LAS VEGAS – Emergency physicians should weigh the benefits and harms of life-sustaining medical treatments that are likely to be ineffective or simply prolong the dying process, especially when patients have comorbidities such as dementia, according to an expert panel.
The panel took up the divisive issue of providing “medically futile” care to patients in emergency departments at the annual meeting of the American College of Emergency Physicians.
Dr. Gregory L. Henry
Panel moderator Dr. Gregory L. Henry, a past president of ACEP and adjunct clinical professor of emergency medicine at the University of Michigan, Ann Arbor, offered an economic perspective, pointing to the escalating cost of health care against the backdrop of staggering national debt.
He noted that patients have a steadfast belief in autonomy and self-determination when seeking care, but the matter of how to pay for this care is unresolved.
“Spending other people’s money is always easy, but spending the money that indentures the yet-unborn is cowardly and immoral, and that’s exactly what we are doing,” Dr. Henry commented.
The default in emergency departments is often to stabilize patients with poor prognoses and let their fate play out in the intensive care unit, he said. But emergency physicians should reflect on their role in starting this “cascade of expensive care rolling down the hill,” he said.
“Everybody in this room who is practicing must decide: Are you just following orders, or are you an independently thinking individual?” he challenged those in attendance. Furthermore, emergency physicians must ask themselves whether they serve only individual patients or larger society.
“It takes no intelligence or courage to stick in a tube, intubate, start IVs, give pressors, raise blood pressure on a 90-year-old who is demented,” Dr. Henry commented. “It takes some courage to take one step back and say, ‘What’s the point?’?”
Although discussion of medical futility by emergency physicians is imperative, he advocated taking up the issue with other specialties, and contended that resolution will require input of society as a whole. Finally, “as this discussion goes forward, I want to see the politician brave enough to lead it.”
Panelist Dr. Daniel J. Sullivan, president of Sullivan Group Risk Management Consulting and assistant professor in the emergency medicine department at Cook County–Rush Medical College in Chicago, noted that courts have established a personal negative right to care, whereby patients can refuse life-sustaining treatment, but they have declined to rule on a potential positive right to care, whereby patients can demand care even when their physicians believe it is futile. In the latter case, the courts have deferred to patient autonomy and self-determination, and cited preemption by federal laws such as EMTALA (Emergency Medical Treatment and Active Labor Act) and the Americans with Disabilities Act.
All 50 states have passed futility statutes that provide immunity to physicians in such situations. But “most of them don’t work,” Dr. Sullivan observed, because they refer to care in terms such as “medically ineffective” and “medically inappropriate,” which themselves are debatable.
“Consider going toe to toe in the emergency department, where somebody says, ‘Do everything,’ and you know with every fiber of your being [that] it’s the wrong thing to do,” he said. “You are at risk. The courts haven’t gotten behind you; the legislature hasn’t gotten behind you.”
Before physicians will be able to withhold or withdraw care with confidence in such situations, certain events must occur, according to Dr. Sullivan. “We need a social mandate; we need society to move on this issue. We need clear-cut legislation, and that legislation probably has to be federal,” he said. Finally, “we need immunity – civil, criminal, disciplinary.”
For now, “you’ve got to back your patient off the conflict,” he recommended. “There are systems in place to bring people away from conflict and into agreement, and there we can all do the right thing.”
Panelist Dr. Jerome R. Hoffman, a professor of emergency medicine at the University of California, Los Angeles, contended that medically futile care is a societal issue and noted that it begs a larger question: “Do we as individuals have the right to demand unlimited resources from our society?”
He pointed to starkly different societal attitudes on and approaches to allocating shared health care resources between Europe and the United States.
“In Europe, they call this having choices – we are going to choose among different therapies; we are going to choose the one that makes sense because it’s rational, it gives us a bang for our buck, and we can afford it,” he commented. “In America, we don’t call it choices; we call it rationing.”