The authors reply.

Abstract

We thank Drs. Eiferman and Jones (1) for their thoughtful comments on our recent publication on the opportunity costs of futile treatment in the ICU. Providing futile treatment is wasteful, and we are pleased that our work has stimulated discussion about this difficult, uncomfortable, but exceedingly important issue. Regarding the question, “Is it time to take a harsher stance on futile care and tell families their loved ones is being transitioned to comfort care rather than asking?”, we must first acknowledge that the ideal paradigm in Medicine is one of shared decision-making(2) and many family conflicts can be resolved with improved communication(3). We are not able, at this time, to identify whether these processes were fully exhausted in the cases we studied. Additionally, further work is needed to develop tools that can prospectively identify patients who are at risk of receiving non-beneficial care, such that automatic interventions (such as palliative care involvement and scheduled family meetings) can be triggered to prevent futile treatment from occurring and therefore, improve the match of care with prognosis. Studies suggest that these measures can be effective(4,5). We agree that when such mechanisms fail, society at large and physicians in particular need to recognize that Medicine must be practiced responsibly and critical care is a resource that needs to be justly stewarded. The U.S. desperately needs an open, informed conversation about the goals of medicine and the societal trade-offs of using critical care to maintain people in severely compromised health states from which they cannot recover. Pragmatic, policy-level mechanisms that will support the cessation of futile treatment after thorough attempts at discussion, conflict resolution and due process are needed. Several institutions have long had such policies in place(6), and clinicians have the responsibility to activate these policies when necessary to avoid the treatments that are non-beneficial or harmful to the patient. A critical aspect of a doctor’s moral responsibility is to relieve suffering and to be able to recognize when Medicine and technology is overmastered by a patient’s condition. Avoiding these difficult conversations and conflict is a disservice: a disservice to the patient whose suffering is prolonged and dignity is compromised in the dying process, a disservice to the family whose unrealistic expectations are fueled by passivity and inadequate communication, a disservice to the medical profession where clinical acumen is cast aside and the tools we were trained with are no longer used to make a patient well, and a disservice to other patients who may be unable to access the health care they need. When faced with a family who “wants everything done,” declining to provide futile treatment is often an uphill climb, but abdicating the responsibility to use the tools of critical care medicine appropriately has steep consequences.