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Physicians Update

 
Winter 2013

When Is the Right Time?

Neil Wenger, MD, director of the UCLA Health Ethics CenterAdvances in technology have made it possible to save lives, but they also have forced providers to wrestle with difficult ethical questions, particularly when a treatment has a low likelihood of success but a substantial chance for leaving patients with an unacceptable quality of life.

Neil Wenger, MD, director of the UCLA Health Ethics Center, emphasizes the importance of realistically outlining the possible scenarios to patients and their families ahead of time and assisting them in reaching decisions that are consistent with the patient's goals.

What have been the implications of life-saving advanced technologies on the physician's role in working with patients and families to make the best decisions about care?
All of these wonderful advances dramatically increase the physician's responsibility to ensure that patients and those making decisions for them are fully informed about the pros and cons of using that technology. To make informed decisions on whether to receive these treatments, patients and their families should understand not only what benefits might come, but also the future outcomes if they don't benefit in the way that's anticipated.

There might be a small to moderate chance for a particularly ill patient that by using a machine like a ventricular-assist device, we might be able to rescue the patient until an organ is available for transplant. Under those circumstances, one is shooting for an uncertain or perhaps even improbable benefit, with a high likelihood that the "miracle" won't happen and decisions will need to be made about future treatments. Frequently, those decisions need to be made when the patients can't talk to us. Therefore, the use of advanced technology necessitates an in-depth and detailed discussion with the patient or the people making decisions for the patient about the purpose of the technology, what will happen if the technology doesn't achieve the intended goal, and how the patient would feel about that.

Neil Wenger, MD discusses health ethicsWhat might be a situation that calls for a discussion of what happens if a technology doesn't achieve its intended goal?
Staying with the example of the patient with a left-ventricular-assist device, one uncommon and very unfortunate outcome is a severe stroke resulting from clots forming in the device. When that occurs, heart transplant is no longer an option. So it must be clear to the patient and the patient's family that this life-sustaining device won't be used to maintain a life that can't be rescued as was intended.

Unlike most treatments, with advanced technology there are some heroic rescue situations in which it may be more likely that the patient will die or that you'll put a patient into an adverse health state than actually achieve the intended benefit. And that has enormous implications for the level of responsibility for high-quality conversations between the treating team and the patient, or those who speak for the patient.


How should physicians approach these conversations?
Any physician employing such advanced technology has to understand all of the possible adverse outcomes and be able to explain them in a clear, understandable and compassionate way to patients. It's important to identify the spectrum of potentially indicated treatments, conveying the likelihood that the treatment is going to be successful and what success would mean as well as the potential adverse outcomes, and discuss the patient's preferences and goals. It's also important to be realistic with families about the chances of success. Too often, patients are kept on lifesustaining treatments because families hold out hope that something might work when in reality the chances are extremely slim.

These are difficult conversations. When you're trying to rescue someone to achieve a heart transplant, the last thing that person wants to focus on is what life will be like after a massive stroke. Yet, if those conversations don't occur, you may end up in a circumstance that virtually no patient would want to remain sustained in, without having had a clear conversation about it beforehand.

Patient, families and physicians communication is important when dealing with difficult health decisionsWhat happens when the physician strongly disagrees with the preferences of patients and families with regard to the use of advanced technology or considers it to be inappropriate?
That can be difficult. There is a responsibility in certain circumstances to consider invalid a request that a treatment be continued that can't reach the intended aim. When patients feel sick and request antibiotics but the physician has a very high suspicion that this is not a bacterial process, we've come to the point where physicians will put up a fight. It's tougher when life hangs in the balance, but more important. The question of what the role of individual physicians should be in stewarding the nation's healthcare resources is complex, and to some extent these decisions need to be made on a societal level. But it is clearly the physician's responsibility not to use an advanced technology if it can't achieve the goal it was designed for.

How about when the patient can't speak for himself or herself and the physician feels that the family's wishes aren't in the patient's best interest, or there is disagreement among family members?
That happens a lot and is one reason having this conversation when the patient is able to talk is so critical. It can be problematic if some of the family views appear not to be reflecting the patient's values. It's incumbent upon the clinical team to sift through these differences and focus on what the patient would have wanted. Under circumstances where we know what patients would want, even if a family is voicing a different view, we will fight very hard to respect the patient's desires.





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