by Michael Kirsch, MD
Consider this hypothetical vignette. Tiger Woods accepts my challenge to play 18 holes. Obviously, the gallery would be packed with golf enthusiasts who would cancel job interviews, vacations and even worship services in order to witness this historic competition. Spectators would be permitted to place bets at even money. Perhaps, my mother would bet on me, but no other sane person would. They would properly conclude that even my best performance against Tiger’s worst would be inadequate. There is nothing I could do to change the outcome. All of my efforts would be futile.
Futility cannot be proved with mathematical certainly. After all, Tiger could develop acute appendicitis on the fairway and have to forfeit. He could be arrested. Lightning could strike. Killer bees could take him down. Nevertheless, the overwhelming odds are that I would be vanquished and humiliated.
Medical futility is a more serious issue that exists in every physician’s office and hospital in the country. Examples can be mundane such as a physician prescribing (or a patient demanding) antibiotics for the sniffles or a viral infection. This treatment is futile; it does no good. Medical futility is usually a controversy that involves end of life care when treatments are initiated or continued that won’t change the outcome. Many of these patients may have already ascended a few rungs up the ladder to the next world.
While physicians must not hasten death, we should not provide futile care. This expends resources, generates unrealistic hopes and demoralizes the medical professionals who are caring for the patient. Why is it done? It is often demanded by families who insist on more medical care and consultations. Sometimes, this is a guilt reaction. Often, they simply cannot accept the outcome. They deny. Or, they may think that the doctors are wrong. These families all know the rare anecdotes of folks who awaken from long comas ready to play chess. Since doctors cannot be 100% sure of anything, they press on hoping for a miracle. Finally, since hospital bills are usually paid by third parties, patients and families have every reason to pursue medical care against all odds.
Medicine is an imperfect discipline. If a patient or a family expect an inviolable guarantee that our advice is correct, then we can never satisfy them. Our job, as physicians, is to empathize and to guide them toward a rational plan. While the views of the family are important, our professional obligation is to serve as the patient’s advocate. When our medical judgment and experience convince us that surgery, a respirator, antibiotics or a colonoscopy are futile, we shouldn’t permit them. Patients should not receive treatments that medical professionals overwhelmingly feel would offer no benefit. In addition, is it fair for others to pay for futile care?
Of course, physicians should approach these issues delicately, but patients and families must be discouraged from pursuing a futile path. These bedside discussions can be difficult and consensus is not guaranteed. But, the goal is worth the effort.
Golfers, have you ever hit a hole-in-one? While this outcome is never impossible, would you bet large sums of money on it? If so, then you might also bet on me in my imaginary contest against Tiger. If you did, all your prayers for my victory would be futile. We can’t win at golf or practice medicine when our only hope for success is divine intervention.
This essay is cited in the KevinMD record on end of life.
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.
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