Tuesday, May 29, 2012

End-of-Life Algorithm: A Silly Idea?

I tweeted about a blog post the other day titled “Algorithm for End-of-Life Decision-Making.” The post was from Thaddeus Pope, an authoritative voice on the law and medicine, especially as relates to cases of medical futility, or when the care team and patient/family devolve into intractable dispute over the efficacy of treatment. 
Awhile later came a response from a self-described “conservative physician” practicing in a “very blue state.”
“An algorithm?” the physician tweeted. “Silly!”
The doctor is probably right. The idea that complex decisions for the dying might fit a single set of rules, a neat calculation, no doubt is silly. But then the physician “explained” his own process for assessing treatment options: “I seek out the best algorithm I can find in hopes it will tell me what to do.” At which point I diagnosed him as superior, sarcastic, and smugly devaluing of even the attempt to give decision-making at the end of life some cohesive, comprehensible shape. 
Perhaps the doctor’s cynicism is built on years of experience, but I’m guessing he doesn’t run a big city emergency room, attend to many patients sustained mechanically in an ICU, or give much weight to the writing of Atul Gawande.
Gratefully, I found a welcome antidote to that exchange at kevinmd.com, where Dr. Marya Zilberberg argues for models synthesizing “everything that we know about a specific course of action” to produce “a number driven by probability.” 

“The absurd complexity of information in medicine deserves no less,” Dr. Zilberberg writes. “It’s time to start the probability revolution.”

Late last year, the American Journal of Bioethics published “Should the ‘slow code’ be resuscitated?" That is, are there end-of-life cases in which resuscitation efforts might be justifiably half-hearted?
The authors’ summary reads: “Most bioethicists and professional medical societies condemn the practice of slow codes. The American College of Physicians ethics manual states, Because it is deceptive, physicians or nurses should not perform half-hearted resuscitation efforts (slow codes). A leading textbook calls slow codes dishonest, crass dissimulation, and unethical. A medical sociologist describes them as deplorable, dishonest and inconsistent with established ethical principles. Nevertheless, we believe that slow codes may be appropriate and ethically defensible in situations in which cardiopulmonary resuscitation (CPR) is likely to be ineffective, the family decision makers understand and accept that death is inevitable, and those family members cannot bring themselves to consent or even assent to a do-not-resuscitate (DNR) order. In such cases, we argue, physicians may best serve both the patient and the family by having a carefully ambiguous discussion about end-of-life options and then providing resuscitation efforts that are less vigorous or prolonged than usual.”
One of the authors is interviewed here
Some pros & cons are considered here 

It ought to surprise no one that the dispute resolution process within the Texas Advance Directives Act is controversial -- it quite literally is a matter of life and death, and carries the potential of taking decision-making power away from a patient or surrogate while bypassing the constitutional guarantee of due process.
How often does this happen? The Texas Hospital Association is attempting to find out by surveying hospital ethics committees within the state to determine how often TADA’s dispute resolution is used. 

TADA is unusual in the way it empowers hospitals and physicians to resolve disputes; no other state in the country goes so far. But the province of Ontario also has established a process for dispute resolution known as the Consent and Capacity Board, which unlike TADA actually takes the decision outside the hospital. 
While TADA is being surveyed, the CCB will be headed to court.
The Canadian Supreme Court has agreed to hear the dispute between the family of patient Hassan Rasouli and his physicians. (Court papers here.) It is rare that a dispute in end-of-life care reaches such an authoritative and decisive level. 


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