EXECUTIVE SUMMARY
About one-third of clinicians reported considering quitting due to provision of futile care, according to a recent survey. Ethicists can:
• educate all involved parties on legal requirements;
• correct inaccurate assumptions about obligations to provide care;
• refer to guidelines and position statements.
About one-third of clinicians considered leaving their jobs due to providing care they saw as futile or potentially inappropriate, found the authors of a recent survey.1
Lead author Jason Lambden got the idea for the study after seeing a presentation on the causes of moral distress in resident physicians. Findings from focus group discussions suggested that perceived futile care provision played a significant role.2 This rang true to Lambden, based on his experience working at Weill Cornell Medicine as a medical student. He discussed the study’s findings with several classmates. “They were similarly uncomfortable with some of the care they were providing, to the point that they were unable to study at night,” says Lambden.
The researchers wanted to explore the relationship between clinician wellness and perceived futile care, with two goals:
• to quantify how often clinicians believe they provide futile care;
• to determine correlations between such care and measures of clinician wellness.
Researchers surveyed 349 clinicians at two New York City hospitals in the fields of internal medicine, surgery, neurology, and intensive care, looking at outcomes of burnout, depression, and intention to quit. Some key findings include:
• Ninety-one percent of the clinicians believed that they had personally provided futile or potentially inappropriate care to a patient in the preceding six months. Not surprisingly, most cases stemmed from disagreements over end-of-life care.
“Similar to what has been reported in other studies, more junior clinicians reported higher rates of futile or potentially inappropriate care provision,” notes Lambden.
• 43.4% screened positive for burnout syndrome;
• 7.8% screened positive for depression;
• the amount of perceived futile care provided was significantly associated with burnout and thoughts of quitting.
This was true regardless of experience, position, department, and the number of dying patients cared for. “This suggests that the greater the amount of futile or potentially inappropriate care you believe you provide, the more likely you are to experience burnout and to think about quitting,” says Lambden.
A large majority of clinicians often are uncomfortable with the care that they provide, the survey’s findings indicate. Given that perceived futile care provision is linked to clinician wellness — an increasing priority in healthcare — Lambden says hospitals should consider taking steps to improve communication among clinicians and families at the end of life. Not all disagreements will be reconciled. “But it is important to recognize the toll that this can take on clinicians,” says Lambden.
Divergent Views
When bedside clinicians report concerns over nonbeneficial care, it is a possible sign of communication breakdown. “If nurses and physicians are not talking regularly about goals of care or patient side effects from care, then they may have divergent views,” says Timothy Lahey, MD, MMSc, director of clinical ethics at the University of Vermont Medical Center in Burlington.
Nurses, who often spend more of the day in direct interaction with the patient than physicians, can alert physicians if patients are suffering because of a given treatment. Similarly, physicians can clarify things with nurses. “Aggressive care that might not be what everyone would choose could nonetheless be driven by a good conversation the physician had with the patient when the nurse was out of the room,” says Lahey.
Clinicians’ moral distress over provision of nonbeneficial care may reflect a larger issue. “Our medical system prioritizes individual patient autonomy over wise allocation of communal healthcare resources,” says Lahey.
Frontline providers sometimes suffer as a result of this reality. “All we can do as ethicists is listen, stand in solidarity, and hope that further clarification of patient goals of care leads to a harmonious resolution,” says Lahey.
Unrealistic Expectations
Clinicians frustrated with what they see as poor choices sometimes call ethics for help. It soon becomes apparent that what they really want is for the ethicist to step in and tell the family to withdraw treatment.
“We explain that sometimes families make decisions that we disagree with, but that doesn’t necessarily make them ethically inappropriate,” says Lauren Jodi Van Scoy, MD, an associate professor of medicine, humanities, and public health sciences at Penn State Milton S. Hershey Medical Center. About 65% of consults involve this scenario, she estimates.
Parsing out legal, ethical, and clinical issues can help. “People will often weaponize the law,” says Van Scoy. When clinicians talk about legal obligations, or families threaten to sue, both sides become defensive. “It’s helpful if the law is explained by an ethics consultant, instead of being it used as a threat,” says Van Scoy.
As a neutral third party, ethics can convey the ethical principles of beneficence and nonmaleficence in the simplest of terms. Ethicists explain the team is obligated to only help patients, not harm them. “We explain that from an ethical standpoint, these things should guide our decision-making,” says Van Scoy.
A 2015 multisociety statement on responding to requests for potentially inappropriate treatments in ICUs provides guidance for clinicians to prevent and manage disputes in patients with advanced critical illness.3
Ethicists offer the statement to clinicians, who often find they are doing exactly what’s recommended. However, clinicians are not always on the same page. One may believe treatment is futile, while another thinks it is highly unlikely to work but does not quite reach the level of futility.
“That can be really hard. In my experience, clinicians are loath to unilaterally lay down the hammer and say, ‘We are not doing this,’” says Van Scoy. This is not necessarily a bad thing, because unilateral decisions about futility are “especially problematic,” she says. Escalated disputes and even litigation become possibilities.
“Am I within my rights to refuse care?” Physicians expect a yes-or-no answer to this question. “But determining whether care is futile is in the clinical realm, often outside the purview of ethics,” says Van Scoy.
Next, clinicians ask what the definition of “futile” is. “We share it, using Trotter’s definition of futility, which seems easy to tease apart for clinicians,” says Van Scoy.4 This states that three conditions are needed: A goal, an action aimed at achieving the goal, and virtual certainty that the action will fail. The “virtual certainty” part is where things get complicated. “The challenge is understanding where the line is between something being very, very unlikely to work and being futile,” says Van Scoy.
Multiple meetings build familiarity and trust. Sometimes, all that is needed is for ethics to be present. “You have a level of authority that maybe the clinical team has lost for whatever reason,” says Van Scoy. “It makes the family say, ‘Oh — ethics is involved. Maybe I need to rethink this.”
As for policies on what to do when clinicians feel care is inappropiate, Van Scoy believes their benefit is somewhat limited: “Every case has a nuance. When there are policies, they need to be vague enough to allow for wiggle room.”
No Moral Obligation
Physicians are not morally obligated to provide a treatment or intervention that they do not believe is medically indicated and/or do not believe will be clinically effective, says George L. Anesi, MD, MSCE, MBE, an attending physician in pulmonary and critical care medicine at the Hospital of the University of Pennsylvania and an instructor of medicine at Perelman School of Medicine.
Resuscitation is an intervention, says Anesi. Therefore, if physicians truly believe it will not achieve its purpose, they’re ethically sound in not offering CPR, or ceasing ongoing CPR.
“The ethical crux lies in what the goal is and how certain we are of the outcome,” says Anesi. The physician’s goal may be recovery from critical illness. CPR, even if transiently effective, may be clearly ineffective at reaching it. A family’s goal for their loved one in the same scenario may be very different. “It may sometimes be transient life prolongation at all costs, for which CPR almost always has a nonzero chance of achieving,” says Anesi. “Those are in conflict.”
Any form of life-sustaining treatment should be considered a trial that involves a reasonable prospect of recovery to a meaningful quality of life, according to a 2018 guidance from the Canadian Critical Care Society.5 “The reality is that often clinicians aren’t as savvy as they should be, in terms of written statements or legalities,” says Bojan N. Paunovic, MD, FRCPC, co-author of the statement and president of the Canadian Critical Care Society.
Sometimes clinicians operate under assumptions rather than facts, believing they are legally bound to provide futile care. Paunovic advises “getting a good grasp of what the law of the land is.” Some families, and even clinicians, have misinterpreted a recent Canadian Supreme Court decision as a right to life-sustaining interventions. Asking an ethicist to step in to clarify legal requirements can defuse tension. “Often, by that time there is an antagonistic situation built up,” Paunovic explains. “It may help offer an objective view that this is not just a physician doing what they want.”
Regardless of what the law says, there may be pushback from hospital administrators fearing bad publicity. Recent highly publicized cases have fueled this fear. “There may be leadership that say, ‘We don’t want this to get ugly,’” says Paunovic.
A family might reject withdrawing life support, but agree to do so after a family member arrives the following day. “But where is that transition point? Is a day OK? What about a week, or a month?” asks Paunovic. This is where jurisdictional policies can be of help. “Leadership wouldn’t feel they are in that position of conceding to inappropriate demands if there is a supported policy they can abide by,” says Paunovic.
REFERENCES
1. Lambden JP, Chamberlin P, Kozlov E. Association of perceived futile or potentially inappropriate care with burnout and thoughts of quitting among health-care providers. Am J Hosp Palliat Care 2018 Aug 5:1049909118792517. doi: 10.1177/1049909118792517. [Epub ahead of print]
2. Dzeng E. Moral distress amongst physician trainees regarding futile treatments. J Gen Intern Med 2016; 31:830.
3. Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015; 191:1318-1330.
4. Trotter G. Mediating disputes about medical futility. Camb Q Healthc Ethics 1999; 8(4);527-537.
5. Bandrauk N, Downar J, Paunovic B. Withholding and withdrawing life-sustaining treatment: The Canadian Critical Care Society position paper. Can J Anaesth 2018; 65:105-122.
SOURCES
• George L. Anesi, MD, MBE, Pulmonary and Critical Care Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. Email: [email protected].
• Timothy Lahey, MD, MMSc, University of Vermont Medical Center, Burlington. Phone: (802) 847-4594. Email: [email protected].
• Bojan N. Paunovic, MD, FRCPC. Email: [email protected].
• Lauren Jodi Van Scoy, MD, Penn State Milton S. Hershey (PA) Medical Center. Phone: (717) 531-6704. Email: [email protected].
About one-third of clinicians considered leaving their jobs due to providing care they saw as futile or potentially inappropriate, found the authors of a recent survey.
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