The Beginning of the End of Futile Care Theory?

Well, this is very refreshing. An article published two years ago in the journal Chest ( 2007; 132:1987–1993) suggests that coercive medical futility be replaced with a different--and from my perspective, far more positive--approach to handling intractable disputes between a medical team wanting to cease life-sustaining treatment and a family insisting that it continue. (I was pleasantly surprised that one of the authors is Robert D. Troug, MD, whom I have criticized here at SHS for supporting killing the dead donor rule in organ transplatation.) From the article (no link, but I have):

The debate about how to resolve cases in which patients and families demand interventions that clinicians regard as futile has been in evolution over the past 20 years. This debate can be divided into three generations. The first generation was characterized by attempts to define futility in terms of certain clinical criteria. These attempts failed because they proposed limitations to care based on value judgments for which there is no consensus among a significant segment of society.

The second generation was a procedural approach that empowered hospitals, through their ethics committees, to decide whether interventions demanded by families were futile. Many hospitals adopted such policies, and some states incorporated this approach into legislation. This approach has also failed because it gives hospitals authority to decide whether or not to accede to demands that the clinicians regard as unreasonable, when any national consensus on what is a "beneficial treatment" remains under intense debate. Absent such a consensus, procedural mechanisms to resolve futility disputes inevitably confront the same insurmountable barriers as attempts to define futility.

We therefore predict emergence of a third generation, focused on communication and negotiation at the bedside. We present a paradigm that has proven successful in business and law. In the small number of cases in which even the best efforts at communication and negotiation fail, we suggest that clinicians should find ways to better support each other in providing this care, rather than seeking to override the requests of these patients and families.

Excellent! When presented with properly educated facts and emotional support, most families do the right thing by their loved ones. Education and compassionate emotional/spiritual support are the keys here. But in those rare cases where agreement cannot be reached, I agree that the right approach is to stop using coercion and provide the treatment--assuming it is not physiologically futile. That's the way to keep trust in medicine particularly at a time of tight medical resources.

I am not optimistic, however. There doesn't seem to have been much follow up to this article--at least none that I have seen. That would be too bad because by following the "third generation," presents the bioethical community with the opportunity to end a humongous public dispute before it really starts.