19.2 Requests for Futile/Inappropriate Interventions near the EOL

Question 1

What is the difference between futile vs. inappropriate interventions?

Answer 1

1. Futile interventions are those that simply cannot accomplish the intended physiological goal
2. Potentially inappropriate interventions are those that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them

Question 2

According to an international multi-organization futility statement, there are 4 types of treatment:
1. Futile
2. Legally proscribed/prohibited
3. Legally discretionary
4. Potentially inappropriate

Define/give an example of each

Answer 2

1. Futile: CPR on a patient with a ruptured left ventricle
2. Treatments prohibited by laws/public policies: i.e. Putting patient on dobutamine infusion to move them up on organ allocation list
3. Treatments for which there a laws that allow physicians to refuse to administer them
4. NG tube in patient with end stage dementia, CPR on a hospice patient

Question 3

When patients/SDM’s demand interventions that the clinician believes are not appropriate

Answer 3

1. Is the requested intervention physiologically futile?
2. Is the requested intervention legally proscribed or discretionary?
3. If it is not physiologically futile, proscribed, or discretionary, what are the specific concerns regarding appropriateness?

a.
Are there concerns about low likelihood of benefit relative to either high risks; excessive burden to the patient, family, caregivers, professional staff; or high demands on the healthcare system?

b.
Are there concerns about distributive justice, for example, occupation of an ICU bed, high cost, or use of other limited clinical resources?

c.
Are there concerns about moral distress for the involved healthcare professionals?

4. What is the assessment of the clinicians regarding the current circumstances and what is their recommended approach?

Question 4

How should clinicians respond to requests for medically futile interventions?

Answer 4

The clinician should not provide the futile intervention and should carefully explain the rationale for the refusal

Question 5

How should a clinician respond to requests for legally proscribed interventions

Answer 5

Clinicians should carefully explain the rationale for treatment refusal and, if there is uncertainty, seek expert consultation to confirm accurate interpretation of the rule

Question 5

How should clinicians respond to requests for legally permissible, non-futile, interventions when there are concerns that the treatment is potentially inappropriate?

Answer 5

1) first listen to the concerns of the patient or family members
2) clarify the patient’s values, goals, and preferences
3) align goals of care
4) explore treatment options
5) negotiate a mutually agreeable treatment plan.

Question 5

How should you respond to requests for potentially inappropriate interventions that remain intractable (i.e. despite intensive communication and negotiation) ?

Answer 5

Should be managed by a fair process of dispute resolution:

1. Enlist expert consultation to continue negotiation (i.e. ethics)
2. Give notice of the process to surrogates.
3. Obtain a second medical opinion.
4. Obtain review by an interdisciplinary hospital committee.
5. Offer surrogates the opportunity to transfer the patient to an alternate institution.
6. Inform surrogates of the opportunity to pursue extramural appeal.
7. Implement the decision of the resolution process.’

Question 5

List 4 techniques to navigate difficult conversations with families requesting potentially inappropriate treatments

Answer 5

1. Open and honest communication regarding the values, goals, and preferences of patient/family, as well as those of the clinicians, can facilitate shared decision-making and minimize conflict.
2. Active listening skills
3. Open, non-judgemental communication skills
4. Interdisciplinary family conference (reduces conflict)