Ethics and Policies Regarding “Medically Inappropriate Care”

EthicsandPoliciesRegarding“MedicallyInappropriateCare”

FeliciaCohn,PhDBioethicsDirector

KaiserPermanete OrangeCountyClinicalProfessor

UniversityofCaliforniaIrvine

Overview• Reviewthemeaningof“medicallyinappropriatecare”

• Assessaprocessforaddressingmedicallyinappropriatecare

• Considerpolicyneedsandimplicationsofmedicallyinappropriatecare.

“NaturalDeath”

“MedicallyInappropriateCare”Not medically indicated

Ineffective

Non-beneficial

Hopeless

Futile

SchneidermanLJ, JeckerNS, JonsenAR. Medicalfutility:itsmeaningandethicalimplications. AnnInternMed. 1990Jun15;112(12):949-54.• …weproposethatwhenphysiciansconclude(eitherthroughpersonalexperience,experiencessharedwithcolleagues,orconsiderationofpublishedempiricdata)thatinthelast100casesamedicaltreatmenthasbeenuseless

• Ifatreatmentmerelypreservespermanentunconsciousness orcannotenddependenceonintensivemedicalcare,thetreatmentshouldbeconsideredfutile.

• …treatprobabilityandutilityasindependentthresholds.…physiciansmustdistinguishbetweenaneffect,whichislimitedtosomepartofthepatient'sbody,andabenefit,whichappreciablyimprovesthepersonasawhole.Treatmentthatfailstoprovidethelatter,whetherornotitachievestheformer, is"futile".

• …physicianscanjudgeatreatmenttobefutileandareentitledtowithholdaprocedureonthisbasis.Inthesecases,physiciansshouldactinconcertwithotherhealthcareprofessionals,butneednotobtainconsentfrompatientsorfamilymembers.

TheElusive“F”Word

•QuantitativeFutility• Likelihoodthatinterventionwillbenefitpt isexceedinglypoor(reasonableprobabilityofsuccess).

•QualitativeFutility• Qualityofthebenefitaninterventionwillproduceisexceedinglypoor,i.e.resultwillbepoorqualityoflife.

TheFutilityofFutility

O!besomeothername:What’sinaname?thatwhichwecallaroseByanyothernamewouldsmellassweet;

ShakespeareRomeoandJuliet

Othernames…• CaliforniaMedicalAssociation:“Non-BeneficialTreatment”• “NBTgenerallynotindicatedforirreversiblemedicalconditionswhereimminentdeathisexpected.”

• “CMAModelPolicy:RespondingtoRequestsforNon-BeneficialTreatment.”July2011

• CriticalCareorganizations:“PotentiallyInappropriateTreatment”• Theterm“potentiallyinappropriate”shouldbeused,ratherthanfutile,todescribetreatmentsthathaveatleastsomechanceofaccomplishingtheeffectsoughtbythepatient,butcliniciansbelievethatcompetingethicalconsiderationsjustifynotprovidingthem.

• AnOfficialATS/AACN/ACCP/ESICM/SCCMPolicyStatement:RespondingtoRequestsforPotentiallyInappropriateTreatmentsinIntensiveCareUnits,June2015

Definitions/Descriptions• Anytreatmentaphysiciandeterminesintheexerciseoftheirprofessionaljudgmentwould:• Beineffective forproducingdesiredphysiologicaleffectthatthept/agentdesiresorexpects;or

• Producenoeffectsthatcanreasonablybeexpectedtobeexperiencedbypt asfurtheringtheirexpressedandmedicallyobtainablegoals;or

• Causeharmtothept significantlydisproportionatetothebenefit;

• Hasnorealisticchanceofreturningpt toalevelofhealththat permitssurvivaloutsideofacutecarehospital;or

• Wouldserveonlytomaintainpt’s lifeinapermanentlyunconsciousstate,unlessthereisevidencethatthepatientwouldvalueremainingaliveinthatstate.

CompetingEthicalObligations

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TreatmentRequestsMoralDistress• Differentinterpretationsofgoodsandharms.

• Perceivedbreakdownoffiduciaryrelationship.

• Decision-makingreducedtostrugglebetweenpatientautonomyvs.clinicianautonomy.

• Treatmentgoalsoftennotclarified.

• Subjectiveperceptionsofqualityofthislife.

• Noestablishedtransparentprocesstoresolvedisputes.

Helft PR,Siegler M,LantosJ.TheRiseandFalloftheFutilityMovement.NEJM343;2000;293-296

Fromdefinitiontoprocess

Whypolicy?InstitutionalPolicy Case-by-CaseBasis

Advantages -Clearguidelines.

-Decreasespotentialdiscrimination.

-Increasedconsistency.

-Moreflexibilityandroomforprofessionaljudgment.

-Lesscumbersomeprocess.

Disadvantages-Processmaybecumbersomeleadingtolackofutilization.

-Caseswillinevitablyfalloutsidethedefinitions.

-Inconsistencyandriskofdiscrimination.

-Lackofofficialadministrativesupport.

SharedDecisionMaking

Patient’sRole• Determinevalues/goalsincludingQoL

• Weighrisks/benefits

Physician’sRole• Explainclinicaloptions

• Fosterunderstanding

• Setlimits

Relationship/Trust/Communication

LegalSupportCaliforniaLaw• CaliforniaProbateCode4735:• “Ahealthcareprovider…..maydeclinetocomplywithanindividualhealthcareinstructionorhealthcaredecisionthatrequiresmedicallyineffectivehealthcare…”

• CaliforniaProbateCode4740:• “Ahealthcareprovider….acting ingoodfaithandinaccordancewithgenerallyacceptedhealthcarestandards…..isnotsubjecttocivilorcriminalliabilityforanyactionincompliancewiththisdivision,including,buttolimitedto,anyofthefollowingconduct:

• Decliningtocomplywithahealthcaredecisionofapersonbasedonabeliefthatthepersonlackedauthority.

• Decliningtocomplywithindividualhealthcare instruction…inaccordancewithSections4734to4736.”

PolicyDevelopment• BasedonCMAModelpolicyandCaliforniastatelaw• DevelopedbyRegionalBioethicsCommitteeover2yearperiod• Vettedbynumerousstakeholdergroups• Reviewedandapprovedbylegalandriskmanagement.• Reviewedandapprovedbyregionalleadership.• Reviewedandapprovedbyservicearealeadership• Annualreview

Steps• Enlistexpertconsultationfornegotiation/conflictresolution• Informpatient/surrogates• 2nd medicalopinion• Interdisciplinaryhospitalcommitteereview• Opportunitytotransferthepatienttoanalternateinstitution• Opportunitytopursueextramuralappeal• Decisionimplementation• Ongoingsupport

PolicyProcess• Step1:IdentifyNBT• Step2:CommunicationamongMedicalTeam• Step3:Communicationwithpatient/ decisionmakers• Step4:SecondOpinionbyReviewingPhysician• Step5:EthicsReview• SupportsInitiation/ContinuationofTreatment— transfertoanotherMD• SupportsForgoingTreatment—opportunityfortransfer,thantreatmentstops

20|©2011KaiserFoundation

HealthPlan,Inc.Forinternaluse

only.

November10,2016

Workflow

PuttingPoliciesIntoPractice

PolicyOutcomes• 1KPservicearea(SouthBay)• Retrospectiveevaluationofallbioethicsconsultations11/6/09(policyadoption)– 8/6/12.

• Case-specificdataforconflictinvolvingwithholdingorwithdrawingofnonbeneficial treatment.

• MainOutcomeMeasures:Conflictresolution• Results:• 146(39.4%)cases• 54(37.0%)ofthecases,resolutionoccurred.• 92(63.0%)NBTeventuallywithheldorwithdrawn.• 87(94.6%)wheretreatmentwaswithheldorwithdrawn,consensusreachedthroughpolicyprocess

• 5conflictsremained• CMNelson,BANazareth,Nonbeneficial TreatmentandConflictResolution:BuildingConsensus,PermJ2013Summer;17(3):23-27

5casesofpersistentconflictCasesofunilateralwithdrawal Patientpreferences

Afterethicscommitteecase

reviewTreatmentwithheld

orwithdrawn OutcomePostoutcomelitigation

1 Beneficialtreatmentperadvancedirective

Familythankful CPR,increaseddoseofvasopressors,antiarrhythmics

Comfortmeasuresinitiated;patientdiedinhospital

No

2 Unknown; familyneverdiscussedtreatmentpreferenceswithpatient

Familyaccepting CPR,stent,increaseddoseofvasopressors

Comfortmeasuresinitiated;patientdiedinhospital

No

3 Noadvancedirective;patientambivalentwithtreatmentpreferences,thenlostcapacity

Familyunaccepting CPR,dialysis,vasopressors,antiarrhythmics,tracheostomy,antibiotics

Comfortmeasuresinitiated;patientdiedinhospital

No

4 Familystatedthatpatientrequestedconservativetreatment;noadvancedirective

Familyunaccepting CPR,dialysis,feedingtube

Comfortmeasuresinitiated;patientdiedinsubacutecarefacilityposttransfer

No

5 Conservativetreatmentrequestedperadvancedirective

Familyunaccepting Nasogastrictubeandpercutaneousendoscopicgastrostomytube

Transferredtoanotherhospitalbyfamily;nofurthercontact

No

Societaldisconnect

Historically…

DoctorsDieDifferently“It’snotafrequenttopicofdiscussion,butdoctorsdie,too.Andtheydon’tdieliketherestofus.What’sunusualaboutthemisnothowmuchtreatmenttheygetcomparedtomostAmericans,buthowlittle.Forallthetimetheyspendfendingoffthedeathsofothers,theytendtobefairlyserenewhenfacedwithdeaththemselves.Theyknowexactlywhatisgoingtohappen,theyknowthechoices,andtheygenerallyhaveaccesstoanysortofmedicalcaretheycouldwant.Buttheygogently.

Ofcourse,doctorsdon’twanttodie;theywanttolive.Buttheyknowenoughaboutmodernmedicinetoknowitslimits.Andtheyknowenoughaboutdeathtoknowwhatallpeoplefearmost:dyinginpain,anddyingalone.They’vetalkedaboutthiswiththeirfamilies.Theywanttobesure,whenthetimecomes,thatnoheroicmeasureswillhappen—thattheywillneverexperience,duringtheirlastmomentsonearth,someonebreakingtheirribsinanattempttoresuscitatethemwithCPR(that’swhathappensifCPRisdoneright).”

DoctorsDieDifferently

“…victimsofalargersystemthatencouragesexcessivetreatment”

KenMurray,JournalofMedicine,August1,2013,https://www.ncnp.org/journal-of-medicine/1240-doctors-die-differently.html

CommunicationIsKey

“….partoftheir[physicians’]angstcomesnotsimplyfromthepressuretoprovideburdensometreatment,butalsofromaninabilitytofindtherightlanguageandconceptualframeworkfortalkingabouttheproblemwithpatientsandfamilies.”

SolomonMZ.Howphysicianstalkaboutfutility:makingwordsmeantoomanythings.JournalofLaw,Medicine,andEthics1993;21:231-237

BeyondCommunication…

• Family“threats”togotothemedia orattorney• Fairapplicationofpolicybasedonmedicalindications,whileremaining sensitivetoculturalandreligiousdifferences.• Institutionalsupportforapplicationinindividualcases.• Societalperspectives

Policyimplications• Physiciandutiesatthebedside• Respectforpatient/surrogateautonomy• Avoidharm(“overmasteredbydisease”)• Stewardresources

• Endsofmedicine• Recognitionoflimitsofmedicine• Limitsofautonomy

• SocietalObligations• Unsustainablecostsandmanpower• Opportunitycosts• Fairness:justdistributionofresources

CompetingEthicalObligationsandSocialContext

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PublicEngagement“Themedicalprofessionshouldleadpublicengagementeffortsandadvocateforpoliciesandlegislationaboutwhenlife-prolonging

technologiesshouldnotbeused.”

OFFICIALPOLICYSTATEMENT:AmericanThoracicSociety(ATS),approved10/15AmericanAssociationforCriticalCareNurses(AACN),12/14AmericanCollegeofChestPhysicians(ACCP),10/14EuropeanSocietyforIntensiveCareMedicine(ESICM),9/14SocietyofCriticalCareMedicine(SCCM),12/14

Individual,PhysicianorSociety?

And the winner is…

Forquestions

FeliciaCohn,PhDPhone:[email protected]

ResuscitativeServicesPolicyMedicallyInappropriateCPR

• AffirmspolicytoprovidemedicallyindicatedCPR,intheabsenceofaDNRorder.• IdentifiessituationsinwhichCPRisconsideredineffectiveandisnotmedicallyindicated:1. Terminallyillpatientwhoisimminentlydying2. Patientexperiencingirreversibleorganfailure

notexpectedtosurvivecurrenthospitalization3. Permanentlyunconsciouspatient

• DecisionthatCPRisnotmedicallyindicatedandwillnotbeofferedmustbedisclosedtopatient/agentanddocumentedinthemedicalrecord.

DNRandMIT/NBT

CPR

MIT/NBT