The dilemma of 'futile health care'
May 8, 2014
It is 3 o'clock in the morning when a colleague in the ward requests a consultation. Ms Haagens, eighty-four years old, is extremely short of breath. I find her ill at ease and breathing heavily in a large hospital bed.
Her daughter next to her bed, looking extremely concerned. "Pneumonia”, my colleague says. "Admitted yesterday. Blood pressure is dropping and she is no longer urinating."
Ms Haagens* had been living in a nursing home for some years. There, she receives loving care and can enjoy regular visits from her children and grandchildren. The situation had declined in the past years. Unfortunately, it is no longer possible to speak with her. She is much too short of breath. My colleague does not have any more information to offer either. "I do not really know her that well, but there is no agreement regarding a policy restriction." Thankfully, the daughter of the patient is present. Liver function disorders, diabetes and heart failure, the family doctor had said.
Yes, she had discussed ‘what if’ with her children in the past. What if she were to become seriously ill. "No pointless suffering, no plant", she had always said. Upon being admitted to the hospital, she had been asked whether she wished to be resuscitated. Eh, well, they had planned to discuss the matter amongst themselves, but had never got around to it. She had been doing quite well at home in the nursing home. Using her walker, she could even manage to shop for things at the local supermarket. A content old lady who never complained. But it was clear that Ms Haagens would not be able to keep this up without intensive care.
There you are, in the middle of the night. Your gut feeling tells you that there is a considerable chance that this will be agonizing for the patient. A prolonged, probably hopeless admittance to the intensive care, on artificial respiration, with a lot of medication, kidney substituting therapy, etc. A considerable chance that medical treatment is futile. But you can never be one hundred percent certain in this acute phase. Knowledge and scientific research are not much help. This consideration, this dilemma, is essential and weighs heavily.
Which is why I follow the discussion in society on 'futile care' from up close. A fascinating ZonMW memorandum was recently published, with the title: Must we do everything we possibly can. It shows that patients and doctors find it difficult to set limits to the treatment of patients. It demonstrates that it is much easier to define futile care from behind a desk compared to doing so at 3 o'clock in the morning at the bedside of the individual patient.
This is one of the dilemma’s in the worthwhile discussion on 'futile care'. What may be futile for one patient, can be worthwhile for the other. What is the point of informing Ms Haagens that she has an eighty percent chance or more of dying in her situation? She may belong to the remaining twenty percent. And this concerns the chance of survival, which has nothing to do with the quality of life once Ms Haagens leaves the IC unit. Quality of life highly depends upon the individual and the time concerned.
Living up to the expectation
As a doctor, the only thing you can humanly do in this acute phase is to live up to the expectation of the patient and the family. That expectation is understandably often aimed towards recovery, even in people of this age and their family! Perhaps this is a task for us as doctors, but even more as a society: managing expectations!
And Ms Haagens? Yes, I moved her to the intensive care. She died three days later. Surrounded by her family. Three days of futile medical treatment, strictly speaking. Would I do it again? Yes! I am a doctor and a manager of expectations…
* the name has been changed for privacy purposes
This blog was previously published on Skipr.nl.