Academic journal article The Hastings Center Report

Physicians Should Not Always Pursue a Good 'Clinical' Outcome

Academic journal article The Hastings Center Report

Physicians Should Not Always Pursue a Good 'Clinical' Outcome

Article excerpt

Increasingly, hospitals are using so-called futility policies to address medical goals that are centered not just on the prospect of mending the organs, but on whether the outcome will actually benefit the patient. The University of California, San Diego Medical Center, for example, defines a treatment as futile when it "has no realistic chance of providing a benefit that the patient would ever have the capacity to perceive and appreciate, such as merely preserving the physiologic functions of a permanently unconscious patient, or has no realistic chance of achieving the medical goal of returning the patient to a level of health that permits survival outside the acute care setting."

The policy goes on to assert that the physician's obligation is to provide optimal comfort care, namely "care whose intent is to relieve suffering and provide for the patient's comfort and dignity. It may include analgesics, narcotics, tranquilizers, local nursing measures, and other treatments including psychological and spiritual counseling. ... [A]lthough a particular treatment may be futile, palliative or comfort care is never futile."

Beginning about fifteen years ago, the topic of medical futility became a matter of stormy contention in medicine. Some critics even argued that the term "medical futility" should be abandoned altogether. But as one critic acknowledged: "The commonsense notion that a time does come for all of us when death or disability exceeds our medical powers cannot be denied. This means that some operative way of making a decision when 'enough is enough' is necessary. . . . [S]ome determination of futility by any other name will become a reality." (1)

Physicians are trained to achieve good clinical outcomes. Unfortunately, many physicians interpret that to mean good physiologic outcomes in the organ system of their specialty. The cardiologist wants to help the patient maintain a strong cardiac output, a nephrologist wants to make sure the patient's kidney function is adequate, and the pulmonologist concentrates on lung capacity and viability.

Patients reasonably assume they, too, have a vested interest in promoting good clinical outcomes. Usually, good clinical and patient outcomes are completely aligned. …

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