Friday, October 17, 2008

Just because we can ........

Just because we can does not mean we should.
All too often in the ICU we find ourselves in the difficult position of what to do next. We can save lives. We do it all the time. We have the best physicians, the best nurses and the best technology that is available and we use it to perform miracles. Sometimes though, even with the best care, people are just too ill or too damaged to save. If our charge as medical and nursing professionals is “first do no harm” then the question has to be asked, is giving or continuing medical care in cases where there is no hope of survival not in fact harmful. I would argue that it is. Offering or continuing care when there is no hope for survival is harmful to the patient, their family and the medical and nursing staff caring for them.
Often when a patient is first admitted to the ICU it is not possible to tell whether or not anything can be done to help or improve their prognosis. Tests are needed, and sometimes time itself gives information that can not be gleaned on admission. In these instances the only ethical course to take is one of maximum intervention until the extent of the damage is known. There are times when following initial treatment it becomes apparent that a loosing battle is being fought. However, these are not the patients I wish to discuss here.

Occasionally, especially in the ICU we will receive report on patients being transferred from another facility who are obviously beyond our help, beyond anyones help. Take, for example, the hypothetical case of the 90 +plus year, it is a common story, the patient, Mr X, has been found down at home no one knows how long he has been there. When the EMS arrive they find him unrousable, blue and cheyne stoking (a breathing pattern associated with the end stages of dying). He is intubated and transferred to the nearest hospital. On arrival at the hospital he is scanned and found to have a massive head bleed. As there are no neurosurgical services at the hospital he is transferred to another facility that can offer a higher level of care. His family are contacted and told he is being transferred for further care On arrival there is no family present. On review of the accompanying scans and physical examination of the patient it is quickly apparent that the patient can not be helped, his brain injury is catastrophic, not to mention the lack of oxygen he has suffered for an unknown amount of time before being found and rescued. The decision is made to keep him ventilated and try to keep his heart beating until family arrive. Mr. X’s family arrive at the Unit the following morning, and are told nothing can be done for their father as he is beyond medical help. A Do Not Resuscitate order is requested and staff attempt to talk about comfort care. This is denied, as is all too common there is a family rift and none of the children are willing to make a decision or take charge of the situation.

I ask you is this “do no harm”
Just because we can, does that mean we should? At three separate points in the care of Mr. X, medical futility could have been identified and treatment stopped. Could the EMS have not intubated him? Could the receiving hospital have made a decision that further care was medically futile and extubated him, or could the receiving hospital? Why was his family even asked to make a decision about something that was after all inevitable, based on evidence that was irrefutable? Why were staff asked to care for a patient they could bring no comfort to, could not heal, why was a hospital, already short of beds asked to take a patient for whom they could offer no help in lieu of a patient they could potentially have helped? Why? Although this case is hypothetical the scenario is all too common and is a familiar one to most medical professionals.
The concept of medical futility is not a new one. “The ancient Greek healers suggested that among the goals of medicine [was] the refusal to treat those overmastered by their illness” (Fine, 2000 Fine R. L., 2000, ) Healthcare resources are finite and should be allocated appropriately. Whilst resources are used to care for some one who we can not cure, save or even improve the quality of life for, someone else is going without because there is no hospital bed to accommodate them. Perhaps we should heed the admonition of the Greeks who warned patients “not to ask healers to attempt that which was impossible to medicine, and physicians, that to attempt a futile treatment was to display an ignorance that is allied to madness. (Fine, 2000)

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