Physicians’ emotional, institutional barriers prolong medical futility at end of life
medwireNews: The most common reasons that clinicians give to explain medically futile treatment at the end of life are emotional difficulties, such as a fear of talking about death, and institutional barriers, such as hospital departments expecting them to "do everything possible," report German researchers.
The team suggests that improved communication training and knowledge transfer, organizational improvements, and emotional and ethical support systems could relieve the difficulty physicians have with communicating medical futility to their patients and patients' families.
Furthermore, the fact that a large part of lifetime healthcare costs are incurred in the last year of life, and that reducing nonbeneficial treatment on intensive care units could reduce these costs, the issue of medical futility "bears considerable economic and ethical relevance to society," say Ralf Jox, from the University of Munich, and co-workers.
The team conducted interviews with palliative care and intensive care staff involved in 17 ethics consultations at a large tertiary medical institution over a 1-year period.
The majority (62%) of the 29 healthcare professionals in the study reported knowing of situations where life-sustaining treatment (LST) was futile, and demonstrated unease at being asked to define futility to the researchers, evidenced by a 17% increase in pauses and use of filler words in their responses.
When the term was defined, staff explained medical futility as having a lack in goals of care, or that goals are overridden by associated risks, harms, and expenses - for example, an irreversible dependency on LST for the remainder of life, report the researchers in the Journal of Medical Ethics.
One intensive care physician reported that being able to say they "did everything we could" was one reason for providing futile treatment, while fear of doing something wrong (ie, legally) was another.
The authors observed differences in communication methods between physicians and families according to physician specialty. Intensive care physicians reported "a more cautious, indirect and matter-of-fact approach" (ie, explaining the difference between prolonging life and prolonging suffering), while palliative care physicians used a more direct and personal approach (ie, an "empathetic conversation" starting with what the patient already knows).
Jox et al propose an algorithm for end-of-life decision-making to assist physicians in communications about medical futility that rests on what the patient's preferred goal of treatment is, and how the patient evaluates benefits versus risks and burdens.
"It intertwines the two principle ethical grounds of treatment decisions: patient autonomy and patient wellbeing," they conclude.
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By Sarah Guy, medwireNews Reporter