The infinite costs of futile care--the ultimate physician executive challenge.

Since dividing by zero defines infinity (1) and the benefits of futile care are zero, a costs/benefits ratio analysis of futile clinical care reveals its costs are infinite.

Yet, for a variety of complex motives, physician executives often leave these infinite costs essentially unaddressed. The issues that preclude them from addressing these issues are predominantly psychological, social, legal, political and spiritual. These are daunting issues for any physician, but the infinite human and economics costs of futile care compel attention.

Causes of futile clinical care

Futile clinical care is delivered because it is ill-defined and the clinical decision making processes that lead to futile care are faulty.

Futile care has been defined in various ways.

* It has been defined numerically as clinical care that has less than a 5 percent chance of patient survival. In these circumstances, the survival chances are the only determinant of futility in clinical care.

* Alternatively, futile care has been defined as "ineffective and incapable of achieving a desired result or goal." (2) In these circumstances, mere survival may not be enough.

* In ordinary language, futility is also ambiguous, identifying interventions that are both useless and frivolous. In the biomedical literature, the term reflects this ambiguity in identifying not just those interventions that have no effect and are in this sense futile in absolute terms, but also those that fail to provide an appropriate level of benefit. (3)

From this, it appears that futile care is determined by its lack of efficacy for specific desires. It is futile clinical care if the desired goals are not met or the desired results cannot be achieved.

Goals and results of clinical care

Most people have unrealistic expectations from clinical care. This is because, although they know they will die, most believe they don't have to die. In fact, many believe that if clinical care was just good enough they wouldn't have to die or, at least, they could live to 120 or 150 years old.

Yet, clinical care can only stop the preventable death and then not always. At some time, all deaths are unpreventable or the goals or results from clinical care are or will be unacceptable to the patients or surrogates. It is in these latter circumstances that clinical decision making determines if futile care is to be delivered or averted.

Clinical decision making comprises unique exchanges between patients or, when necessary, surrogates and physicians.

Ideally, patients or surrogates determine their desired goals and results from clinical care. Then it is up to the physicians to determine whether these are clinically achievable and at what human and economic costs.

If the patient's desired goals or results are not clinically achievable or the costs are unacceptable to the patient, the physician must then determine what alternative goals and results are achievable and the human and economic costs of these. It is then up to patients to determine whether any of these achievable goals and results are desirable (as lesser choices) and/or if the human and economic costs are worth it. This is the essence of clinical decision making.

Unfortunately, many physicians never ask about the patient's desired goals and results or determine whether what they can achieve is desirable. Instead physicians present what clinical care they can offer that has a reasonable chance of achieving unrevealed goals and results. The patients must then make a choice from these limited offerings without really knowing the expected goals and results. Also, discussions of the human and economic costs of this offered care are rarely detailed or complete.

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The incongruence between the patients'/surrogates' desired goals and results and those of the clinical care the physicians offer is a major cause of futile care. In futile care, the essence of clinical decision making is lost in what is unsaid and not discussed.

The "do everything" directive

When physicians have no clinical care that can achieve any desired goals or results, they uncharacteristically ask patients or their surrogates what they want done. The common answer to this bewildering question is the "do everything" directive. This exchange is followed by the unenthusiastic provision of non-efficacious and therefore, futile clinical care.

These circumstances occur because of physician and patient/surrogate misunderstandings. The physician is asking patients/surrogates what they want done since no clinical care will achieve any desired goals or results. Yet, they do not explicitly say that nothing more can be done and leave this message implicit. The family does not comprehend the implicit message and give their explicit directive to "do everything."

Physicians misunderstand this directive believing that the futile care is being requested. Patients/surrogates do not comprehend that a physician would offer or provide clinical care that would not help reach some desired goals or results.

In truth, the "do everything" directive means, "do everything that will help meet the desired goals or results." It is up to the physician to frankly depict the bleak clinical status and explicitly state that no clinical care will achieve any desired goals or results. They should then offer end-of-life comfort care.

The physicians' reactions to the "do everything" directive can take several approaches. One could be to just explicitly state that nothing will help achieve the desired goals or results and that comfort care is the "everything" that can be done. Another is to explicitly outline the comfort care that can be provided as the "everything" that is requested and offer this care as the only option.

These approaches relieve the patients or surrogates of having to make medical decisions regarding what clinical care should be provided. They should only accept or decline clinical care that is offered and let physicians', as their professional duties dictate, determine what should be offered.

The failure of DNR policies

Decision making processes for end-of-life clinical care are in complete disarray. There are neither standardized processes nor widely accepted practices. The "do not resuscitate" (DNR) policies are at the foundation of this disarray.

When cardiopulmonary resuscitation (CPR) was first codified in the early 1970s, it was suggested that CPR was not for everyone and for these circumstances and order "not to resuscitate" should be written. Subsequently, DNR policies were developed, but paradoxically, these led to more rather than less confusion.

The "R" in DNR is shorthand for CPR in the event of cardiac arrest. Alas, this is not clearly understood, so confusion as to what hemodynamic and cardiac support "resuscitation" should be provided arose.

Also, emergency cardiac care (ECC) is a separate issue from CPR, yet it, too, was inappropriately limited under the DNR status.

Misunderstood ethical issues regarding DNR have generated conflicts. For example, some patients are required to "sign DNR orders" or progress notes in the medical records. This is ludicrous since DNR is a physician order and patients do not have the legal right to write or cosign physician orders. Hopefully, this nonsensical practice will not set a precedent for patients' signing other physician orders or progress notes.

Finally, CPR is the only procedure in clinical care that requires a physician order not to provide; otherwise, it is automatically provided in the event of a cardiac arrest. Most physicians do not take the extra proactive steps required to write a physician order to stop something that should not be done. These physicians' failures to write DNR orders are a prime source of futile care.

Preventing futility in clinical care

Minimizing futile care involves understanding the causes and developing strategies to counter them.

The key to preventing futile care lies in the definition of quality clinical care. Ironically, even though it is frequently talked and written about, quality care is seldom defined. Without a definition, quality is always in the eyes of the beholder and therefore different for each person. This leads many to believe futile care is quality care.

In spite of this status, quality care has been defined as: (4)

* The care must be warranted and efficacious for the specific condition(s) in light of the individual's general bio-psycho-social status and values.

* This care must maximize benefits and minimize risks.

* This care must be cost efficient.

* This care should achieve an individual's desired, or at least acceptable, goals or results.

With this definition, a major portion of futile care would not be delivered because the patient's general bio-psycho-social status and/or values would prevent it or because the desired goals or results cannot be met.

As a result, futile care is not quality health care and referral to quality care committees may be warranted. Asking physicians in quality care committees why futile care was not addressed and therefore provided is effective in changing physician behaviors.

Beyond DNR

Scrapping and replacing confusing and non-useful DNR policies can be very helpful in stopping futile care. My colleagues and I published a "patient care category" (PCC) policy as a replacement to DNR Policy. (5)

The PCC policy described three categories:

1. Full support, including CPR

2. Full support, excluding CPR

3. Modified support, excluding CPR

It describes "full support" as everything that was warranted and efficacious given the general conditions. Modified support was anything less than full support and had to be specifically described. Support was modified because the achievable goals and results were not acceptable to the patients or surrogates or the human and economic costs were too high for them. The CPR was cardiopulmonary resuscitation as codified by the American Heart Association.

This PCC policy led to marked reduction in futile care in a community teaching hospital. (6) These marked reductions were in the number of CPR and the number of days patients spent endotracheally intubated on mechanical ventilators. These reductions occurred without any change in the hospital mortality rates suggesting only futile care was being prevented and the inevitable deaths were allowed to occur without it.

Since patients had to have a PCC assigned on admission (with full support, including CPR as the default), failure to discuss and assign a PCC was an event that was reviewed by the hospital's quality care committee.

The mandatory discussions as a result of this policy led to improved clinical decision making since physicians had to explicitly discuss the achievable goals and results. Thus, the PCC policy solved the defects in DNR policies and the faulty clinical decision making processes that led to futile care. It also corrected any unrealistic expectations from clinical care and essentially eliminated the "do everything" directive.

The infinite human and economic costs of futile care can no longer be ignored. Physician executives must begin the dialogues and institute policies that will avert the vast majority of futile care. Only through this courageous leadership can physicians lead the country in making sound choices in clinical care and prevent the infinite costs of futile care.

Fidel Davila, MD, MSMM, FCCP, FCCM, FACPE, CPE, is founder/CEO of objectHEALTH, a bealth care processes improvement concern in Plano, Texas. He can be reached at 972-378-5704 or [e-mail]

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References:

1. Seife, C. Zero. The biography of a dangerous idea. New York: Penguin Books (USA), 2000.

2. Barnette, RE, Knudsen, J. "Futile care and the critically Ill." Critical Care Medicine. 24(2), 1996.

3. Engelhardt, Jr., HT, "Rethinking concepts of futility in critical care." Center for Medical Ethics and Health Policy, Baylor College of Medicine 23 October 1996. http://www.mediscene.com/medpub/futile.htm

4. Davila, F. [untitled editorial] Baylor University Medical Center Proceedings 15(1), 2002.

5. Davila F, Boisaubin EV, Sears DA. "Patient care categories: an approach to do-not-resuscitate decisions in a public teaching hospital." Critical Care Medicine. 14(12), 1986.

6. Davila F. "The impact of patient care categories on cardiopulmonary resuscitation and ventilator support." Arch Int Med. 156, 1996.

By Fidel Davila, MD, MSMM, FCCM, FCPE, CPE