Why Some "Futile" Care Is "Appropriate": The Implications for Conscientious Objection to Contraceptive Services

In response to the criticism of Schneiderman and colleagues (2017) that two recent policy statements of professional medical organizations referred to some medical treatment that were traditionally called "futile" by the terms "inappropriate" or "potentially inappropriate," this critique accepts their claim challenging these terms as being hopelessly ambiguous. However, this critique rejects the conclusion they all share that clinicians or hospitals should have the unilateral authority to refuse to provide treatments that will plausibly achieve the end that the patient or surrogate is pursuing. Although clinicians should be presumed authoritative in deciding to reject treatments that will not achieve the patient or surrogate's end, they should be obligated, provided five conditions are met, to provide those treatments that will achieve the patient or surrogate's end. The implications of honoring a physician's right to conscientious objection to treatments they deem "futile" are compared to physician claims of the right to refuse to provide contraceptive services on the same grounds.

[Healthcare services citizen's right and healthcare systems safeguard. Considerations rising from the Charlie Gard story.]

The story of Charlie Gard, an 11-month-old boy suffering from a rare inherited mitochondrial disease called 'infantile encephalomyopathic mitochondrial DNA depletion syndrome' and kept alive thanks to life supports, rises some issues regarding the provision of healthcare. Is there a right of an individual person to buy any healthcare benefits only because he has enough money to do so? If the answer is 'yes', in light of the distributive justice principle how do governments balance this right with the obligation to regulate health care systems ensuring that all treatments are useful and affordable for everybody? Many considerations of the best interest of patients can be found in this debate, but we cannot ignore neither the value of the scientific method as the cornerstone of the medical profession nor a commitment to support the moral integrity of clinical practice by refusing to provide treatments that do not meet a reasonable threshold of scientific justification evidence-based.

What happens when the doctor denies a patient's request? A qualitative interview study among general practitioners in Norway

OBJECTIVE

To explore general practitioners (GPs') experiences from consultations when a patient's request is denied, and outcomes of such incidents.

DESIGN AND PARTICIPANTS

We conducted a qualitative study with semi-structured individual interviews with six GPs in Norway. We asked them to tell about experiences from specific encounters where they had refused a patient's request. The texts were analysed with Systematic Text Condensation, a method for thematic cross-case analysis.

MAIN OUTCOME MEASURES

Accounts of experiences from consultations when GPs refused their patients' requests.

RESULTS

Subjects of dispute included clinical topics like investigation and treatment, certification regarding welfare benefits and medico-legal issues, and administrative matters. The arguments took different paths, sometimes settled by reaching common ground but more often as unresolved disagreement with anger or irritation from the patient, sometimes with open hostility and violence. The aftermath and outcomes of these disputes lead to strong emotional impact where the doctors reflected upon the incidents and sometimes regretted their handling of the consultation. Some long-standing and close patient-doctor relationships were injured or came to an end.

CONCLUSIONS

The price for denying a patient's request may be high, and GPs find themselves uncomfortable in such encounters. Skills pertaining to this particular challenge could be improved though education and training, drawing attention to negotiation of potential conflicts. Also, the notion that doctors have a professional commitment to his or her own autonomy and to society should be restored, through increased emphasis on core professional ethics in medical education at all levels.

Acceptance of Antidepressant Treatment by Patients on Hemodialysis and Their Renal Providers

BACKGROUND AND OBJECTIVES

Depression is common in patients receiving chronic hemodialysis but seems to be ineffectively treated. We investigated the acceptance of antidepressant treatment by patients on chronic hemodialysis and their renal providers.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

As part of a clinical trial of symptom management in patients on chronic hemodialysis conducted from 2009 to 2011, we assessed depression monthly using the Patient Health Questionnaire 9. For depressed patients (Patient Health Questionnaire 9 score ≥10), trained nurses generated treatment recommendations and helped implement therapy if patients and providers accepted the recommendations. We assessed patients' acceptance of recommendations, reasons for refusal, and provider willingness to implement antidepressant therapy. We analyzed data at the level of the monthly assessment.

RESULTS

Of 101 patients followed for ≤12 months, 39 met criteria for depression (Patient Health Questionnaire 9 score ≥10 on one or more assessments). These 39 patients had depression on 147 of 373 (39%) monthly assessments. At 103 of these 147 (70%) assessments, patients were receiving antidepressant therapy, and at 51 of 70 (70%) assessments, patients did not accept nurses' recommendations to intensify treatment. At 44 assessments, patients with depression were not receiving antidepressant therapy, and in 40 (91%) instances, they did not accept recommendations to start treatment. The primary reason that patients refused the recommendations was attribution of their depression to an acute event, chronic illness, or dialysis (57%). In 11 of 18 (61%) instances in which patients accepted the recommendation, renal providers were unwilling to provide treatment.

CONCLUSIONS

Patients on chronic hemodialysis with depression are frequently not interested in modifying or initiating antidepressant treatment, commonly attributing their depression to a recent acute event, chronic illness, or dialysis. Renal providers are often unwilling to modify or initiate antidepressant therapy. Future efforts to improve depression management will need to address these patient- and provider-level obstacles to providing such care.

Factors associated with the difficulty in hospital acceptance at the scene by emergency medical service personnel: a population-based study in Osaka City, Japan

OBJECTIVES

To investigate the association between the difficulty in hospital acceptance at the scene by emergency medical service (EMS) personnel and prehospital demographic factors and reasons for EMS calls.

DESIGN

A retrospective, observational study.

SETTING

Osaka City, Japan.

PARTICIPANTS

A total of 100 649 patients transported to medical institutions by EMS from January 2013 to December 2013.

PRIMARY OUTCOME MEASUREMENTS

The definition of difficulty in hospital acceptance at the scene was EMS personnel making ≥5 phone calls to medical institutions until a decision to transport was determined. Multivariable analysis was used to assess the relationship between difficulty in hospital acceptance and prehospital factors and reasons for EMS calls.

RESULTS

Multivariable analysis showed the elderly, foreigners, loss of consciousness, holiday/weekend, and night-time to be positively associated with difficulty in hospital acceptance at the scene. As reasons for EMS calls, gas poisoning (adjusted OR 3.281, 95% CI 1.201 to 8.965), trauma by assault (adjusted OR 2.662, 95% CI 2.390 to 2.966), self-induced drug abuse/gas poisoning (adjusted OR 4.527, 95% CI 3.921 to 5.228) and self-induced trauma (adjusted OR 1.708, 95% CI 1.369 to 2.130) were positively associated with the difficulty in hospital acceptance at the scene.

CONCLUSIONS

Ambulance records in Osaka City showed that certain prehospital factors such as night-time were positively associated with difficulty in hospital acceptance at the scene, and reasons for EMS calls, such as self-induced drug abuse/gas poisoning, were also positive predictors for difficulty in hospital acceptance at the scene.

Countering Vaccine Hesitancy

Immunizations have led to a significant decrease in rates of vaccine-preventable diseases and have made a significant impact on the health of children. However, some parents express concerns about vaccine safety and the necessity of vaccines. The concerns of parents range from hesitancy about some immunizations to refusal of all vaccines. This clinical report provides information about addressing parental concerns about vaccination.

Can pay for performance improve the quality of primary care?

Martin Roland and Frede Olesen explore what other countries can learn from the UK’s experience with the Quality and Outcomes Framework