MEDICAL
FUTILITY MONITOR:
AVOIDING
THE MILLION-DOLLAR DEATH
SYNOPSIS:
Medical science and technology has now advanced so
far in the West
that it is quite common for patients to be 'treated to death'.
Because it is always possible to apply one more treatment,
some specialist will suggest trying something new.
And new treatments will be used unless and until someone says "enough".
A Medical Futility Monitor would be a compassionate
doctor
with many
years of experience in terminal care.
She (or he) would apply information contained in a world-wide data-base
for the purpose of deciding whether any proposed medical treatment
would be useful or useless for the patient being considered.
The Medical Futility Monitor would issue written
recommendations.
And if these were not followed,
under careful safeguards for life-ending decisions,
the Medical Futility Monitor would have the power to 'pull the plug'
for patients who will no longer benefit from medical treatment.
Supportive care will be provided until natural death.
OUTLINE:
1.
WHICH DOCTORS WOULD BECOME THE BEST MEDICAL FUTILITY MONITORS?
2.
THE MEDICAL FUTILITY MONITOR WOULD BE EMPLOYED BY THE HOSPITAL.
3.
AVOIDING THE MILLION-DOLLAR DEATH.
4.
A WORLD-WIDE DATA-BASE OF THE EFFECTIVENESS OF TREATMENTS.
5. HOW WILL THE EVALUATIONS OF THE MFM BE IMPLEMENTED?
6.
THE MFM HAS FINAL AUTHORITY TO 'PULL THE PLUG'.
7. THE SAFEGUARDS MOST
LIKELY TO
BE USED BY THE MEDICAL FUTILITY MONITOR.
8.
USUALLY THE FAMILY WILL DECIDE TO END TREATMENT.
9. SOMETIMES THE MEDICAL FUTILITY MONITOR WILL MOVE ON TO OTHER CASES.
MEDICAL
FUTILITY MONITOR:
AVOIDING
THE MILLION-DOLLAR DEATH
by
James Park
During most of the life of human beings on the
planet Earth
(which is about 7 million years since the human race branched off from
the other large apes),
there has been too little
medical care.
In fact, scientific medical care has only been possible for the last
350 years.
And then, only in the 20th century did modern medical technology
really come into its own.
But now—at
least in the West—a
new problem has
arisen: too much medical care.
Because modern hospitals do in fact have the capacity
to replace almost all of the natural functions of the human body,
this technology will often be used on each patient
until that patient dies, still connected to the "tubes and machines".
Termination of useless medical treatments is a
well-established medical option,
but it might need to be established as a new specialty in medical care.
Often the patient, the family, and the treating doctors are so close to
the situation
that they cannot be rational about the best time to terminate treatment.
But here they might be helped by a medical professional whose only role
is to evaluate the efficacy of treatments already being used
and all possible new treatments that might be proposed.
1. WHICH DOCTORS WOULD BECOME THE
BEST MEDICAL
FUTILITY MONITORS?
A Medical Futility Monitor is an MD with at least 30
years experience in terminal care.
Because of the fear of applying mindless abstractions to actual
patients,
the Medical Futility Monitor should be a female doctor.
This would counteract the worry that a bean-counting administrator
might have the power to say when medical treatment should end.
Becoming a Medical Futility Monitor would thus not
be a specialty
that one would train for in medical school.
This is a specialty that might emerge near the end of one's medical
career.
Because it takes so many years of training just to begin a career as an
MD,
the usual length of that career is about 30-40 years.
The doctor who has practiced bed-side medicine
with actual dying patients for at least 30 years
would have a wealth of experience with dying patients and their
families.
She would be able to handle the interpersonal dimensions
of asking the most relevant end-of-life questions.
Becoming a Medical Futility Monitor would be a
second medical career,
lasting as long as the doctor is still able to help make life-ending
decisions.
A Medical Futility Monitor would be an advisor
to patients, their families, and to the doctors providing terminal care.
The primary-care physician is often so responsible for the care of the
dying patient
that he or she must be available at any time.
This sometimes results in an exhausting schedule of work.
Returning to medical care as a Medical Futility Monitor
would be a regular salaried position with a 40-hour work-week.
The process of evaluating the efficacy of terminal
care
will not be an instant-by-instant decision-process,
as exemplified in its more extreme form in the emergency room.
Rather, the Medical Futility Monitor will be doing
careful and reflective background research,
meeting with the patient and the family
probably over a period of weeks
rather than hours.
2. THE MEDICAL FUTILITY MONITOR
WOULD BE EMPLOYED BY THE HOSPITAL.
In order to simplify the process and to make sure of
the lines of authority,
the Medical Futility Monitor would not be paid
from the funds provided for the medical care of the patient.
Rather, the MFM would be a professional employee of the hospital
or other medical institution that is providing terminal care.
Thus, the MFM would be parallel to the hospital
administrator
and other professional staff who make sure
that the best medical care is provided to all patients.
Seen in the total budget of the hospital,
the Medical Futility Monitor would not add to the costs,
since much of her work would result in less medical treatment for
the
patient.
And some of this useless terminal care was being paid by the hospital
because the insurance for the patient has run out.
For each day of useless care that can be omitted,
the medical costs will be a few thousand dollars less.
Such savings somewhere in the system of paying for medical care
will more than pay the salary of the Medical Futility Monitor.
3. AVOIDING THE MILLION-DOLLAR
DEATH.
Under the standard medical procedures of the recent
past,
it was common for terminal care to be extended for months and even
years,
so that the total costs mounted to more than a million dollars.
The predictable outcome was the same: death.
But the process was long and drawn-out
because the practice of terminal care was handled by so many
specialists,
each giving attention to only one bodily system
but no one really taking responsibility for the life of the
patient.
Once the patient has been taken in by an advanced
hospital system,
the process of care sometimes goes on automatic pilot:
Everyone is employed in familiar procedures,
all of which are intended to save the life of the patient.
The billing department could probably give a total
for the expenses already incurred,
but usually these are behind-the-scenes accounting
not known to the people who are providing the care
and not known to the patient and/or the family.
And sometimes only the insurance company knows
how much has been paid out for this patient
because there might be several different agencies and institutions
asking to be paid for whatever they have provided.
Only some months after the death has occurred
will it be possible to add up the total cost for this terminal care.
Cost will be a factor in the deliberations of the
Medical Futility Monitor,
but even more immediate will be the question of
what good is being provided
for the patient
by means of the present and proposed medical treatments.
4. A WORLD-WIDE DATA-BASE OF
THE EFFECTIVENESS OF TREATMENTS.
The Medical Futility Monitor will have at her
fingertips
a data-base on information gathered from all similar cases
wherever such patients have been treated anywhere in the advanced world.
This is a perspective not usually employed by the treating doctors.
They are so focused on saving this particular patient
that they do not know what the probability of success might be.
But computers can collect data far too vast to be
contained in any human mind.
The Medical Futility Monitor will be able to type into her computer
more and more
specific facts
about the patient whose care is being reviewed.
When the closest parallels have been discovered,
the outcomes of various medical treatments can be summarized.
The statistical data must never make the final decisions,
but the facts about similar cases form the background
for making decisions for the specific patient
who is receiving the
specific treatments
—or
who might receive
such treatments.
Experimental treatments should never be discounted,
especially when the patient has only one, very specific, medical
problem.
If the patient is otherwise in good health,
then an organ transplant might solve all of his or her medical troubles.
But terminal care of patients who are in the last
years of their lives
usually includes several parallel medical problems being treated at
once.
Each such medical problem has been solved in other patients.
But has any patient recovered from having all of the same problems
simultaneously?
And there will be even more obvious cases,
such as patients in persistent vegetative state (PVS),
whose bodies depend on life-support systems.
Even when surgeons suggest hip-replacement or removing another tumor,
the fact the patient will never return to life outside of the hospital
should be taken into account by someone.
And that someone might be the Medical Futility Monitor.
5. HOW WILL THE EVALUATIONS OF THE
MFM BE IMPLEMENTED?
Once the Medical Futility Monitor has been called
upon to evaluate the terminal care,
he or she is free to come to any conclusion based on the evidence.
She will be completely independent of the patient and family,
independent of the doctors (both primary-care physicians and
specialists),
and independent of any other medical or financial systems.
The Medical Futility Monitor will issue a written
report of conclusions as of a certain date.
She should include in this summary how any future changes might affect
the conclusions.
For example, she might say that
if the patient continues to be
unconscious for another month
and if there are no other changes,
then all
treatments should be stopped.
This report will become a permanent part of the
medical record.
And it will be explicitly shared with everyone involved in making
decisions for this patient,
including the patient himself or herself
to whatever degree he or she is still able to understand what is
happening.
The normal deciders should be given sufficient time
to assimilate this new information.
And usually they will take the necessary medical decisions
without any further input from the Medical Futility Monitor.
In other words, the Medical Futility Monitor can recommend
ending all medical treatments as of a stated date.
6. THE MFM HAS FINAL
AUTHORITY TO 'PULL THE PLUG'.
However, if the deciders fail to follow the
recommendations of the MFM,
then the MFM should have the authority to begin a process
of fulfilling safeguards for life-ending decisions on her own.
The specifics facts about each patient will dictate which safeguards
would be more relevant.
And the normal deciders might already have fulfilled some of these
safeguards
—such
as getting additional medical opinions—
in their own process of examining their medical options.
When sufficient safeguards have been fulfilled,
and if the normal deciders still fail to carry out the necessary
life-ending decisions,
then the MFM should have the necessary authority to 'pull the plug'
herself.
In order to prevent mistakes,
a resisting family does have the possibility of delaying the death
if there is some possibility of judicial review of the life-ending
decision.
But under all normal circumstances, any judicial review
will only determine that all of the appropriate safeguards were
carefully fulfilled.
And therefore, there is no reason to reverse or delay the life-ending
decisions.
The detailed work of the Medical Futility Monitor
will shorten the lengthy legal processes seen in the early right-to-die
cases.
The medical record will already show the medical facts,
which could be summarized by the Medical Futility Monitor.
Consequently, there will be little original work for the courts to do.
And in the vast majority of cases, the record created by the Medical
Futility Monitor
will be so thoro that no court will agree to take the case.
7. THE SAFEGUARDS MOST
LIKELY TO BE USED BY THE MEDICAL FUTILITY
MONITOR.
The following 13 safeguards for life-ending decisions
are the most relevant ones from the 26 recommended safeguards:
http://www.tc.umn.edu/~parkx032/SG-A-Z.html.
The letters at the beginning of each safeguard are retained.
And each safeguard is linked to its complete explanation on the
Internet.
A. ADVANCE
DIRECTIVE
FOR MEDICAL CARE
If the patient himself or herself has had the
foresight to create an Advance Directive,
then there might be an explicit affirmation that futile medical care
should not be applied.
Exactly what did the patient write about terminal care when he or she
was in good health?
What financial limits did the patient include?
How does the over-all philosophy expressed in the Advance Directive
apply to the specific situation at hand?
C.
REQUESTS
FOR
DEATH FROM THE
PATIENT
If the patient has made any explicit, recordable
requests for death,
these should be given special weight
by those who must now make
terminal-care decisions.
Are continuing treatments being carried forward
against the express
wishes of the patient?
E.
PHYSICIAN'S
STATEMENT
OF CONDITION AND PROGNOSIS
If no one has yet asked for a written statement of
the medical condition of the patient,
the Medical Futility Monitor can be the person who will request such a
document.
The medical facts form the foundation for any determination of
futility.
F.
INDEPENDENT
PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS
And especially since death cannot be reversed,
a second professional opinion should be written
by another doctor who has independently examined the patient.
G.
CERTIFICATION
OF TERMINAL ILLNESS OR INCURABLE CONDITION
If the doctors have officially declared the patient
to be in a terminal condition,
this fact will be one of the most powerful arguments in favor of
terminating treatments.
The doctors who create and sign such a declaration of terminal illness
are saying that no matter what future treatments are tried,
this patient is already on a downward pathway
towards a death that cannot be avoided.
H.
UNBEARABLE
SUFFERING
If the patient is obviously in pain
and all efforts to alleviate that suffering have failed,
this will be further reason to decide that this life is over.
Further treatments will not only be useless,
but they might also be extending the torment of the patient.
J.
PALLIATIVE
CARE
TRIAL
If the patient has already tried various methods of
relieving suffering,
this part of the medical record will also be relevant
for evaluating the efficacy of further efforts to relieve the terminal
pain.
K.
INFORMED
CONSENT FROM THE PATIENT
If the patient is still able to make meaningful
medical decisions,
then the written and signed informed consent from the patient
will be the most dramatic proof
that terminating treatment is the wisest course of action.
L.
REQUESTS
FOR
DEATH
FROM THE PROXIES
And if the patient can no longer make a meaningful
life-ending decision,
then the official requests for death from the duly-authorized proxies
will be further support for taking the actions
that will allow the patient's life to end.
N.
STATEMENTS
FROM
HOSPITAL OR HOSPICE STAFF MEMBERS
The Medical Futility Monitor might also gather
expressions of opinion
from the people who are most closely involved in the care of the
patient.
Do they also agree (based on their experience with similar patients)
that further medical treatments would not be useful?
O.
STATEMENTS
FROM FAMILY
MEMBERS
AFFIRMING OR QUESTIONING CHOOSING DEATH
Sometimes family members will also give their
personal opinions
about the terminal care of the patient.
Any such statements should also be included in the report of the
Medical Futility Monitor.
P.
A MEMBER
OF THE
CLERGY
APPROVES OR QUESTIONS CHOOSING DEATH
Also, if a clergy-person selected by the patient
and/or the family
has written a statement about the proposed death,
this will be further support for any decision by the Medical Futility
Monitor
that additional medical treatments would not be meaningful.
R.
AN
INSTITUTIONAL
ETHICS COMMITTEE REVIEWS THE PLANS FOR DEATH
When the medical institution providing the terminal
care has an ethics committee,
the written conclusions of any such deliberations
should also be included in the report of the Medical Futility Monitor.
The Medical Futility Monitor will select which of
the possible safeguards
are most relevant for the patient whose life-and-death are being
considered.
And if the 13 possible safeguards mentioned above do not yield an
obvious conclusion,
then there are 13 more possible safeguards that might be applied:
http://www.tc.umn.edu/~parkx032/SG-A-Z.html.
8. USUALLY THE FAMILY WILL DECIDE TO
END TREATMENT.
Since the family will be fully aware of the work of
the Medical Futility Monitor,
in most cases, the reasonable recommendations by the MFM
will lead the patient, the proxies, or other family members called upon
to decide
to authorize the termination of treatments, resulting in the patient's
death.
The length of time before death comes will depend on the nature of the
life-supports.
If a respirator was keeping the patient alive, death will come
immediately.
If a feeding-tube was sustaining life, then death will come in a week
or 10 days.
If drugs were keeping something in balance,
the doctors will be able to predict how quickly
the natural processes of the body will shut down
in the absence of these chemical supports.
9. SOMETIMES THE MEDICAL
FUTILITY MONITOR WILL MOVE ON TO OTHER CASES.
Whenever there might be some difference of
conclusions,
the MFM might just leave the recorded opinion in the medical record
and move on to other cases of possible useless medical care.
These will always be more than enough possible cases to keep the MFM
busy.
Even if her recommendations are not followed in one case,
her work will still be effective in other cases.
In retrospect, the abandoned cases will result in later deaths,
after a few more months or years of useless medical care.
And as the public becomes more aware of this new dimension of terminal
care,
they will be more ready to accept the conclusions
of this new profession—the
Medical Futility Monitor.
Created
June 24, 2009; Revised 7-1-2009; 7-2-2009; 7-8-2009
AUTHOR:
James Park is an existential philosopher and medical
ethicist.
He has written extensively about end-of-life issues.
Some related cyber-sermons are linked below.
Everything else you might like to know about him
will be discovered on his website, called
An Existential
Philosopher's Museum.