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* From the Department of Medicine (Drs. Rivera, Kim, and Garone), Cedars-Sinai Center for Health Care Ethics (Dr. Morgenstern), and Division of Pulmonary/Critical Care Medicine, (Dr. Mohsenifar), Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
Correspondence to: Seth Rivera, MD, 8700 Beverly Blvd, Suite 5610, Los Angeles, CA 90048; e-mail: il1md{at}home.com
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Abstract |
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 TOP Abstract IntroductionMaterials and MethodsResultsDiscussionReferences |
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2 5 degrees of freedom = 26.7,
p < 0.001). When the bioethics consultation resulted in
cessation of the therapy, patients died in a median of 2 days as
opposed to 16 days if therapy continued
(p < 0.001).
Key Words: bioethics • futility • medically inappropriate
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Introduction |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Ethically, society is very concerned about denial of treatment, even when outcomes are hopeless. The time-honored orientation of medical personnel is toward the preservation of life at all costs, an attitude that often overshadows realistic medical expectations. The issues of treatment in the desperately ill are fraught with emotional distress on the part of the patient, family, and physician. Interventions with no hope of a successful outcome impose a tremendous burden on societal resources. It has been well established that a major expenditure of health-care dollars occurs during the last 6 months of life.5 6 7 8 Furthermore, in this era of increasing managed care, patients and families may believe health-care systems are protecting their own economic interests over what is best for patient care.9 10
While many articles have been written discussing the ethical issues surrounding futile care11 and a smaller number have addressed medically inappropriate care, there has been no study to date that has attempted to rigorously define the people and factors that lead to these interventions. We sought to determine the types of patients who receive futile or medically inappropriate interventions, which parties were the driving force behind these interventions, and what factors motivated them. In addition, we analyzed the role of a timely bioethical consultation in curtailing such interventions.
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Materials and Methods |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Not all of the consultations involved futile or inappropriate medical treatment. Of 331 records, 100 sequential cases were identified by two of the authors as meeting the criteria of futile treatment plans. At a minimum, two conditions needed to be met for cases to be included in this study. First, a bioethics consultation needed to be performed (some patients died before a consultation was performed). Second, the patient must have died during the current hospital stay. From this starting point, the reviewers included all patients in whom therapy was being rendered without hope of achieving the patient’s minimally acceptable outcome (futile) or with little hope of any outcome other than postponing death (medically inappropriate).
Basic demographic information included gender, age, and religion. The nature of disease and nature of terminal event were grouped into one of five major categories: (1) congenital; (2) traumatic, as in injuries sustained in a motor vehicle accident; (3) degenerative, such as intracranial hemorrhage or myocardial infarction; (4) inflammatory, for example, pneumonia or inflammatory bowel disease; and (5) neoplastic, such as colon cancer. The nature of the disease was defined as the condition that precipitated admission to the hospital or constituted the patient’s underlying disorder. The nature of terminal event was the disease process that ultimately precipitated the patient’s demise. As an example, if a patient was admitted for a hip fracture and then developed a perioperative myocardial infarction and died soon after, the nature of disease would be classified as traumatic and the nature of terminal event would be degenerative.
From the information on the chart, we sought to determine the party who was most responsible for the futile or medically inappropriate interventions being delivered and what factor principally motivated them. We determined the time in the hospital before the ethics consultation was obtained, as well as the number of days after the ethics consultation that the patient died. Finally, we determined whether the ethics consultation led to the discontinuation of the futile or medically inappropriate therapies. The approximate cost of a hospital day was determined using the California Office of Statewide Health Planning and Development data for all the inpatient facilities in California. The total amount of cost was divided by the number of patient-days spent in these facilities. Although this cost includes many surgical procedures, we believe this number is justified, as most of our patients were in an ICU and many had surgical procedures performed.
Statistical calculations were performed using software (Excel;
Microsoft Corporation; Redmond, WA; and WinStat; Kalmia Corporation;
Boston, MA). Parametric data are expressed as the mean ± 2 SD. The
median data point, range, and interquartile range are given for
nonparametric data. To evaluate differences in frequencies,
crosstabulation techniques were utilized to develop
2 statistics or a Fishers’ Exact Test p
value. Correlations with age were done using a Student’s independent
t test.
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Results |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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Underlying Factors
In most cases, multiple parties and factors led to the delivery of
the futile or medically inappropriate care. However, we sought to
narrow this down to one principal responsible party and one major
factor. The three parties we were able to identify were the family in
62% of cases, a physician in 37%, and a conservator in one case. None
of the patients were able to participate in the decision-making process
of their own care since they were universally too impaired. The
principal factor implicated was an unreasonable expectation of
improvement in 58% of the cases. Other factors were fear of legal
consequences in 14%, religion in 9%, guilt in 7%, family dissent in
7%, and patient desire in only 5%.
Physicians feared legal liability in 12 of 37 cases where they were
primarily responsible for the delivery of the futile or medically
inappropriate care, as opposed to family members who considered legal
consequences in only one of 62 cases (2 5
degrees of freedom [df] = 26.7,
p < 0.001). The final case where legal issues were the primary
motivating factor was primarily driven by a conservator.
While dissention among family members motivated the interventions in 7
of 62 patients for whom the family was responsible, it did not play a
role in the 37 patients for whom the physician was the responsible
party (2 5 df = 26.7, p < 0.001). Age and
nature of disease did not play a role in the delivery of futile and
medically inappropriate interventions.
Fifty-two of 73 families of patients with a known religious preference
were the principal party prolonging the delivery of futile care in
contrast to only 10 of 27 families of patients who stated no religious
preference (2 1 df = 10.4, p < 0.001).
Ethics consultations were effective in 39 of 71 cases when the patient
had a known religious preference, compared to 20 of 27 cases when the
patient did not (2 1 df = 3.0, p = 0.07).
While religious reasons were expressly cited in only a small number of
cases, our experience has shown that religious issues are present in
many more cases than were found with our screening instrument.
Consequences
Patients were in the hospital a median of 16 days (range, 1 to 102
days; interquartile range, 8 to 30) before a bioethics consultation was
obtained. Consultations were effective (defined as leading to a
cessation of the futile or medically inappropriate therapy) in 59% of
cases. In two cases, the patient died before any action could be taken
based on the consultation. In cases where the bioethics consultation
was effective, patients died in 2 days (range, 0 to 61 days;
interquartile range, 1 to 4), whereas when the consult was ineffective,
patients did not die for 8 days (range, 0 to 157 days; interquartile
range, 5 to 1; p < 0.001). Ethics consultations were effective in 28
of 36 cases where a physician was primarily responsible, but only 31 of
61 when family was responsible (2 1
df = 6.9, p = 0.007). Age did not determine whether a consultation
was effective or not. The California Office of Statewide Health
Planning and Development lists the average price per patient-day as
$1,810 (total operating costs divided by patient-days). Using these
data, the cost savings per patient receiving futile or medically
inappropriate care would be $10,860 per patient where futile care can
be stopped.
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Discussion |
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TOPAbstractIntroductionMaterials and MethodsResultsDiscussionReferences |
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While families were the principal responsible parties in a majority of cases, it was surprising how often physicians were the primary motivating party in the delivery of futile or medically inappropriate care. However, physicians were much more likely to site fear of legal consequences or misunderstanding of the legal issues and very often responded favorably to bioethics consultations. Despite these facts, there were still many cases where physicians expected unrealistic outcomes despite the intervention of a bioethics consultation. In these cases, hospitals may need to institute peer-review systems where physicians in the same specialty could review the case and discuss whether there is any foreseeable medical benefit to be obtained from the intervention being pursued.
Whereas religion was only noted as the primary factor in a small number of cases, it may play a larger role in futile and medically inappropriate interventions. However, in our data, there was not a statistically significant difference in the effectiveness of a bioethical consultation in cases where the patient stated a religious preference compared to those who did not.
Finally, we believe this study demonstrates the benefit of a timely bioethical consultation in ameliorating needless patient suffering and in reducing unnecessary costs. The ability of anyone in the patient’s orbit or anyone on the health-care team to initiate a consultation expands the responsibility and increases the frequency of such consultations. In our opinion, this has been a useful activity, the basic pattern of which should exist in all hospitals.
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Footnotes |
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Received for publication October 3, 2000. Accepted for publication December 12, 2000.
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References |
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This article has been cited by other articles:
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  J. P. Burns and R. D. Truog Futility: A Concept in Evolution Chest, December 1, 2007; 132(6): 1987 - 1993. [Abstract] [Full Text] [PDF]
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