Ethics

1. Approaches to Issues
of Futility

2. E. M. Cioran
…once pain rouses us, there is no one but ourselves,
alone with our disease, with the thousand
thoughts it provokes in us and against us.

3. California Probate Code 4650
An adult patient has the fundamental right to have life-sustaining
treatment withheld or withdrawn.
The prolongation of the process of dying for a person for whom continued
health care does not improve the prognosis for recovery may:
Violate patient dignity, and
Cause unnecessary pain and suffering,
While providing nothing medically necessary or beneficial

4. Problems with determination of futility are
often caused by physicians
Institute of Medicine study on improving care at the end of life
1.There is overuse of care;
2. Inconsistent with patient preferences and
prognosis;
3. Underuse of care to treat symptoms;
4. Untimely referral to hospice;
5. Poor palliative care;
6. Poor communication regarding prognosis and
treatment preferences.
Annals of Internal Medicine (2001) 135:8.

5. Physicians are obligated to initiate
patient dialogue
 Give patient the greatest opportunity to make
his or her own choices –
 Communicate with the patient while you can -
before loss of capacity.

6. Physicians Don’t Generally Discuss
End of Life Decisions
In a prospective cohort study in five tertiary medical
centers found that:
 <23% physicians discussed CPR performance
with seriously ill patients
(n1589)
Annals of Internal Medicine: (1997) 127:1; 1-12

7. Prolonged Ventilation
12% discussed preferences with their physicians
20% said that they wanted it
80% said that they did not want it. (n 1573)
Annals of Internal Medicine 1 July 1997 | Volume 127 Issue 1 | Pages 1-12

8. Effective vs. Excessive
Benefit of Treatment vs. Burden on Patient
 Are we keeping the patient alive when there is no benefit to
life of the patient?
 Are we giving the patient time to recover to a level of
quality of life that the patient will accept,
 Or are we merely prolonging or exacerbating the process
of death?

9. What does the patient/surrogate need to
understand when considering futility
 Diagnosis, prognosis
 Burdens of Illness
 Effectiveness of Treatment
 Potential of rehabilitation, and
 Diminished quality of life.
 Right to refuse treatment, and
 Right to request palliative care/comfort care

10. Faith and Dignity
 Fiduciary: from Latin - fides, meaning faith
 A fiduciary is expected to act with the highest
level of good faith, loyalty and trust.

11. The surrogate is not your patient.
When a patient looses capacity to make decisions, he or she does
not loose the right to effectuate his or her choice.
 There is no fiduciary relationship or duty to the surrogate.
 The fiduciary relationship with your patient continues,
 The Surrogate must be solely used as a conduit for the
wishes and choices of the patient.
 Therefore the surrogate must receive the same type and
amount of information the patient would receive if able to
make decisions.

12. Dealing with Surrogate Decision Makers
 Surrogates are agents. They must effectuate the
wishes of the patient - not their own wishes.
 To do so they must understand the illness, its effect
on the patient, and the prognosis.
 If they won’t listen and /or will not act, they cannot
be a surrogate.

13. California Probate Code §4714
A surrogate shall make a health care decision in accordance with the patient's
individual health care instructions, if any, and other wishes to the
extent known to the surrogate.
Otherwise, the surrogate shall make the decision in accordance with the surrogate's
determination of the patient's best interest.
In determining the patient's best interest, the surrogate shall consider the patient's
personal values to the extent known to the surrogate.

14. Surrogates and the Therapeutic Privilege
 Physicians may decide that telling a patient the truth
about their illness is not in the patient’s best interest.
 This does not, however, apply to a surrogate decision
maker.
 If a surrogate cannot fully and intelligently participate,
then he or she cannot be the surrogate. Then a second
surrogate must be identified, if possible. If not turn to a
best interest standard.

15. Significant Delay must not be permitted to
impact on pt’s best interests
 A surrogate cannot be permitted to cause a delay in
decision making which will harm the patient.
 If a surrogate cannot or will not be fully informed and
understand the diagnosis and prognosis, he or she
may not continue as surrogate – because they are
not speaking for the patient.
 If a surrogate cannot or will not decide – find a new
surrogate

16. California Probate Code 4714
A surrogate, shall make a health care decision in
accordance with the patient's individual health care
instructions, if any, and other wishes to the extent
known to the surrogate. Otherwise, the surrogate
shall make the decision in accordance with the
surrogate's determination of the patient's best interest.
In determining the patient's best interest, the surrogate
shall consider the patient's personal values to the
extent known to the surrogate.

17. Statutory Right of the Physician regarding the
Determination of Futility
A health care provider or health care institution may
decline to comply with an individual health care
instruction or health care decision that requires
medically ineffective health care or health care
contrary to generally accepted health care standards
applicable to the health care provider or institution.
California Probate Code § 4735

18. California Probate Code
§4766
A petition may be filed under this part for…
(c) Determining whether the acts or proposed acts of an agent or surrogate are
consistent with the patient's desires as expressed in an advance health care directive
or otherwise made known to the court or, where the patient's desires are unknown
or unclear, whether the acts or proposed acts of the agent or surrogate are in the
patient's best interest.
(d) Declaring that the authority of an agent or surrogate is terminated, upon a
determination by the court that …
(1) The agent or surrogate has failed to perform, or is unfit to
perform, the duty under an advance health … [or] , is acting (by action or
inaction) in a manner that is clearly contrary to the patient's best interest.

19. Disqualification of a Surrogate
 A patient having capacity may disqualify, at anytime,
another person, including a member of the patient’s
family, from acting as the patient’s surrogate by a
signed writing, or by personally informing the
supervising healthcare provider of the disqualification.
(California Probate Code Section 4715).
 Such disqualification should be promptly recorded in
the patient’s healthcare record, noting the date and time
of such declaration.

20. Technology can Mask Futility
 Physicians may tend to overuse technologically
aggressive, life-prolonging treatments and,
underuse communication skills that can assist
patients in making choices.
Miettinen T, Tilvis RS. Medical futility as a cause of suffering of dying patients: the family members’
perspective. J Palliat Care. 1999;15:26-29

21. Do not mask futility with medicine
 Things look better today, his
white count has come down
somewhat…
 We think we can wean him
tomorrow - if not, we can
trach him…
 He is still fighting this
infection, we don’t know yet
if he will be able to
overcome it…
 If we cannot wean him we
should talk about whether
he would want to have a
tracheostomy and go to a
long term nursing facility, or
refuse further treatment.

22. Don’t frighten the patient or surrogate with
the word “futility.”
 If we wait until the therapeutic impasse to tell the patient or
surrogate we create panic rather than understanding –
 We risk loosing our ability to reason and discuss;
 This leads to protest, denial and anger with the medical
treatment which you have been providing;
 It hurts the patient
 It sets the stage for consideration of claims of malpractice.

23. Discussing futility is made more difficult by:
 Overly Optimistic or pessimistic prognoses
 Lack of or poor communication about treatment
 Failure to know the patient’s values, expectations,
and cultural and religious orientation.
G. Holloway, R. et al. JAMA 2005;294:725-733.

24. Elicit patient’s valued life activities to
help evaluate QOL
 Time with family and friends, autonomy,
recreation, other
 Probe positions on "life worth living" and
states considered "worse than death"
 Include spiritual and ethical dimensions of
these values

25. Time-Limited trials
 Gives surrogate opportunity and time to
participate and gain a better understand of
the benefits and burdens of treatment;
 To allow families to work through grief and
intelligently participate in evaluating treatment
options and the patient’s values and wishes.

26. All Patients or surrogates must:
 Be told their diagnosis and prognosis;
 Be told what therapy is effective;
 Told that they have the option to Refuse
Treatment;

27. Risks of Demanding Futile
Treatment Must be Disclosed
 Just as informed consent is required for the
refusal of treatment, it is also required for the
demand of futile treatment: the patient
/surrogate must be told of:
 Unnecessary Suffering
 Unnecessary Prolongation of Imminent Death
 Needless anguish, fear and insecurity for loved
ones

28. Acceptable Criteria
 I don’t want to live in a SNF on machines –
So, I am refusing treatment. I understand that
I will die without this treatment.
 I want everything done and let the Lord
decide when it’s my time.

29. Unacceptable Criteria
Patients:
 My family wants my life insurance benefits.
 I want to refuse treatment and die, but my children
want me to fight on, even though you have told me
that further treatment is futile.
Surrogates:
I know she is suffering needlessly but I don’t want to
feel I am killing her…
Her sister does not want me to …

30. Jose Ortega y Gasset
Law is born from despair of human nature.

31. The Law
 Generally, Courts do not want to see you
unless there is a dispute.
 Courts adjudicate disputes – they do not like
to make medical decisions.

32. California Probate Code 4765
 4765. …a petition may be filed by
 (a) The patient
 (b) The patient's spouse, unless legally separated.
 (c) A relative of the patient
 (d) The patient's agent or surrogate
 (e) The conservator of the person of the patient
 (f) The court investigator, …
 (g) The public guardian
 (h) The Primary treating physician or hospital caring for the patient
 (i) Any other interested person or friend of the patient.

33. Judicial Powers:
California Probate Code §3208 …
 … the court may make an order authorizing withholding or
withdrawing artificial nutrition and hydration and all other
forms of healthcare where the recommended healthcare is
in accordance with the patient’s best interest, taking into
consideration the patient’s personal values to the extent
known to the petitioner.

34. The Law for Withholding Life Sustaining Treatment
Terminal Non Terminal
PVS
Yes Yes
Yes CCE of
Pt’s Intent
Minimally
Conscious

35. Transparency
 Issues of futility address the most serious and fundamental
rights;
 In cases where a patient has no surrogate, it is advisable to
have the Ethics Committee at your hospital review the case
and support your decision. Note in your progress record your
meeting with, and recommendations of the Ethics Committee.
 Discussions with patients and families regarding, DNR orders;
transfer to hospice; withdrawal or withholding of treatment,
must be noted with specificity, and if possible, before a
witness.

36. Seeking Review and Recommendations of Ethics
Committees
 Protects the patient;
 Protects and supports the Primary Treating
Physician’s decision;
 Assists the Court, if it’s assistance is sought

37. The ethics of terminal care
Dignity varies with different stages of life.
For the terminally ill, dignity is best reflected in
our level of respect for a person’s right to choose
and in the provision of truly humane and personal
care.