Futility II

How do you approach a family to say that medical care is futile and ought to be stopped? How do you look at a patient on cardiovascular drips, a mechanical ventilator, artificial nutrition, continuous renal replacement therapy, and broad-spectrum antibiotics and decide to stop them? Even if a patient will never get better, they are alive now, and what does it mean to stop those interventions keeping them alive? Modern medical ethics makes a point to say that withdrawing support is ethically equivalent to not beginning the support in the first place. Had we known this patient was not a transplant candidate and would not get better, we would not have intubated her, started pressors, continued CVVH. But now that we have started these things, it's so much harder to stop them, even if nominally there's no difference.

I spend two hours in family meetings over two days. End of life conversations are never easy. But over time, I've become better. I make a point to plan things out. I find a quiet room. I introduce everyone, learn everyone's names. I ask family what their understanding of the situation is. I explain the medical issues as clearly as I can; I avoid vagaries. I survey responses, from "I cannot stand her suffering; I think we should let her go in peace" to "I'm not God, I don't know what to do" to "I don't understand, why is this happening" to "I need more time" to "I think a miracle might still happen." When asked, I make my medical recommendation, that futile care should not be prolonged, that the patient is suffering, and that we should move to comfort care once everyone who needs to be here has arrived. With each meeting, I inch toward that goal. Although medically, we can unilaterally transition the patient to comfort care, my job now is to care for the family and help them cope.