Question
Why provide interventions deemed futile?
Answer
The thought of taking away something that could help a family member live is extraordinarily challenging. The study that Jox et al. (2012) completed asked those folks why we would provide these interventions. The reasons that we do such things are primarily emotional. Guilt, grief, fear of the legal system, and concerns about the family's reactions. They are providing an opportunity for the family to come to terms with the end of life. It may take a few days or a week for those folks to come to terms and understand that this might be the best thing to do—also some institutional barriers. There could be a delay for several reasons, establishing a serious prognosis. In some states, the courts allow the hospital to discontinue futile medical intervention after a specific time. They wait for that time to expire, go through the court system, and have families visit the patient before the patient passes away. In this study by Cifrese et al., 2018, the authors conclude that managing futility could be improved through communication training, knowledge transfer, organizational improvements, and emotional and ethical support systems.
Jox et al. (2012) study provided a treatment algorithm based on the results of their study. Number one, asking about the patient's preferred goal of treatment. In some situations, this might be a challenging conversation because perhaps this was an unexpected event. There was no time to talk with the patient about this. In that case, you must rely on the patient's family or surrogate decision-makers. Perhaps this is a stage four COPD patient who has been in the hospital many times. This happens to be the last of those admissions—but understanding the patient's preferred goal of treatment is important. Patient preferred goal, what would you like to receive? What is your goal from this admission? Are you trying to get back to a higher quality of life? Are you trying to get home so you can pass away at home? What is your goal here?
Then we must identify whether we can realistically achieve these goals. If they cannot, if this patient is on a mechanical ventilator, their pupils are dilated and non-reactive, the patient's family says, "I want my patient to get up, walk out the door, go home, have a steak dinner," there is a strong likelihood that that is not going to happen. As factual judgment, now we have to say, "Okay, this is not a reasonable expectation of the outcome of this patient's disease process." If it is realistic, does the benefit of that goal outweigh the risks and burdens? Yes, we can institute mechanical ventilation, but we all have to remember that mechanical ventilation is not a benign intervention. If it is, if the mechanical ventilator is mismanaged, then we can cause structural damage. We can cause barotrauma and volutrauma. We can cause all kinds of fun issues that we would prefer our patients not to experience. It is not a foregone conclusion that the patient will rest on mechanical ventilation to become extubated. There will be no consequences. Again, can the benefits outweigh the risks and burdens? If not, we are back to that pathway of identifying an alternative goal of treatment.
This Ask the Expert is an edited excerpt from the course, Futile or Fruitful: Medical Interventions and the Respiratory Therapist, presented by Shawna Strickland, Ph.D., CAE, RRT, RRT-NPS, RRT-ACCS, AE-C, FAARC.
