The following consultation report is based on a real clinical dilemma that led to a request for an ethics consultation. Some details have been changed to preserve patient privacy. The goal of this column is to address ethical dilemmas faced by patients, families and healthcare professionals, offering careful analysis and recommendations that are consistent with biblical standards. The format and length are intended to simulate an actual consultation report that might appear in a clinical record and are not intended to be an exhaustive discussion of the issues raised.
Must we continue "futile" ICU support for this dying man at the insistence of his son?
Malcolm ("Mac"), age 64, is an architect who was found to have an incurable cancer of the esophagus 5 months ago. He came to the Emergency Department 35 days ago with shortness of breath and it was found that his tumor was compressing the large airways going into both lungs. He was emergently intubated, admitted to the ICU, and given ventilatory support which has now continued for more than a month. Vigorous treatment has failed to shrink the tumor, and the ICU physician and oncologist are both convinced that his condition cannot be improved. Efforts have been made to awaken him to discuss limitation of treatment, but he remains too confused to understand or to engage in meaningful conversation. Because of his unawareness and his very poor prognosis, his professional caregivers have said they believe continued ICU care is futile.
His only son, Paul, and wife, Lindsey, have been very attentive and willing to consent to any therapy that has been suggested so far. When presented a few days ago with information about his terminal condition and imminent death, however, they were unwilling to consider or even discuss any limitation of treatment, insisting that he remain in the ICU, on ventilator support, on a “full code” status. They stated that their deep religious faith (Methodist) required them to do everything possible to preserve life, and they were counting on God to perform a miracle. They report that the patient was also a man of deep faith who would likewise insist on this approach.
Mac’s ICU nurse reports that he remains unresponsive and does not appear to be uncomfortable. She further reports overhearing a conversation between Paul and Lindsey about the need to get the patient’s signature on a document that would finalize a real estate venture that he and his son have developed. An attorney came to the ICU to obtain the patient’s signature a few days ago, but Mac was unable to understand or to sign the document.
When it is clear that a patient is dying, is unaware, and cannot improve, it is appropriate to review his treatment and to consider limiting life-extending treatment. Decisions for or against the use of such therapies should be based on the patient’s wishes, expressed by him in writing or verbally. While it may occasionally be suspected that family members have "another agenda," the presumption in most cases should be that they best know the patient’s wishes and values, and their decisions should almost always be honored. Exceptions to this generalization include (a) if the treatment is clearly physiologically futile, as determined by at least two physicians, or (b) if the treatment will be unable to restore the patient’s awareness and it is also causing him unrelievable suffering.
In this case, the patient’s professional caregivers are convinced that he is dying and will never again have awareness, and they interpret this to mean that continued treatment is futile. However, his family believes that he would want to continue treatment while they are praying for Divine intervention. Since his current ICU care is postponing his death, it is not truly futile.
Mac continued to live in the ICU, on full support for the next 13 months without recovering awareness. He had several episodes of sepsis and was successfully resuscitated from four cardiac arrests. Two more ethics consultations were requested at intervals, essentially asking the same question, with essentially the same recommendations. When he did not survive the final resuscitative attempt, the ICU physician called his son, saying, “We did everything we could, but I’m sorry to report that your father has died.” His frustration with his father’s lack of improvement came through in his response: “Well, you obviously didn’t do enough!”
Talk about frustration—Mac’s professional caregivers were exceedingly frustrated, believing that their heroic efforts had no reasonable expectation of helping the patient. They believed that they were being poor stewards of medical resources. (Mac’s care for this hospitalization exceeded $2,500,000.) It is very easy in retrospect to confirm their belief that this extent of treatment was “inappropriate,” but it clearly was not futile in the literal sense since it did postpone his death for many months.
This case study, used by permission, originally appeared in Ethics & Medicine: An International Journal of Bioethics 25, no. 3 (2009). The piece is an adaptation of a case report that appears in Dr. Orr’s recent book, Medical Ethics and the Faith Factor, (Eerdmans, 2009). This book is the most recent volume in CBHD’s Critical Issues in Bioethics series.
