Letters
Palliative care
Volume 189 - Issue 6

What has happened to clinical leadership in futile care discussions?

Authors:  Thomas R Solano and James D Fratzia

Med J Aust 2008; 189 (6): 348-349. || doi: 10.5694/j.1326-5377.2008.tb02065.x
Published online: 15 September 2008
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To the Editor: We share the sentiments of Murphy’s article in the 7 April issue of the Journal.1 As intensive care physicians, the issue of futile care is an almost daily consideration. We agree with his assertion that “the community looks to the (senior) medical practitioners for the security they need to accept decisions of great moment, such as withholding futile treatment”.1

It is common for a referral to an intensive care unit to be made because “We asked the family, and they want everything done”. This is the least confrontational manner of “sorting out the resuscitation status” with the next of kin. Unfortunately, it shifts end-of-life decision making to others, particularly the family in crisis.

This places additional stress on an already stressful situation. It often results in undignified, ultimately futile medical interventions and prolongation of dying. It is also a potential pastoral and mental health disaster for families. It is our duty of care to such patients to minimise the iatrogenic damage to their families by having senior clinicians communicate which therapies are appropriate, and thereby help families accept the likely prognosis. Ethically, we believe doctors should not harm families in crisis.

Establishing when treatment is futile is difficult. The decision is often qualitative, with differing thresholds for futility. Personal and religious beliefs and anecdotal experience all affect the ability of a clinician to determine when a therapy is futile.

We believe it is the duty of the clinician who performs an intervention, not the referring clinician, to determine its utility. A patient should not be referred to an intensive care unit if the intensivist believes the multitude of life-supporting therapies are not of clear benefit. If initiated, the intensivist should determine when such therapies are no longer of benefit. A framework for debate and review of contentious cases should be established within institutions as a matter of process.

Sadly, intensive care units are increasingly seen as locations for palliative care. When a patient dies, it is unreasonable for referring clinicians to claim a clear conscience by saying “we did everything we could”, when the outcome is a prolonged, undignified death in an intensive care unit. Such deaths are not just wasteful of resources, but cause unnecessary distress to patients, their families and staff who care for them.

We must not mistake “treating” our patients for “caring” for them. Doctors should be part of the solution, not part of the problem.

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