Ethics and Medically Ineffective Treatment II

Most of our cases of medically ineffective treatment happen in the ICU. For me, in particular, it's an interesting experience. For the most part, I don't think the goals of a critical care physician and a clinical ethicist conflict; after all, we strive to be as ethical as we can. However, in the large gray of the end of life where decisions have real consequences but little evidence, treating physicians may want help navigating care that may be futile. I've had so many families pray for a miracle for a loved one when from a medical and scientific standpoint, there is nothing more to offer. How do we tread those circumstances? On the one hand, it is easy to simply continue everything, giving the family that one last hope. On the other hand, prolonging the inevitable which usually involves suffering and loss of dignity is rarely the right thing for a patient. From a systems standpoint, we cannot sustain a health care infrastructure if we provide interventions and treatments that have no benefit.

In situations where families pray for miracles, who is to say what is futile and what is not? This is something that ethicists have grappled with and written about, and a commonly accepted threshold is that if the last one hundred patients who were in this situation and received this treatment did not have any benefit, then the treatment is futile. This can be quite controversial, and some people argue for a stricter threshold while others think this is too narrow. I tend to agree with it. Since we commonly accept a scientific trial to be significant if there is less than 5% of doubt, then setting the threshold at less than 1% gives me reasonable certainty in determining whether an intervention is worthwhile.

Ethically, withdrawing and withholding treatment is equivalent. That is, if I believe putting someone on a ventilator is futile and I do not offer it, I can also discontinue the ventilator in someone already on it if it's futile there as well. For families, of course, this feels entirely different. Many people accept when an intervention like dialysis will not be offered. It's much harder to go to them and say that since dialysis is not helping and not expected to help, we will withdraw it. I encounter all these situations in the ICU both as a primary treating physician and as an ethics consultant.