Sorry for the big lag time since my last post. I was on call almost all of February which just completely drained me. In addition this case ended up dragging out as you will see.

In my previous post, I brought up a case that came up in the ethics committee. In a nutshell, it involved an elderly gentleman in a coma due to cardiogenic shock with no realistic hope for recovery. With no living will or designated health care proxy, the decision as to his care was left to the family. Unfortunately, like most cases, the family was divided with one daughter holding out for full care and the rest wanting to withdraw care. Ultimately, the daughter prevailed as the family chose to defer to her as the default decision maker. However, the medical team felt uncomfortable acquiescing to the daughter’s wishes to go through with full measures (insertion of a feeding tube and a tracheostomy) which were felt to be medical futile and asked for our input.

After a long discussion which was more divided than they usually are, the majority of the committee agreed that going through with the medical procedures was not in the patient's best interest and supported the team's decision to withhold this. However, they also felt that withdrawing care completely over the wishes over any family member, even if it were only one holdout, would not be ethical. Thus the team was encouraged to try to convince this daughter of the gravity of the prognosis but in the meantime, supportive care (IV fluids, nutrition, antibiotics, artificial respiration) was to be continued.

I and a significant minority completely disagreed with this decision though for different reasons. Here is my opinion at the time what I would have done an dmy reasons why. I felt that this was a "cop out" in that the committee simply advocated keeping the status quo while the tough decision of either going full bore or withdrawing care was sidestepped. A few felt that all care should be withdrawn despite the lack of family consensus but this was quickly rejected. Withdrawing all care would be medically, ethically and legally defensible but it would put the family through more of an emotional wringer and the last thing we want to do is put the idea that "hospital killed their loved one" in the family's mind. It goes without saying that creating an adversarial relationship between the medical team and the patient's family should be avoided at all costs.

In my opinion, the team should do everything and in retrospect should have done it all from the beginning once there was a breakdown in the family's consensus. I would have put in the feeding tube, the tracheostomy, stabilize him medically and transfer the patient to a permanent care facility. Why do this if we felt it's not what the patient would have wanted? Well, that's part of the problem; the patient's actual wishes were never specifically stated. True, most of the family members expressed that he wouldn't want this but one daughter did think he would and furthermore, the family gave their tacit backing to this daughter by letting her call the shots. What we think is immaterial since we have no standing in that decision. To me, it's pretty simple to accept family's decision and regardless how that came to their decision, you have to honor it.

But why support doing procedures that are medically futile? Isn't that a waste of health care dollars on a hopeless case? It is..... but honestly, it's cheaper and quicker than not doing anything and maintaining the status quo. The one aspect of health care ethics that often gets overlooked is the impact of these decisions to the rest of society. We often view these cases in a vacuum, not fully appreciating the ramifications of our decisions on future patients yet to be treated yet we have an ethical obligation to them as well. I feel it is our duty as health providers to provide quality care as expeditiously as possible, not only to save costs for the hospital but to enable us to move on to the next sick patient as soon as possible. By struggling over this decision for days and even weeks, that is one less ICU bed available to treat another patient. Also it means additional days of uncompensated care since insurance doesn't cover situations like this.

In the end, pretty much as expected, the patient remained in the ICU for another two weeks while the team unsuccessfully tried to have the family agree to withdraw care. Subsequently, he developed a drug resistant pneumonia, as many patients do during a prolonged ICU stay and ultimately died.

During this time, I received a call from a community hospital where one of my very complicated epilepsy patients presented with intractable seizures and I wanted him transferred to us. Unfortunately, we had no ICU beds available and we couldn't accept him and he was sent to another hospital instead. I found out later that he had a heart attack possibly as a complication of a mix-up in his medications but fortunately he did fine.