Content area
Full Text
Arthur Rivin, M.D., had seen many patients like this one--too many. She was 85 years old, with an inoperable brain tumor. She needed a respirator, artificial nutrition and hydration. She received this care for weeks because her family insisted on it, not because her doctors recommended it. This scenario was occurring at least once a month at Santa Monica (CA) Hospital Medical Center, says Rivin, chair of the institution's ethics committee. It was situations like these that made him advocate a futility of care policy. These situations, he says, cause "physical and psychological suffering for the patient and family with no possibility of a favorable outcome," and economic losses for the hospital. "Medical care costs are going out of sight and we've got to stop doing this."
HOW ONE FUTILE-CARE POLICY WORKS
Santa Monica, whose policy has been in effect since 1991, defines futile care as "any clinical circumstance in which physicians and their consultants, consistent with the available medical literature, conclude that further treatment (except comfort care) cannot, within a reasonable possibility, cure, ameliorate, improve or restore a quality of life that would be satisfactory to the patient."
The policy also includes seven steps (see figure, page 28), dealing mostly with ways that clinicians can discuss a patient's situation with the patient and family. If after discussion of the patient's condition, the family is still in conflict with the hospital, the physician may ask the bioethics committee to counsel the doctor or family.
The bioethics committee gets involved in about 2 percent of cases, Rivin says. This is because by the time an ethics committee conference is scheduled, the issue has often been resolved among the physician, nurses, social worker, chaplain, patient and family. The decision is made to keep the patient on life support or withdraw the care, or the patient dies before the conference is held.
Rivin says that one of the most important aspects of the guidelines is that they encourage an interdisciplinary conference between the care-givers and the family. The hospital has never reached the last two steps in the process--refusing care and invoking personal payment for care that the staff believes is unjustified (see figure, page 28).
Besides forcing a dialogue between families and caregivers, the policy has...