I was covering for my partner over the weekend and saw his patient with end-stage liver disease, a consequence of decades of alcohol abuse.|
He was one of the most deeply jaundiced individuals I have ever seen. His mental status was still preserved. He could converse and responded appropriately to my routine inquiries, although he was somewhat sluggish in his thinking. It’s amazing that even after the majority of a liver is dead, that a person can still live.
When I do my hospital rounds, it is rare that one of my patients is not suffering some complication of chronic alcoholism. In the hospital, the disease is rampant. In my office, this addiction is much more easily disguised. I know that many of the high functioning alcoholics whom I see there have kept their addiction a secret. Some lie and others deny.
There was a dispute with regard to the jaundiced patient referenced above. There was no disagreement among the medical professionals on treatment options. At this point, there was no medical treatment to offer beyond his current medications. A palliative care specialist advised that hospice care was the most appropriate option. The physicians and nurses concurred. Why didn’t it happen?
The patient’s wife, who lived out of town, insisted that all medical measures be pursued. Hospice care was a non-starter. While the patient and his wife were separated, she was still the legal spouse and next of kin. The patient had not prepared a living will. It was not felt that the patient possessed sufficient mental capacity to make this profound medical decision. So, the wife’s view prevailed.
My task was easy as I was only responsible for his gastro care over the weekend. But, there was a huge ethical task that demanded to be confronted. Physicians were continuing to provide futile care because a wife demanded it. Such care, in my view, is unethical and need not be provided, despite the insistence of a family member.
Physicians are under no professional obligation to provide care that is futile, or is extremely unlikely to offer benefit, even if patients and families demand it. The fact that a third party is usually paying for this treatment only deepens the ethical infraction. Physicians should not feel obligated to accede to futile care requests, or feel that they need a court order to protect them against such requests. In my experience, surgeons are more comfortable than are medical specialists and internists in declining to provide care that won’t help. I have often heard surgeons tell patients and their families that an operation simply won’t help and shouldn’t be done. For some reason, this issue seems to be murkier for non-surgeons.
Of course, physicians must be sensitive when discussing these issues with patients and families who understandably want anything and everything done to save their loved one. But, giving care that won’t work is wrong.
Over the weekend that I saw this patient, I was not in a position to set the patient free. It seemed surreal that everyone on the case knew the right thing to do, but none of us were doing it.
Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.
Image credit: Shutterstock.com
