not to alter disclosure of medically viable procedures but to inform of all possibilities and options. The patient, in consultation with his or her family, must then consent. And that is the true meaning of informed consent: doctors inform and advise; patients choose the course.

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