US, WASHINGTON (ORDO NEWS) — Let me first outline the context a bit. “Unpromising medical care” is “the provision of medical care or treatment to a patient in cases where there are no reasonable hopes for his cure or improvement of his condition”.
This is the situation that we face when our patients are on the verge of death. When it comes to a few more months or years of life, doctors rarely can tell exactly when death will occur, but doctors often accurately identify those patients who have no more than a week left to live. In such cases, we can already discuss with the patient or his relatives the futility of further “aggressive” methods of treatment and, of course, with consent, concentrate on alleviating the patient’s suffering. We often do this.
If decisions about “unpromising medical care” have to be made at times of crisis, this most often leads to the fact that the patients themselves and their family members make a choice in favor of the seemingly obvious option – do everything possible! In the field of behavioral economics there is a mass of literature devoted to such a “default choice”. Simply put, we are much more afraid of losing something than we want to gain something, that is, we are much more upset if we lose money than we rejoice if we get it. Death is the ultimate loss.
Today, another strange twist has appeared in our train of thought: the decision to stop treatment is often perceived as something more destructive than the decision not to start this treatment at all. I suspect this is because that cessation of treatment is a much more obvious event and is always directly related to the need to make a very difficult decision. And the more directly your participation in the process, the more responsibility you can feel later.
During the COVID-19 pandemic
If there is one ventilator and two or more patients, which of them will be connected to the apparatus? The framework for such a decision, which is now supported by more and more specialists, was formulated by the doctors of the intensive care unit at the University of Pittsburgh. This is a well-thought-out, ethically-based and clinically tested approach, which assumes the existence of certain selection criteria, and also establishes who should make this choice and how.
These criteria allow you to shift the focus from the patient in front of you towards possible consequences for public health, that is, for the community. The basis of this approach is the idea that it is necessary to save not one life of a particular person, but as many lives as possible or as many productive years of life as possible.
As many lives as possible
When distributing ventilators, doctors will give preference to those patients who can survive if such assistance is provided, rather than those to whom it will not help. On a scale of dynamic assessment of organ failure (Sequential Organ Failure Assessment), doctors evaluate the level of oxygenation, blood coagulation, metabolic processes and some other parameters.
This system has been used for many years to predict the future course of illnesses, and not as a tool for making a final verdict. The degree of accuracy of forecasting in this case increases with the failure of various body systems. There are other scales for assessing the condition of patients, but the main thing here is to identify those who recover as soon as possible and release the ventilator for the next patient.
More productive years of life
The second point is how many years the patient will have after recovery. The age of the patient is the main factor in this case, but we all know people who are healthy and alert or, conversely, painful and weak, despite their age. Instead of age, doctors take into account those of your diseases that shorten life expectancy – for example, senile dementia, heart failure, aggressive forms of cancer. In general, conditions that can significantly reduce the quality of a relatively long life affect the decisions of doctors to a greater extent than those conditions that do not lead to disability.
How are decisions made?
Based on the previous two factors, patients are divided into three groups according to priority – high, medium and low. And, if there are not enough resources, they are distributed according to what category the patient fell into. Of course, there are controversial situations here. Firstly, what if there are two patients belonging to the same category and only one ventilator? In such cases, it is recommended to consider which of them has a longer life ahead, that is, give preference to a younger patient. In addition, it is recommended that preference be given to those “people who play an important role in providing emergency care”. And before you grab this phrase and blame the doctors for bias, I’ll say that not only doctors and nurses, but all hospital staff fall into this category.
“It is possible that patients, their families, or treating physicians will challenge specific decisions regarding patient sorting. “Procedural fairness requires that they have access to an appeal mechanism to resolve disputes.”
The proposed appeal mechanism is short and clear: when it comes to sustaining life, there is simply no time for lengthy discussions. The only basis for appeal is evidence that the initial assessment of the chances of survival and life expectancy was incorrect.
Sometimes, despite all our efforts, the condition of the patient connected to the ventilator continues to deteriorate. The ventilator is a means of sustaining life, not a cure. Although currently about a third of patients lying on the ventilator are removed from these devices and discharged home, the remaining two thirds still die from respiratory failure or for some other reason.
In fact, in conditions of tight distribution of resources, these patients use a vital resource in a futile attempt to survive. In order to track those patients who, at first, seemed to have a good chance of survival, but who became increasingly hopeless over time, the procedure of triage or categorization of patients is carried out daily. Remember
“Decisions to deprive a scarce resource, such as a ventilator, of a patient who is already receiving treatment using this resource, may contain a serious moral background. Moreover, such decisions are much more dependent on clinical evaluation than on initial estimates. Thus, it is necessary to develop a clearer appeals procedure in order to take away and redistribute places and services in intensive care units. ”
The phrase about the “moral background” echoes what I wrote above – that stopping the provision of assistance is much harder than not starting it at all. There is a protocol designed to mitigate these moral experiences, which allows you to turn to the tribunal commission. However, such appeals boil down to “give another day,” rather than a complete review of the decision.
Who makes decisions
The function of triage or sorting of patients must be performed by the impartial side, that is, the attending physician, who often monitors this process under normal conditions, cannot become a judge. His role, as always, is to uphold the interests of his patient. The ethical dilemma between “do no harm” and “justice for all” is too difficult for those who look directly into the eyes of their patients and their families.
“It is desirable that a member of the tribunal commission be a doctor with experience in treating terminally ill patients and possess such qualities as pronounced leadership abilities, effective communication skills and conflict resolution.”
Experienced nurses in intensive care units and the administration of the medical institution help them collect all the necessary data. The decisions of the tribunal commission are communicated to patients or their families by one of its members or the attending physician.
Contact us: [email protected]