In the latest issue of Health Care Ethics USA [20(1), Winter 2012], Ron Hamel and Michael Panicola contribute "Enhancing Communication and Coordination of Care: A Third Generation Approach to Medical Futility." Hamel is Senior Director of Ethics for the Catholic Health Association. Panicola is Director of Ethics for SSM Health Care in St. Louis.
They trace the history of approaches to futility: (1) definitional, (2) procedural, and (3) surrogate selection. But they found that these approaches were not adequately addressing a significant increase in futility cases at SSM acute care facilities. Futility policies were not followed, because physicians, who "felt as though they had no legal coverage," usually "ended up acquiescing to requests for treatment." Hamel and Panicola describe an approach focused on preventing conflict from arising in the first place, including care conferences automatically triggered for "patients with an ICU length-of-stay of more than five days." Included with the article are seven pages from SSM's "Health Care Guidelines." These are good guidelines. Other facilities should consider incorporating aspects into their own policies.
But the SSM Guidelines have some limitations. First, section I(E) advises physicians to "offer only those treatments that are reasonable and realistic in light of the patient's overall condition." But this seems to ignore the diachronic nature of critical care. Certain interventions might have seemed appropriate at T1. The futility conflict arises weeks or months later after it becomes increasingly obvious that the intervention that, at first, seemed appropriate is no longer indicated. It is precisely this situation that frames the Rasouli case pending before the Supreme Court of Canada.
Second, section II(G2) of the guidelines advises that if agreement cannot be reached, then treatment "could be withdrawn provided there is wide agreement among the attending/primary physician, other caregivers, hospital president, ethics committee, and so on." The family "should be notified" and "given an appropriate time to reconcile with the situation or make alternative plans." But this unilateral action is unlikely to be taken. As Hamel and Panicola observe at the start of their article, a procedural approach does not work without legal cover. Oddly, the policy does not include surrogate selection as a dispute resolution pathway.
They trace the history of approaches to futility: (1) definitional, (2) procedural, and (3) surrogate selection. But they found that these approaches were not adequately addressing a significant increase in futility cases at SSM acute care facilities. Futility policies were not followed, because physicians, who "felt as though they had no legal coverage," usually "ended up acquiescing to requests for treatment." Hamel and Panicola describe an approach focused on preventing conflict from arising in the first place, including care conferences automatically triggered for "patients with an ICU length-of-stay of more than five days." Included with the article are seven pages from SSM's "Health Care Guidelines." These are good guidelines. Other facilities should consider incorporating aspects into their own policies. But the SSM Guidelines have some limitations. First, section I(E) advises physicians to "offer only those treatments that are reasonable and realistic in light of the patient's overall condition." But this seems to ignore the diachronic nature of critical care. Certain interventions might have seemed appropriate at T1. The futility conflict arises weeks or months later after it becomes increasingly obvious that the intervention that, at first, seemed appropriate is no longer indicated. It is precisely this situation that frames the Rasouli case pending before the Supreme Court of Canada.
Second, section II(G2) of the guidelines advises that if agreement cannot be reached, then treatment "could be withdrawn provided there is wide agreement among the attending/primary physician, other caregivers, hospital president, ethics committee, and so on." The family "should be notified" and "given an appropriate time to reconcile with the situation or make alternative plans." But this unilateral action is unlikely to be taken. As Hamel and Panicola observe at the start of their article, a procedural approach does not work without legal cover. Oddly, the policy does not include surrogate selection as a dispute resolution pathway.
