The ethics of saying no to patients
No obligation to provide futile treatments
The American Medical Association's policy in Opinion 2.035 on Futile Care clearly states: "Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them. . . ."
Likewise, Opinion 2.19 on Unnecessary Medical Services suggests that "Physicians should not provide, prescribe, or seek compensation for medical services that they know are unnecessary."
While the AMA's policy is clear, patient expectations and/or demands for treatment can range from the highly complex to the more common situation, where a patient asks for an antibiotic when the physician thinks his or her ailment is viral. In both cases, physicians can sometimes be challenged by patients.
So, what are the ethics of saying no to patient care?
"I think this is an interesting and a complicated question," J. Randall Curtis, MD, MPH, a professor of medicine in the division of pulmonary and critical care at University of Washington. Curtis is the chair of the ethics committee at his hospital, which is Harborview Medical Center.
"And the reason why I say it's complicated is because it depends on the situation and the circumstances. So, I think most physicians believe and practice [with the belief] that physicians are under no obligation to provide therapies that are not indicated just because a patient demands them."
In extreme examples, he says, a patient may demand surgery that the surgeon doesn't think will benefit that patient. Or, a patient requests a bone marrow transplant for a disease "where a bone marrow transplant hasn't been shown to help, then physicians say no to that all the time."
In situations where a requested treatment might cause significant harm or create significant expense — and provide no benefit — it's common for a physician to say no to that treatment.
"I think where it gets more complicated or trickier is when the therapy is not risky and not expensive," Curtis tells Medical Ethics Advisor.
"The classic example — there is a patient coming in with what a doctor believes is a viral upper respiratory infection. The doctor doesn't believe antibiotics are indicated, but the patient insists on getting antibiotics, and the doctor feels like 'Well, you know what, this is not expensive therapy and I'm not 100% sure there isn't a bacterial infection. There are some risks involved, but generally, these are pretty safe therapies — and I'm going to go ahead and prescribe them.'"
Curtis says that if you look at the data on the "use of antibiotics for upper respiratory symptoms in otherwise healthy people, the data suggests that doctors will do that, at times," he says. "Whether that's good practice or not, I really think it depends on the scenario. In point of fact, a lot of times, we're not 100% sure that there isn't a bacterial infection…"
But if it were one of the physician's family members in that scenario, the physicians probably would not prescribe the antibiotics, he says.
Futile treatment can have exceptions
The same sort of pattern for physicians follows when the questions surround futile treatments. That is, Curtis says, when the patient requests a very expensive or risky treatment and the physician doesn't feel there will be a benefit, that physician is likely to decline to provide it.
"I think what is more complicated is when the therapy has already been instituted — which happens not infrequently in the intensive care unit — and the situation has worsened. So that, if circumstances have changed where the therapy that's currently being provided — now thought to be futile — and the doctor feels that this therapy should be withdrawn . . . that is much more complicated," Curtis tells MEA.
In such circumstances, Curtis says that the health care team will enter discussions with the patient, or often, family members, and "try to resolve the conflict without withdrawing life-sustaining treatment against the wishes of a patient or family."
This type of scenario is a common source of ethics consultations at hospitals, in his experience, he says.
In most of those cases, "the recommendations of the ethics committee are, 'Gee, futility is a little hard to determine here. It's hard to be 100% sure if the therapy is futile.' And it may not be therapy that physicians and nurses would want for themselves or their loved ones, but in fact, in this situation it's best just to continue to work on building trust and negotiating with families and continue the therapy," Curtis suggests.
In those rare circumstances, when a hospital decides it will withdraw futile therapy against the wishes of a family, the process for withdrawing life support is often to advise the family that the medical team suggests withdrawing life-sustaining support and give the family 72 hours to find another provider to take on the case, if the family disagrees with the suggestion.
Curtis says he has seen three cases that came to an ethics committee, in which the team decided that the patient was clearly dying, life support was only prolonging death, and that it would be ethically permissible to withdraw life support.
In two of those cases, the decision was made to withdraw care. In one of those circumstances, "this was a family that felt like they had to do everything they could to keep their loved one alive, because of their own religious and cultural beliefs, but in point of fact, they knew this was the right thing. But they had to fight it, and they couldn't be involved in the decision. Once the decision was made [and] it was taken out of their hands, they were actually very appreciative for all the care that their loved one got."
In the third situation, the decision was made to continue care, because otherwise, the family would have been "terribly angry and upset." The decision by the medical team was that "even though it is futile, and even though we know the patient will die, we're not going to withdraw life support against the family's wishes, because it feels like an assault on the family," Curtis recalls.
Advice for physicians in difficult cases
In dealing with patients or their families who may be demanding care, it is important that physicians focus on using good communication skills and good mediation skills, Curtis says.
"In my experience, one of the most important things in this situation is to focus on building trust, so that when there's conflict between patients and clinicians or families and clinicians, it's often a situation where trust has eroded, and I have found it to be very helpful to focus on building trust back, rather than the decision at hand, if that's possible," Curtis tells MEA.
While some medical decisions need to be made immediately, other medical decisions can wait for this process to occur, even in the ICU setting, he says.
"I think sometimes working on . . . understanding the patient's or the family's perspective and why they're making the decisions or demands that they're making and focusing on that aspect of the relationship — putting the decision-making about treatments aside temporarily while doing that can be very helpful," Curtis suggests.
Source
- J. Randall Curtis, MD, MPH, Professor of Medicine, Division of Pulmonary and Critical Care at the University of Washington, Seattle. E-mail: [email protected].
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