Use of a DNR order over family objections: the case of Gilgunn v. MGH

Reason-Giving and Medical Futility: Contrasting Legal and Social Discourse in the United States With the United Kingdom and Ontario, Canada

Disputes regarding life-prolonging treatments are stressful for all parties involved. These disagreements are appropriately almost always resolved with intensive communication and negotiation. Those rare cases that are not require a resolution process that ensures fairness and due process. We describe three recent cases from different countries (the United States, United Kingdom, and Ontario, Canada) to qualitatively contrast the legal responses to intractable, policy-level disputes regarding end-of-life care in each of these countries. In so doing, we define the continuum of clinical and social utility among different types of dispute resolution processes and emphasize the importance of public reason-giving in the societal discussion regarding policy-level solutions to end-of-life treatment disputes. We argue that precedential, publicly available, written rulings for these decisions most effectively help to move the social debate forward in a way that is beneficial to clinicians, patients, and citizens. This analysis highlights the lack of such rulings within the United States.

Management of the hopelessly ill patient: to stop or not to start?

The paper discusses the subject of futile treatment in the case of a hopelessly ill patient. The topic has many facets, among them the ethical precepts of preventing futile treatment, but also the economic and logistic impact of treating patients who do not have a fair chance of benefitting from managing their medical condition. A 75-year old patient, suffering from an advanced stage of Alzheimer's disease and a clinical picture of acute surgical abdomen, is presented and two approaches are discussed. The first scenario is the aggressive management, including immediate laparotomy and admission to an intensive care unit, a solution without a fair chance of saving the patient's life. The most favorable, but theoretical, output in this case would be the patient's return to his previous mental condition, without any connection with the reality and surroundings and in permanent need for help, supervision and assistance. The second option is letting the patient die in dignity, alleviating pain and surrounded by family. The role of the primary care physician and family is discussed and some ethical principles are presented in order to emphasize the importance of preventing futile treatment in a case of a terminally ill patient.

Futility and the care of surgical patients: ethical dilemmas

Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is "qualitative futility" which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician-patient communication, these authors have advocated for methods of improving communication and strengthening the patient-physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision.

End-of-life decision-making in the United States

Decision-making at the end-of-life in the United States has evolved over the last 50 yr, beginning with the development of the concept of brain death as a criterion for permitting patients who are in a state of 'irreversible coma' to be considered as 'dead' for purposes of ventilator withdrawal and organ transplantation. Since then, a firm consensus has emerged in American law and ethics that 'Patients have a virtually unlimited right to refuse any unwanted medical treatment, even if necessary for life itself.' With regard to patients who are unable to make decisions for themselves, both Europe and the United States are converging toward a view that respects a role for surrogates in decision-making while recognizing the need to limit their authority. Beyond decisions to withdraw and withhold treatments, both the United States and Europe are experimenting with active hastening of the dying process through euthanasia and physician-assisted suicide. In the author's opinion, the next big question to be addressed in end-of-life decision-making is 'Just how bad does the neurological condition and prognosis need to be before it is acceptable to allow a decision to withdraw life support'? Although the practices described here have wide acceptance throughout the United States and Europe, the worldwide emergence of religious fundamentalism and the associated vitalistic view about the sanctity of life may result in significant changes over the next few decades.

An ethical analysis of cardiopulmonary resuscitation for elders in acute care

Despite empirical evidence that cardiopulmonary resuscitation (CPR) is of questionable effectiveness in elders with comorbidities, it continues to hold a unique place in the armamentarium of life-sustaining treatments in that consent for CPR is implied and, when needed, is administered emergently. These conditions of implied consent and emergency implementation often preclude an opportunity for patients/surrogates, in conjunction with their nurses and physicians, to determine the appropriateness of the intervention, given the patient's medical and functional status. Healthcare providers who perform CPR on elderly patients often find themselves in morally distressing circumstances because of their anecdotal knowledge of poor outcomes and realization that a multitude of barriers has precluded an anticipatory discussion regarding appropriateness of the treatment. Nurses and other healthcare providers must take the lead in helping patients/surrogates appreciate the meaning of CPR as a life-sustaining intervention and ensure that each patient's situation receives the ethical reflection deserved for each individual as a matter of human dignity.