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And esteemed Medical Ethicist gives them a mild rebuke.

Somehow, this professor has not seemed to notice the change in delivery of medical care in our country-- not since the passing of the Affordable Healthcare Act two years ago, but of Medicare in 1965.

This was conveyed in a videoed talk by Arthur Caplan, PhD, Renowned Bioethicist with the most extensive credentials

He starts by describing a study:

Medscape just conducted a survey of 24,000 doctors, and only 25% said they would not provide futile interventions. A very significant percentage, more than 30%, said that they would. The rest of those surveyed said they might, depending on the circumstances. That is a startling finding because the way we understand futility in ethics and in medical practice is "no benefit." So why would you do things that don't benefit the patient?
Professor Caplan, came down on the right position, against the majority of doctors who said that they would, in fact, continue treatment that is futile, meaning will not extend life or comfort of the dying patient.  What he avoids is any sense of outrage, of contempt for a profession that abides by this practice, and tries to explain why they are wrong, as if they were rather dull children instead of seasoned educated professional who have an obvious, but unstated, reason to continue treatment until the last painful breath of the comatose person has ceased.

The obvious reason, once every medical explanation is refuted, is that doctors and hospitals make a ton of money on them, and because they are terminal and will not be in a position to complain, never cause any trouble.

He even refutes the main excuse here:

The fact that a lot of doctors are still willing to give futile care is probably tied in with another reality, and that is fear about the law. People worry that "if somebody sues me, and I didn't do x, y, or z, then I'm going to be on the wrong end of a malpractice suit."

I have never seen it. I have acted as an expert witness. You don't lose those cases. If you say in good conscience, as a physician, as an expert, that I believed that doing something was futile and I didn't do it, and I talked about that with the patient -- anybody can sue you at any time for anything -- you are not going to lose that case because you are following the standard of care and what you believe to be true as the expert.

Using futile care as a way to stave off or avoid malpractice suits or litigation is not good for the patient, and in these kinds of situations, you want to do what is best for the patient. Prolonging suffering, causing the patient more harm -- if that is part of what futility means, to have a false sense of security about a lawsuit -- is not the way to go.

Prof. Caplan's ethical schemata would be perfectly appropriate in the absence of any public funding for medical care, such as where the funds for such treatment, as currently is the case, for instance, for cryogenic preservation, is between the individual and the supplier. If anyone chooses to have their body preserved in the hope of eventual revival, there are no public funds, taxpayer wealth extraction, that will be diverted for their individual expenditure. The only ethical question in this case is between provider and patient.

Prof. Caplan describes the situation with end of life medical care in this matter at least a half dozen times in this short presentation.  There is not the least hint that those in this terminal condition are almost universally being financed by public funding such as Medicare.  There is not the least acknowledgement of this fiscal expense that is growing at an unsustainable rate, that came within a hair's breadth of being curtailed days ago, and still faces reduction.  

The decision to extend futile care of the suffering terminally ill, which in itself is ethically abhorrent, is more than compounded by the not arcane fiscal reality, namely that scarce resources expended for hopeless treatment will mean denial of medical services that could provide actual ease of suffering and extension of life.

What this video demonstrates goes beyond one individual's failings, but that his universal acclaim within the medical-academic community shows the depth of its deep immorality. It demonstrates how difficult, but how necessary, it is to wrest control of delivery of medical care from a corrupted profession.  

Those physicians, including researcher writer Eric Topol, represent the 25% who gave the ethical response are saluted. . Thihs detailed comment by a physician to this essay gives his personal explanation why doctors do futile treatment.  

I have grave doubts that President Obama,or anyone currently in political life has the capacity to engage the majority, those who award the prestigious positions in bioethics to those who challenge their depredations with barely a whisper.  This systemic waste by futile treatment ultimately results in the death of innocents, and eventually must lead to the failure of this mechanism of social responsibility that we refer to as Obamacare.  

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Comment Preferences

  •  I thought it was Death Panels (9+ / 0-)

    deciding matters of life and death. Your diary puts this lie to bed.

    Secondly, my understanding of futile care is that these decisions are rarely black and white. Experts and family members can have disagreements on the efficacy of treatments.

    •  It'll Be the Claim if Any Dem Even Touches (5+ / 0-)

      this issue.

      We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

      by Gooserock on Sat Jan 05, 2013 at 05:40:06 PM PST

      [ Parent ]

    •  Suggest reading the full article linked.... (6+ / 0-)

      We are talking about clearly futile, not the grey area that you describe.

    •  End of life care is a place where very significant (15+ / 0-)

      Medicare savings could be achieved. I don't have the numbers at my fingertips but something like a third of Medicare is spent on the last year of life. What we need to do is have Medicare established protocols that if followed would make physicians bullet proof from malpractice lawsuits. Up until the very end US physicians practice defensive medicine. It's how they are trained and managed. The first goal is don't be sued, not do no harm.

      "let's talk about that"

      by VClib on Sat Jan 05, 2013 at 06:04:31 PM PST

      [ Parent ]

      •  Cradle to grave CYA. (4+ / 0-)

        From childbirth on, it's defensive medicine all the way. That's the only reason why approx. one  out of three women in the U.S.apparently "need" Cesarian sections.

        "I was so easy to defeat, I was so easy to control, I didn't even know there was a war." -9.75, -8.41

        by RonV on Sat Jan 05, 2013 at 06:36:00 PM PST

        [ Parent ]

        •  That's completely incorrect. (4+ / 0-)

          I've been delivering babies for nearly 30 years, and you're dead wrong on this one.

          I've been around a lot of turns of the great hamster wheel of medical progress. When I started practice we were working very hard indeed to reduce the cesarean section rate, with some success. We hit a low point of about 15% primary Cesarean section rate around 20 years ago with aggressive efforts to perform vaginal birth after Cesarean section, use of vacuum extraction, careful monitoring and so on.

          Everything's going the other way now for a host of reasons. First and foremost is the inescapable reality that obesity rates have skyrocketed, and obesity correlates very strongly with maternal diabetes, very large babies, and Cesarean sections. It is flat-out terrifyingly difficult to perform a vaginal delivery for a mom over 300 lbs. Trust me on this. Next is the loss of legacy skills: 50 years ago the ability to perform vaginal delivery of a baby in breech presentation was routine. Today you cannot find a practicing obstetrician who has done more than one or two; hence Cesarean section is the safer choice for both mom and baby. Next is the demonstrable fact that Cesarean section has become so safe (largely due to anesthesia advances) that it is statistically equivalent to vaginal delivery. Then there is the recent recognition that vaginal birth after Cesarean is not as safe as we once hoped. The rate of uterine rupture after prior Cesarean is non-trivial, and it is a seriously bad event.

          Next is the steady rise in percentage of moms with high risk serious medical illnesses who nonetheless have children. I have delivered babies for women with artificial heart valves, with cystic fibrosis, with severe traumatic brain injuries...all kinds of very sick moms who never would have had children 50 years ago. They are far more likely to end up with a Cesarean section for maternal reasons.

          Finally, there is an expectation of a perfect outcome from every pregnancy, despite the iron hard reality that 2-5% of pregnancies result in an infant with some impairment or congenital anomaly no matter how good the care. Hence the threshold for surgical intervention when the fetal heart monitor strip starts looking scary is pretty low. You can call it CYA if you insist; but if it is your newborn baby's brain at risk, are you going to sit on your hands when the fetal heart rate is plummeting?

          •  I glad that you aren't participating... (0+ / 0-)

            in this alarming situation, however, on a national basis, I am correct. Maybe your statistics are localized to you, but nationally, the c-section rate from 2010-2011 was almost 33% (32.8) That's pretty much one out of three births. The hospital closest to me is around 31%, last I heard.

            VBACs are no longer even considered at that hospital. Breech? Don't even think about it. Although if you are willing to travel an extra 30 miles, there is a hospital that will do them.

            The cascade of unnecessary interventions starts with impatient providers who induce based upon a set of rather arbitrary guidelines. Treating the clock/calendar rather than the mother, for instance.

            And while there are valid medical reasons to have a c-section, a rate of around 5% is much more reasonable. Although the World Health Organization thinks that 15% is realistically achievable.

            Why Is the National U.S. Cesarean Section Rate So High?

            C-section rates hit all-time high, study finds

            Too Many C-Sections: Docs Rethink Induced Labor


            "I was so easy to defeat, I was so easy to control, I didn't even know there was a war." -9.75, -8.41

            by RonV on Sun Jan 06, 2013 at 10:36:42 AM PST

            [ Parent ]

      •  The ethicist Caplin made clear the the lawsuit... (4+ / 0-)

        fear is an excuse for baesless useless treatment.  That's the most important part of his report and of this diary.

        •  arodb - I agree that the fear of malpractice is (6+ / 0-)

          not always rational. However, it is how we train our physicians and how those who work for large groups are managed. I work with physicians every week, and have many who are friends. They are very candid that they practice medicine to not be sued. Defensive medicine is one of the leading causes of higher healthcare costs in the US as compared to other first world countries. Defensive medicine is not practiced anywhere else than the US.

          Physicians have been practicing defensive medicine for decades in the US and even today that is how they are trained in medical school. We need to provide some carrots for not over-treating and agree on some standards of care that immunize physicians from malpractice. Without both of those, why would physicians change their clinical practice?

          "let's talk about that"

          by VClib on Sat Jan 05, 2013 at 07:23:50 PM PST

          [ Parent ]

          •  Tragically, there are also MANY doctors ... (4+ / 0-)

            who UNDERtreat, especially as regards pain relief.  From personal experience, I've learned that most doctors are under-educated and overly paranoid regarding this subject and are committing a particularly cruel form of malpractice as a result.  You'd think they'd be ashamed of themselves; instead, they're often arrogant.  Their patients needlessly suffer considerable misery, and it's no solution to pass the buck and refer them to "pain clinics" that are only interested in offering exorbitantly priced treatments like epidurals which they well know often don't work (or don't work very well), leaving millions of patients in pain and hating life (and doctors).

            "Two things are infinite: the universe and human stupidity, and I am not sure about the universe." -- Albert Einstein

            by Neuroptimalian on Sat Jan 05, 2013 at 11:39:38 PM PST

            [ Parent ]

  •  Thank FSM My Mom's Doc is an Ethical One. (18+ / 0-)

    She's in the wind down phase with dementia and he cancelled all her treatments now except comfort. So far, so good. Even now when she's still communicating, any care beyond comfort is futile.

    Mom has on file a clear no-nonsense DNR care directive but there was some question with a supervisory person at her facility of the leeway the caregivers may have. I'm having that checked just now with her nursing home.

    We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

    by Gooserock on Sat Jan 05, 2013 at 05:39:29 PM PST

  •  Hmmmm, (12+ / 0-)

    Futile to me is a treatment that would not prolong the patient's life. A given treatment may not do that but may ease symptoms, making the final days easier.

    After my mom was diagnosed with inoperable cancer last year, the doctors advised that she have some chemotherapy to ease her symptoms (breathing and eating problems). We were all clear that Mom was dying. Mom was looking forward to be with Dad again after almost 8 years. She had two chemo therapy sessions, and they did help her symptoms, but the last didn't as much as they had hoped so the treatments were stopped.

                      Just my two cents,

    Torture is ALWAYS wrong, no matter who is inflicting it on whom.

    by Chacounne on Sat Jan 05, 2013 at 06:07:11 PM PST

    •  What you descrive is differentiated from... (4+ / 0-)

      futile, which has no value except maybe a "miracle" occurring.  This poll was not meant for public distribution.

      •  My family's experience. (10+ / 0-)

        In March my father-in-law was diagnosed with a malignant brain tumor. Just two children: my wife & her sister. The two women & their husbands (me & bro-in-law) got together soon after & I suggested the four of us meet with doctor to ask: how much will radiation or chemo or both extend my FIL's life expectancy? What will side effects of treatment be--how much will they affect quality of life for better or worse? My sis-in-law immediately shut that down: "He's my father, and I just want him treated." So he had chemo & radiation for awhile.

        My sis-in-law at the time was in her final semester of nursing school. So I expected her to have a bit more analytical perspective. If it's too much to expect from her, it's probably too much to expect from most people.

        FIL quickly blew through the donut hole, and after that Medicare or Medigap covered everything. The Medicare paperwork says the chemo & radiation cost the taxpayers over $10,000 a month.

        The tumor continued to grow, so they finally stopped treatment in June, I think. My father-in-law passed away in early July.

        "The true strength of our nation comes not from the might of our arms or the scale of our wealth, but from the enduring power of our ideals." - Barack Obama

        by HeyMikey on Sat Jan 05, 2013 at 07:47:37 PM PST

        [ Parent ]

        •  weird motivations (1+ / 0-)
          Recommended by:

          I wish I could understand these motivations.  Am friends with an elderly couple, he in the final stages of alzheimer's. When he became too hard for his 85yo wife to care for he was moved to his daughter's residence for her to take over care.  Contrary to his medical directive (DNR) and wife's wishes the daughter had a feeding tube installed when he started refusing food.  So now their assets are being dissipated by the daughter who is demanding they continue to pay for full time care.

  •  Don't discount the family. Some people can't bear (5+ / 0-)

    to let go of a loved one.

    Some people are living on the patient's Social Security check.

    **Your beliefs don't make you a better person, your behavior does** h/t Clytemnestra/Victoria Jackson

    by glorificus on Sat Jan 05, 2013 at 07:28:33 PM PST

  •  I approach this discussion of the appropriate (10+ / 0-)

    dispensation of 'end of life care' with a good deal of caution.

    I have seen papers which actually approach this topic from the standpoint of determining care based on an individual's age, and earnings potential.  At least one paper suggested that extensive medical care be restricted to individuals ages 18-40.

    And, just as 'end of life' care should be rationed, it purported that extraordinary care for the very young (ostensibly premature births, etc., that potentially could run up astronomical hospital and doctors' bills), since we have not collectively invested very many resources in them, should also be limited or restricted somewhat.

    I understand the need to keep down the costs of absolutely useless procedures or treatments, but the language in these medical ethics white papers can be a bit disturbing.

    Some of the ethicists sound much more like economists, than medical doctors/ethicists.

    So I say, proceed with extreme caution.

    [BTW, I'm not implying that the diarist here is suggesting this in any way.]


    “If a dog won’t come to you after having looked you in the face, you should go home and examine your conscience.” -- Woodrow Wilson

    by musiccitymollie on Sat Jan 05, 2013 at 07:31:27 PM PST

  •  People vastly over estimate physicians ability (11+ / 0-)

    to communicate with family or otherwise deal with end of life issues.  I think they sometimes provide futile treatment because they have failed to clearly convey to families that the situation is definitely terminal.  No doctor ever told us my sister was dying but it became clear to all of us that she was and did.  A few days before my father's death his physician said to me "Doesn't your mother know he is dying".  Well, duh, you didn't tell her!  You expected her to figure it out.  She didn't want to figure it out.  So a couple of days later they kicked him out to a hospice due to "futility" but that was really miserable because he spent literally his last hours getting transferred and admitted and died never having gotten reoriented enough to say good bye. But at least they medicated the pain.

    Now, when they don't get THAT right - A co-worker's husband was kicked out of the hospital due to futility before his pain was anywhere near controlled.  His wife was unable to cope with this alone at home - no home hospice care had been offered.  She was terrified.  He was in horrific pain.  They were young and had a child at home.  It was an absolutely horrible death.  

    It's not simple for families or for physicians.  There is no awesome bean counter in the sky who can declare with utter certainty the exact time that care should come to an end and how.  And just because the physician stops treating doesn't mean the pain or the caregiving requirements end.  

    If you are going to order physicians to pull the plug you better be ready to accept the consequences because your loved one may be left screaming.  The system will serve the metric as ordered and if the only metric is the plug, that will be the only metric served.

    •  "Medical abandonment," (10+ / 0-)

      which that sounds like, used to be a serious breach of ethics that could cost a doctor's license. If treatment of a medical condition is "futile," then "palliative care" is appropriate treatment -- NOT abandoning a patient to suffer.

      Shame, shame on whoever did that!!

      "Let each unique song be sung and the spell of differentiation be broken" - Winter Rabbit

      by cotterperson on Sat Jan 05, 2013 at 08:35:07 PM PST

      [ Parent ]

      •  Ahh, but if Medicare or whatever says out the door (8+ / 0-)

        then it's not the hospital's problem and these days most doctors seem to be pretty much ordered around by hospital systems.  

        It's been my experience that when you hit a metric that says stop treatment, they stop treatment and the transitions in care are horribly managed.  

        If they could do a better job managing care transition they'd eliminate a lot of unnecessary costs.  People getting shipped back and forth between facilities willy nilly or sent home without proper provisions for care and then readmitted.  The trouble with the absolute metrics is that people don't tend to act like machines nor do their stressed out families.

        It is easy to say, stop treating but then what?  What if the person has no family?  Unless you are going to literally kill them on the spot, the transition has to be managed.  

        I mean how do any of us want to die?  We say we don't want futile treatment and I certainly do not, but I also want to be treated with dignity when I am dying and unfortunately that does not seem to be a metric.

  •  That is a disturbing finding. (4+ / 0-)

    I'm pretty convinced a  lot of doctors order futile care because they don't want to tell the patient they are going to die very soon. It's a problem we need to face as a nation and we need to do it without hysterics. Unfortunately, we aren't able to have an adult conversation with the GOP (or most people for that matter) about end of life care either.

    If a nation expects to be ignorant and free, in a state of civilization, it expects what never has and never will be. Thomas Jefferson

    by JDWolverton on Sat Jan 05, 2013 at 10:10:30 PM PST

  •  Caplan is an ethicist, not an economist (1+ / 0-)
    Recommended by:

    Caplan is the dean of medical ethics, and a crucial voice in the conversations over treatment standards of care. He is not speaking to the financial issues -- nor should he be. That is not his job. Indeed, having financial issues enter into ethical judgments is contrary to what he does.

    The importance of what he is saying here, for me, is that in this case the financial arguments ("We should not be paying for futile treatments") and the ethical argument ("We should not subject patients to futile treatments") coincide.

    But that is not always the case. (For a simple example, look at the current controversies in Massachusetts and elsewhere about whether the state has to pay for gender-reassignment treatment for prison inmates who identify as trans.)

    •  Respectfully disagree..... (0+ / 0-)

      Ethics is broadly understood as transcending a specific groups interest and seeking ultimate good, or more realistically the good of a given society.

      The point of this essay was that with any form of socialized medicine, including the AHA variation, the larger society is part of the formula.   There is a finite amount of resources for all social goods, education, national defense, protection against disasters....and now health care.  All have to weighed against each other.

      Futile by its very definition means doing no good, yet it is not a personal choice such as cryogenic preservation with no public funding, and therefore must be evaluated against what other public goods will be diminished.

      This is not yet being done in general, as this poll and the ethicist's analysis describes.

  •  What about self-doubt? (2+ / 0-)
    Recommended by:
    wilderness voice, arodb

    I would suggest that at least in some cases, doctors might actually believe treatment is futile, but continue on just in case they're actually wrong...

  •  It's a lot more complicated, says this doc. (4+ / 0-)

    In my experience, there isn't a lot of frankly futile treatment provided purely to avoid malpractice suits, although it's frequently the asserted reason.

    Here are the biggest reasons, in rough order of importance:

    1) Habit/sloth/inertia. This really is the most common reason. Pathetic, I know, but there it is. We do a lot of things that don't work simply because "we've always done it that way", and no one wants to rock the boat. Because doctors keep doing things out of habit long after they've been shown to be ineffective. Because the patient expects a particular treatment, or family members expect it since that's how uncle Bob was treated. There's plenty of documentation in the medical literature of the persistence of ineffective therapy long after it has been shown to be useless. It takes far too long for us to change therapy in response to newer information.

    2) Unwillingness to discuss uncomfortable truth. Patients with bad diseases eventually get to the point where continuing a particular treatment is no longer helpful, and even becomes harmful. But stopping the treatment means having an intense discussion with the patient about where things are headed, and why we should probably stop. Some patients welcome an honest discussion, but others can't handle it. Far too many physicians can't gracefully handle the intensity. It's often a lot easier just to let things slide, and keep doing things that are pointless or even harmful.
    A corollary of this is treatments that patients or families demand, and that physicians acquiesce in despite knowledge that they are futile, because the physician just doesn't want to fight that battle. This is an evasion of our responsibility to treat the patient to the best of our abilities; we have an obligation not to provide worthless or counter-productive treatment, even if the patient wants it.

    3) Physician self-interest. It's grossly unethical for physicians to provide treatment primarily for personal financial gain rather than patient well-being. Doctors routinely insist that they make all their decisions for the good of the patient, but it has been abundantly shown that financial incentives have a shockingly consistent and pervasive effect on treatment choice. Like the studies showing that twice as many x-rays and CT scans are done when the physician has a financial interest in the x-ray facility. Or studies showing that rates of surgery track more closely with per capita number of surgeons in town than with nominal objective 'need'. This is the shame of my profession, and something we desperately need to correct.

    4) Futile treatment provided solely out of fear of being sued is way, waaaaay down the list. Usually this is an excuse provided to avoid copping to one of the above reasons.

    •  when my brother-in-law was dying (3+ / 0-)
      Recommended by:
      wilderness voice, arodb, Ralphdog

      of liver cancer in the hospital, the medications in his drip included one that would prolong his life for a few more days but otherwise not help him.

      We only knew this because we asked, otherwise it would have been given routinely. We asked if it could be discontinued since he didn't want his life prolonged.

      We were told that it could be discontinued and that we were doing the right thing by requesting that.

      We were able to "do the right thing" because we asked, otherwise they wouldn't have recommended or even suggested this "right thing" to us.

      working for a world that works for everyone ...

      by USHomeopath on Sun Jan 06, 2013 at 08:39:33 AM PST

      [ Parent ]

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