Introduction to Potentially Inappropriate Treatments and Futile Treatments

by Mark Hughes, MD, MA

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    00:01 When we're thinking about life sustaining treatments, there may be times when the clinician judges, the treatment may be too burdensome, or even not worth offering to a patient or family.

    00:13 We call these, potentially inappropriate and futile treatments.

    00:17 There's distinction between the two that I'm going to walk you through.

    00:21 So potentially inappropriate treatment is, there's some chance that it will accomplish the effect sought by the patient or their authorized decision makers.

    00:30 So there's some rationale for considering the treatment.

    00:34 It's not a treatment that's forbidden by law, so it's permissible for the clinician to offer it.

    00:41 But the clinician feels that there are ethical justifications for refusing to provide the requested treatment.

    00:48 For instance, they feel that it's not going to offer the benefit that is hoped for or, the benefit relative to the burdens imposed by the treatment are not worth trying to achieve.

    01:01 That could be that there's less than desirable outcomes, could be that there are quality of life considerations that the person's quality of life is going to be worse if you instituted the treatment than if you decided not to offer it in the first place.

    01:18 So there could be a couple of examples of this of, take a patient for instance, that's in the intensive care unit, they have multi-organ system failure.

    01:27 Now their kidneys are also failing.

    01:30 There is an option for consideration of offering hemodialysis, that would be the next step for managing renal failure.

    01:39 But the clinician judges, this is potentially inappropriate, because the really the chances that it's going to be successful are pretty minimal.

    01:48 And it's going to be burdensome to offer the hemodialysis when they already have multi-organ system failure.

    01:54 So it might be presented by the clinician of, this is something maybe we don't want to offer to the family or to the patient.

    02:02 There may be another example, but patient with cancer.

    02:07 They're judged to have a cancer that's inoperable and its current state but maybe if they underwent a course of chemotherapy, it would shrink the tumor enough to make it operable.

    02:18 There could be the option of offering the chemotherapy to the patient.

    02:23 But there's concerns that the chemotherapy that would be involved would have a lot of side effects, potential complications, might be too burdensome to get through the chemotherapy, in order to get to that milestone of being able to have the surgery down the road.

    02:41 So the clinician might present this as this might be potentially inappropriate to offer you because I'm concerned, it's going to be more burdensome than beneficial.

    02:49 There may be, surgeons that would say, You know, I'm not going to offer this operation, knew it's clear, the patient needs surgery, if they're going to try to, keep the person alive but I'm concerned that the patient is going to die on the operating table.

    03:05 And I think it would be inappropriate for me to bring them to the operating room, knowing that their chances of success are close to nothing.

    03:13 In there, again, I may not want to offer this treatment to the patient or to the family.

    03:21 So you present this to the family or to the patient.

    03:24 And, if you explain the rationale for why you would not recommend it, why you might choose a different course of action, different treatment plan, may be based on something that's going to be more attentive to the patient's comfort than trying to, you know, keep them alive.

    03:42 Maybe they're, presented with that information, they're going to accept your conclusion and your recommendation.

    03:48 But there may be times where they disagree with that assessment and so because they know that this is a potentially available treatment, you've offered it as an option, they may wish to pursue it, even if you think it's potentially inappropriate.

    04:04 So now you've got a conflict and you have need to figure out a way to resolve this difficulty, resolve this conflict.

    04:12 There are going to be various ways when we think about clinical ethics in resolving conflicts.

    04:17 One is avoidance, , so just avoiding the conflict in the first place.

    04:21 Just, not even considering that there is a conflict.

    04:26 The other is accommodation, just going with what the other person says and going along with their wishes.

    04:33 There could be competition of just saying, Nope, I'm going to put up a fight and, argue for my position against your position.

    04:40 There could be a compromise, so trying to see if you could negotiate and figure out a way that, , some of your interests could be met as the clinician, some of the patient or family's interests could be met and you reach some sort of compromise agreement or there could be an opportunity for collaboration.

    04:57 So trying to work together with them to figure out what's going to be the best course of action that everyone can sort of get behind.

    05:06 When you think about conflict resolution, the things that are going to be most important in achieving desirable outcomes are, first of all, this idea of emotional safety and relationships.

    05:17 So if you've established a therapeutic relationship with the patient or therapeutic relationship with their surrogate decision makers, knowing that they feel safe in having, , really difficult conversations with you, it's going to be the first step in achieving a desirable outcome.

    05:33 There has to be a recognition that there's a fair process underway, it's not, a unilateral decision.

    05:40 But there is an opportunity for discussion, debate, reflection, figuring out a course of action that everyone could, could agree to.

    05:48 And then the last thing that generally needs to happen for there to be a desirable outcome is the outcome itself.

    05:55 So after a plan is instituted, what actually happens with the patient.

    06:01 If it's an outcome that people can get behind, then, it's going to be successful conflict resolution, take an example of, you know, everyone is convinced on the medical team, that CPR would not be appropriate for a patient, they're concerned that it either work, or that, if the resuscitation works, that the patient is going to be worse off in whatever condition they're in, post resuscitation.

    06:29 And they're convinced that they don't want to offer CPR to the patient.

    06:35 But the family member comes to them and says, you know, my loved one said, he always wanted to be there for his children, he always wanted to fight to the end, and demonstrate to them that he never wanted to give up on them.

    06:49 And, going through with the CPR, even if we don't think it's going to be successful, is going to be a demonstration, that he's done everything possible, to stay alive for his children.

    07:01 If the healthcare team hears that, maybe they would change their perspective, and get behind this idea of trying to, continue with full code and attempting CPR, even if it has limited chances of success.

    07:15 So it's always in the discussion, and this fair process of trying to resolve the conflict.

    07:21 That's where the clinical ethics, stands of making sure everyone's interests are respected here, you're hearing them and figuring out a path forward.

    07:35 So how do you do that? Well, you need to have a family meeting, we have a separate lecture about how to conduct a family meeting.

    07:42 This is an opportunity to really clarify goals of care sort of, again, understand the patient's perspective, we need to decide which interventions are going to need to have discussion.

    07:55 Maybe, you know, while there's the conflict underway, there's the disagreement, you're going to continue the interventions that are in place, or you're going to offer the life sustaining interventions that are in question, in case, they are needed in the future.

    08:13 Sometimes you need to bring in a third party.

    08:16 So there might be an opportunity for bringing in an ethics committee or an ethics consultant, to facilitate a discussion, to try to reach some resolution in this disagreement, get some recommendations about how they would think about the issues.

    08:30 Again, knowing what the patient's preferences, values and goals are, and what the medical condition is.

    08:38 And then really, if the clinician feels that it would be against their conscience to institute this treatment, there is the possibility of considering transfer.

    08:50 If the disagreement persists, you can reach any resolution, you might offer, the patient and the family the opportunity to transfer their care to another institution to another provider, that might be able to offer the care that you don't think is appropriate, or the treatment that you don't think it's appropriate.

    About the Lecture

    The lecture Introduction to Potentially Inappropriate Treatments and Futile Treatments by Mark Hughes, MD, MA is from the course Ethical Considerations in Palliative Care.

    Included Quiz Questions

    1. A treatment that may accomplish the intended effect but has ethical reasons for refusal
    2. A treatment that may accomplish the intended effect but is not approved by law
    3. A treatment that may accomplish the intended effect and has no strict regulation by law
    4. A treatment that may accomplish the intended effect and has no ethical reasons for refusal
    5. A treatment that cannot accomplish the intended effect but has no ethical reasons for refusal
    1. Divergence
    2. Accommodation
    3. Competition
    4. Collaboration
    1. Emotional safety
    2. Fair process
    3. Outcome
    4. Ambiguity
    5. Decisiveness
    1. Ethics committee
    2. Court order
    3. Anonymous email to the hospital human resources department
    4. Tribunal
    5. Anonymous letter of concern

    Author of lecture Introduction to Potentially Inappropriate Treatments and Futile Treatments

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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