Futile Care: Who decides?
Futile Care: Who decides?
Imagine your husband is in a hospital, struggling against a debilitating or life-threatening disease. If something goes wrong, you tell the doctor to do what he can because your husband wants to live. But the doctor says no, he does not believe that the quality of your husband's life is worth doing as you ask. Indeed, he is so adamant, he puts a Do Not Resuscitate (DNR) order on your husband's medical chart over your objections, meaning that if he suffers a cardiac arrest or some other life-threatening event, he plans to stand by idly and watch your husband die.
Frightening stuff. Unfortunately, it is also true. This is close to what befell Andrew Sawatzky, 79, of Winnipeg, a resident at the Riverview Health Centre since May. Sawatzky has had strokes and has advanced Parkinson's disease. Helene, his wife, says her husband can communicate (this is disputed by doctors) and wants to live as long as he can. Moreover, their religious faith requires continued care.
If Sawatzky has a heart attack, Helene wants him to have CPR. But she was told by Riverview that they won't do it, that CPR would be "futile." Over Helene's objections, a DNR order was entered upon his medical chart. She sued to require his own doctors to treat him in a medical emergency. On November 11, she won a victory. But it is only temporary, pending court proceedings.
In a similar case, a Quebec man didn't survive long enough to take his doctors to court. Earlier this year, Herman Krausz, 76, was admitted to Montreal Jewish General Hospital, in respiratory distress from a lung infection. At first, he improved; then he developed pneumonia and had to be put on a respirator.
According to his family, Krausz, who was not unconscious or incompetent, knew he would probably last only a few weeks. Still, he wanted to continue to receive respiratory support so he could spend his remaining time with his family. According to Krausz' family, that did not sit well with the intensive care medical director who ordered the respirator turned off against his patient's and the family's wishes. Krausz died 15 hours after he was taken off the respirator. The matter is now set for a coroner's inquest.
Ironically, most people are more worried about being "hooked up to machines" against their will than of being denied wanted medical care. That is because in too many cases, doctors used to keep people alive regardless of their desires. But that danger faded substantially after medical ethicists successfully argued that patients should be allowed to re-fuse unwanted medical treatment even if ceasing care would lead to death. As a result, patient autonomy became a mainstay ethic of medicine.
Under the principle of patient autonomy, if Sawatzky wanted a DNR order placed on his chart, that was his right. Similarly, if Krausz had wanted his respirator turned off, that would have been done. So, one would suppose that these men had a similar right to receive treatment. Autonomy is autonomy, right?
Not necessarily. Increasingly, when it comes to end of life care, patient autonomy is a one-way street toward death. If a patient refuses care, the decision is sacrosanct. But if the patient's "choice" is for treatment such as CPR, antibiotics, ventilator, feeding tube, or blood transfusion in order to stay alive, we are told by some doctors, medical ethicists, and health care cost utilitarians that autonomy has its limits. Treatment requests they view as "inappropriate" will be refused.
This heads-I-win, tails-you-lose philosophy is known generically as Futile Care Theory. To fully comprehend the wickedness at work here, it is important to understand how medical ethicists have turned the traditional concept of medical futility on its head. A futile intervention used to be defined as one that had no possible physiological benefit. To use an extreme example to illustrate the point, if you asked your doctor to remove your appendix to cure an ear infection, the doctor should refuse because the surgery could not benefit you medically and would harm you.
In contrast, futile care (also called "inappropriate care") is about subjective value judgments by medical professionals rather than physiological outcomes. Sawatzky's involuntary DNR order was imposed not because CPR would have no physical benefit, but because it might. Similarly, Krausz's respirator was turned off against his will not because it wasn't benefiting himâ€”but because it was. Thus, it isn't the proposed treatments that were deemed futile in these cases, but the patients. Bluntly stated, Sawatzky and Krausz were seen as people who should die.
Throughout Canada and the U.S., hospitals and medical associations are quietly adopting formal futile care policies with which to browbeat families and patients who want "inappropriate" care and to convince courts to permit doctors' and medical ethicists' values to prevail over patient and family decision making. This is nothing less than the modern equivalent of exposing unwanted infants on hills and abandoning the infirm and elderly by the side of the trail.
A case in Spokane, Washington, demonstrates just how dangerous all of this really is. On October 27, 1994, Baby Ryan was born prematurely at 23 weeks gestation. He was put on dialysis, but the doctors determined that continuing treatment was "futile" and they halted it over his parents objections. Ryan would have died, but his parents obtained a court order to continue his treatment.
Administrators and doctors fought the parents in court swearing under oath that "Ryan's condition is universally fatal" and that the infant had "no chance" for survival, contending that Ryan's continued treatment was a violation of their integrity, values and ethics. The court never decided who had ultimate say over Ryan's care â€” his parents or the hospital â€” because he was transferred to Emanuel Children's Hospital in Portland, Oregon, where he was soon weaned off dialysis and survived.
Had his original doctors successfully imposed their values on their patient, Ryan would be dead today. Instead, he is a living four-year old child. If patient autonomy is to have any meaning other than providing a veneer of respectability for a "duty to die," the futile care movement must be stopped. Our lives and dignityâ€” and that of those we loveâ€” depends on it.
Wesley J. Smith is an attorney for the IAETF and the author of Forced Exit: The Slippery Slope from Assisted Suicide to Legalized Murder, published in 1997 by Times Books/Random House. His article originally appeared in Canadaâ€™s National Post (11/23/98:A14), and is reprinted here with the authorâ€™s permission