Medical Futility — drawing the line

icuToday’s medical futility is tomorrow’s routine care.   A very hopeful thought.  However, in the present consider a modern intensive care unit.  A treatment area in most hospitals where a month of care could easily cost half a million dollars.   That’s a big bill for any individual, hospital or insurance company and there is mounting pressure to use technology more wisely.

Cost is the most important factor to consider in a discussion of medical futility.  Futility means doing something that will fail.  Of course, our modern definition is doing something that will likely fail but might not if we spend enough money.  If there is only one treatment for a horrible disease and it only costs a penny — we would spend it instantly, even if the treatment is futile.  But,  if it costs ten million pennies …  we think about futility.

American medicine has been plagued with the problem of implementing treatments before they are affordable or even proven.   Nobody asks a medical innovator “could you work on the invention a little more to make it less expensive”.  Nobody asks a surgeon if a surgical procedure is proven — coronary bypass surgery is a good example, since the proof of effectiveness came 20 years later — turns out it’s not for every patient, just a select few.

The same question of effectiveness exists for intensive care.  It’s clearly not for every patient,  just a select few.  But, how are doctors identifying  those select few?

Critical illness is fraught with uncertainty.  We have lots of expensive treatments but where do we draw the line.  Deploy the technology or let nature take it’s course?   Ethicists and theologians suggest they know the answers.

Yet, patients and families seek a pragmatic solution:  grandpa was in great health but now his aneurysm has ruptured — he looks bad, should he have surgery?

Research shows critical care doctors actually predict outcome fairly well in this sea of uncertainty.   They tend to favor using their skills to “give it a try” and make money doing so.  But, if they say the chance of meaningful survival is less than 10% — absolutely do not go down that road.  The road is often a dead end — the end may be after weeks in the ICU, or weeks in rehabilitation, or months in a nursing home.

Critical care is extremely stressful to the body.  Research has shown that persons over 65 who survive an illness but who spend a week connected to a mechanical ventilator only have a 50% chance of living 6 months.  So, even walking out of the hospital after critical illness is not a guaranteed success.

Back to the question of futility.  Severe illness does not provide the luxury of time, time to check the internet, or time to go to the best doctor.  This is when going to a hospital with a high quality score is important.   There are always media splashes about miracle cures or soap opera dramas — the reality is patients and families do not want futile care.  This is one time “ask your doctor” is exactly the right thing to do — listen carefully.

 

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