Just (Don't) Do It
A previous post of mine discussing the fact that the "last year of life" is a retrospective designation was not, as some have misinterpreted, meant to be about futile care. This one is.
Futile care can be defined as medical intervention with no hope of prolonging life or easing suffering. Although there seems to be substantial agreement that determining the futility of a specific intervention for a specific patient can be difficult at times, many practitioners (or at least several bloggers) feel quite confident of their ability to do so. The Happy Hospitalist has said (in my comments) that he is 100% certain he can predict on admission who will not leave the hospital alive. If so, then why does he proceed to hook these patients up to nine IV pumps? Panda relates similar stories of demented grannies (his term) sent over from nursing homes to be
So why do it?
Why do you go ahead and admit someone to the ICU if you know they won't live? [Note: I'm not talking about borderline cases; I mean those patients you really do *know* won't make it. You claim to know who they are, and I believe you.] Why do you consult the surgeon when nothing he does will make a difference? Why don't you stop? Why don't you say NO?
I know what you're going to say: "We don't know the patient. The families are strangers to us. We don't have the right to say no; to initiate these kinds of discussions. That's your job; the Family Doc. It's your long-term relationship with the patients and families that makes you the person to have those difficult talks, helping the families come to grips with the idea that medicine can't do anything more. It's not my place."
You're the treating physician. You seem to have no difficulty forming relationships quickly enough to tell someone they need emergency surgery, and heaven knows you have far more experience than I conveying tragic news in the case of horrific trauma. You're the one standing there in the room with the patient, certain that nothing you do matters [a determination I'm agreeing with, mind you.] Whether or not there's a formal DNR order in front of you, all 50 states have legal protections for physicians who refuse to provide futile care. Yet you go ahead and intubate; start the pressors; call the ICU. Somehow you manage to grow a backbone and refuse inappropriate narcotics to blatant drug seekers. This is no different, no matter how you protest.
If managing the problem if futile care is important (and given the demographics of aging Baby Boomers, I would say it is rapidly becoming critical) then we all have to step up to the plate and do something about it, by not doing what shouldn't be done in the first place. I have two concrete suggestions (to be discussed in future posts) but first and foremost, you -- the ER docs and the hospitalists -- must stop passing the buck back to us, the primary care docs, to help patients and families make end-of-life decisions.
Don't tube that demented old granny. Explain to the family why it's not appropriate to put dad in the ICU. For heaven's sake, stop thinking "Hospice" is a synonym for "we give up"! When faced with a terminal patient (and yes, we all know dementia is terminal; why can't we face that?) just don't do it.
It is your job.