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When all's futile

"When all's futile" Continued...

Issue: "An evolving debate," May 21, 2005

Meanwhile, individual hospitals are instituting policies controlling futile-care and DNR decisions. At the Medical University of South Carolina (MUSC), for example, if two doctors agree that a patient should not be resuscitated, they may issue a DNR order regardless of whether the family or surrogate objects.

When hospitals institute such policies, no announcement is made, said Wesley J. Smith, an attorney with the International Task Force on Euthanasia and Assisted Suicide. "Indeed, the first time most learn of these matters is if they come up against a desire to terminate wanted life-sustaining treatment."

When disputes arise, they look something like this: A patient's family member wants doctors to render care that the doctors deem "futile" or "inappropriate." Medical staff, chaplains, social workers, and bioethicists will first try informally to resolve the problem. If neither side cedes ground, the matter will go before the hospital's bioethics committee. If the committee nixes the care the patient's family wants, the patient is left to die, unless the family fights for a transfer to another facility, or in court.

Mr. Smith noted, the majority of physicians "are overwhelmingly dedicated to the well-being and proper care of their patients." But, he said, that doesn't mean to blindly trust, as Kay McClanahan found out.

In April 2004, Bill McClanahan, 74, a retired federal intelligence officer, took his wife out to dinner then suffered a cardiac arrest. Medics were able to revive him. But Mrs. McClanahan now charges that doctors at MUSC immediately diagnosed Mr. McClanahan as a vegetable, then consistently ignored signs of improvement, withheld treatment (even for pneumonia), and urged her to let him die.

One doctor, Mrs. McClanahan said, told her she felt "an ethical duty" not to treat Mr. McClanahan because he would experience an "impaired quality of life." The same doctor, Mrs. McClanahan says, put a DNR order on her husband's chart against her wishes. When she objected, she says the attending physician told her about MUSC's two-doctor override policy.

"Bill was looking at me, smiling at me, coming back to me, yet somebody else had decided he would be better off dead. They told me that," Mrs. McClanahan said. "It was amazing how determined they were not to be proven wrong."

Mrs. McClanahan said she felt powerless against the array of MUSC doctors, legal personnel, and ethics committee members who, she said, agreed Mr. McClanahan should be allowed to die.

MUSC Medical Director John Heffner told WORLD that according to South Carolina law, when a patient is incapacitated, the hierarchy of authority for medical decision-making begins with the spouse. He also said he did "not have knowledge of those conversations" that led to the DNR order for Mr. McClanahan.

Asked whether it was true that his staff had encouraged Mrs. McClanahan to let her husband die, Dr. Heffner said, "I don't have firsthand knowledge of that. I'm sure a lot of caring comments were made and taken out of context."

Mrs. McClanahan said Dr. Heffner "answers questions like a politician." Last month, a Tennessee internist accepted care of her husband at a hospital where, Mrs. McClanahan reports, doctors and nurses are rendering compassionate care.

The definition of "caring" is at the root of the futile-care controversy. A growing number of physicians and medical ethicists opine that it is more compassionate to live and let die than to let live. It is in part the concept of medical futility, or "futile care," that drives this.

Prior to the 1950s, doctors-carrying admittedly fewer cures in their bags-exercised total control. Regarded by many as small-G gods in white coats, they generally ordered or denied treatment they deemed fit, and patients had little voice in the matter. But in the 1960s and '70s, the concept of "patient autonomy" emerged, and a series of court cases-Roe v. Wade among them-established the general principle that Americans have a right to control what is done to their bodies. That sent the ethical pendulum hurtling toward an untenable ethic of absolute patient autonomy.

About 15 years ago, doctors and ethicists began debating the concept of medical futility, partly as a way to reclaim some authority. But the concept proved an unwieldy beast as ideas on what, exactly, constituted "futile" were as varied as the details in each patient's case file. Attempts to neatly package any set of guiding principles or protocols proved-well, futile. In 1994 the American Medical Association issued an opinion that "denial of treatment should be justified by . . . openly stated ethical principles and acceptable standards of care . . . not on the concept of 'futility,' which cannot be meaningfully defined." Acceptable standards, the AMA stated, included resource allocation and quality of life.

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