Weighing Appropriate End-of-Life Care in the ED

LAS VEGAS – Emergency physicians should weigh the benefits and harms of life-sustaining medical treatments that are likely to be ineffective or simply prolong the dying process, especially when patients have comorbidities such as dementia, according to an expert panel.

The panel took up the divisive issue of providing “medically futile” care to patients in emergency departments at the annual meeting of the American College of Emergency Physicians.

Panel moderator Dr. Gregory L. Henry, a past president of ACEP and adjunct clinical professor of emergency medicine at the University of Michigan, Ann Arbor, offered an economic perspective, pointing to the escalating cost of health care against the backdrop of staggering national debt.

He noted that patients have a steadfast belief in autonomy and self-determination when seeking care, but the matter of how to pay for this care is unresolved.

“Spending other people’s money is always easy, but spending the money that indentures the yet-unborn is cowardly and immoral, and that’s exactly what we are doing,” Dr. Henry commented.

The default in emergency departments is often to stabilize patients with poor prognoses and let their fate play out in the intensive care unit, he said. But emergency physicians should reflect on their role in starting this “cascade of expensive care rolling down the hill,” he said.

“Everybody in this room who is practicing must decide: Are you just following orders, or are you an independently thinking individual?” he challenged those in attendance. Furthermore, emergency physicians must ask themselves whether they serve only individual patients or larger society.

“It takes no intelligence or courage to stick in a tube, intubate, start IVs, give pressors, raise blood pressure on a 90-year-old who is demented,” Dr. Henry commented. “It takes some courage to take one step back and say, ‘What’s the point?’?”

Although discussion of medical futility by emergency physicians is imperative, he advocated taking up the issue with other specialties, and contended that resolution will require input of society as a whole. Finally, “as this discussion goes forward, I want to see the politician brave enough to lead it.”

Panelist Dr. Daniel J. Sullivan, president of Sullivan Group Risk Management Consulting and assistant professor in the emergency medicine department at Cook County–Rush Medical College in Chicago, noted that courts have established a personal negative right to care, whereby patients can refuse life-sustaining treatment, but they have declined to rule on a potential positive right to care, whereby patients can demand care even when their physicians believe it is futile. In the latter case, the courts have deferred to patient autonomy and self-determination, and cited preemption by federal laws such as EMTALA (Emergency Medical Treatment and Active Labor Act) and the Americans with Disabilities Act.

All 50 states have passed futility statutes that provide immunity to physicians in such situations. But “most of them don’t work,” Dr. Sullivan observed, because they refer to care in terms such as “medically ineffective” and “medically inappropriate,” which themselves are debatable.

“Consider going toe to toe in the emergency department, where somebody says, ‘Do everything,’ and you know with every fiber of your being [that] it’s the wrong thing to do,” he said. “You are at risk. The courts haven’t gotten behind you; the legislature hasn’t gotten behind you.”

Before physicians will be able to withhold or withdraw care with confidence in such situations, certain events must occur, according to Dr. Sullivan. “We need a social mandate; we need society to move on this issue. We need clear-cut legislation, and that legislation probably has to be federal,” he said. Finally, “we need immunity – civil, criminal, disciplinary.”

For now, “you’ve got to back your patient off the conflict,” he recommended. “There are systems in place to bring people away from conflict and into agreement, and there we can all do the right thing.”

Panelist Dr. Jerome R. Hoffman, a professor of emergency medicine at the University of California, Los Angeles, contended that medically futile care is a societal issue and noted that it begs a larger question: “Do we as individuals have the right to demand unlimited resources from our society?”

He pointed to starkly different societal attitudes on and approaches to allocating shared health care resources between Europe and the United States.

“In Europe, they call this having choices – we are going to choose among different therapies; we are going to choose the one that makes sense because it’s rational, it gives us a bang for our buck, and we can afford it,” he commented. “In America, we don’t call it choices; we call it rationing.”

Drawing on his own life experiences, Dr. Hoffman offered his opinion that in the United States, “we sort of believe that we can control everything and that – why not – we should be immortal. ... We can fix everything,” he said. “Part of what goes along with that is the notion that if we didn’t fix it [and] the outcome was bad, the process must have been bad, and somebody’s got to be to blame.”

Dr. Hoffman agreed that resolving the controversy around medical futility will require discussion as a society.

“I honestly believe that law doesn’t drive society; society drives law,” he concluded. “If we want to fix this ... we have to get the society thinking about this; we have to get the society to decide that there’s a better way. And when we do, the laws will follow.”

Panelist Dr. Arthur R. Derse, director of the center for bioethics and medical humanities and a professor of bioethics and medical humanities and emergency medicine at the Medical College of Wisconsin, Milwaukee, advised emergency physicians to follow their professional judgment in cases of medical futility.

“Whether or not to offer or perform an emergency medical treatment or procedure in a given situation is actually a professional medical determination,” he asserted. “So even if the family says, ‘Do everything,’ it’s your implementation of medical judgment as to whether or not it is going to be done.”

Most litigated futility cases have pertained to persistent vegetative state, according to Dr. Derse. “The number of emergency physicians who have been found to be in violation of EMTALA by not providing medical treatment that they considered would not work is – well, we don’t have a number,” he said. “It’s certainly not a lot, because we don’t know about any,” although the risk cannot be entirely ruled out, he acknowledged.

Dr. Derse offered a set of recommendations for emergency physicians when it comes to approaching these difficult cases, which he abbreviated as the “5 C’s.”

Namely, he recommended carefully defining futility; being cognizant of codes, policies, and laws supporting futility determinations; exercising well-grounded clinical judgment; communicating with patients, families, and caregivers; and continuing to care for the patient.

“Even when withdrawing or withholding treatment that you think is ineffective, you still need to attend to the care of the patient,” he commented on the last point. “Obviously, we know that ‘do not resuscitate’ does not mean ‘do not care.’?”

Panelist Dr. Gregory L. Larkin, professor of emergency medicine and section chief for international emergency medicine and global health at Yale University in New Haven, Conn., noted that survey data show emergency physicians are conflicted when it comes to providing futile care. “The bottom line is that we docs provide this kind of care all the time, even though we don’t believe in it,” he said.

Aggressive end-of-life treatment may be not only ineffective, but also harmful to patients and families alike, Dr. Larkin reminded attendees. “We are called on to be a profession the public can trust to protect them from harms, and there are harms worse than death,” he commented, noting, for example, that some family members are traumatized by witnessing such treatment.

When it comes to resource use, “I think we have an affirmative duty to be stewards of the resources, even though it is a societal issue,” he commented. “We are often the best judge of what should be used and not used in the ED setting. Rationing is part of our job; we do it at the bedside. A lot of ethicists don’t like that; they think it’s wrong. But they have never worked in an ED.”

Stewardship is especially important for emergency physicians, as they are often the front door to the health care system, according to Dr. Larkin. Moreover, he cautioned, new legislative mandates are coming that could have dire consequences for the specialty.

“We will be, as emergency physicians, part of these shared accountability schemes, where repeat visits will not be paid for and the use of resources will be restricted,” he noted. “I guess if we don’t continue to try to steward resources, we are going to be closing more and more emergency departments.”

Dr. Larkin recommended a judicious approach to communication in cases of medical futility. “When you talk to patients and families, try to be more affirmative about what you will do, not what you will withhold,” he advised. “And don’t put [an intervention] on the menu if you don’t think it’s appropriate. ... Don’t even bring it up, is my humble but strong opinion.”

For example, physicians can focus on how aggressively they will manage the patient’s pain, anxiety, and other symptoms. “When you have a positive and affirmative, goal-oriented discussion with families, you give them back a sense of control,” he commented.

“We need to lead by example,” Dr. Larkin concluded, encouraging emergency physicians to have an advance directive in place for themselves. “I think for us to be credible leaders in this issue, we need to embrace that as well.”

LAS VEGAS – Emergency physicians should weigh the benefits and harms of life-sustaining medical treatments that are likely to be ineffective or simply prolong the dying process, especially when patients have comorbidities such as dementia, according to an expert panel.

The panel took up the divisive issue of providing “medically futile” care to patients in emergency departments at the annual meeting of the American College of Emergency Physicians.

Panel moderator Dr. Gregory L. Henry, a past president of ACEP and adjunct clinical professor of emergency medicine at the University of Michigan, Ann Arbor, offered an economic perspective, pointing to the escalating cost of health care against the backdrop of staggering national debt.

He noted that patients have a steadfast belief in autonomy and self-determination when seeking care, but the matter of how to pay for this care is unresolved.

“Spending other people’s money is always easy, but spending the money that indentures the yet-unborn is cowardly and immoral, and that’s exactly what we are doing,” Dr. Henry commented.

The default in emergency departments is often to stabilize patients with poor prognoses and let their fate play out in the intensive care unit, he said. But emergency physicians should reflect on their role in starting this “cascade of expensive care rolling down the hill,” he said.

“Everybody in this room who is practicing must decide: Are you just following orders, or are you an independently thinking individual?” he challenged those in attendance. Furthermore, emergency physicians must ask themselves whether they serve only individual patients or larger society.

“It takes no intelligence or courage to stick in a tube, intubate, start IVs, give pressors, raise blood pressure on a 90-year-old who is demented,” Dr. Henry commented. “It takes some courage to take one step back and say, ‘What’s the point?’?”

Although discussion of medical futility by emergency physicians is imperative, he advocated taking up the issue with other specialties, and contended that resolution will require input of society as a whole. Finally, “as this discussion goes forward, I want to see the politician brave enough to lead it.”

Panelist Dr. Daniel J. Sullivan, president of Sullivan Group Risk Management Consulting and assistant professor in the emergency medicine department at Cook County–Rush Medical College in Chicago, noted that courts have established a personal negative right to care, whereby patients can refuse life-sustaining treatment, but they have declined to rule on a potential positive right to care, whereby patients can demand care even when their physicians believe it is futile. In the latter case, the courts have deferred to patient autonomy and self-determination, and cited preemption by federal laws such as EMTALA (Emergency Medical Treatment and Active Labor Act) and the Americans with Disabilities Act.

All 50 states have passed futility statutes that provide immunity to physicians in such situations. But “most of them don’t work,” Dr. Sullivan observed, because they refer to care in terms such as “medically ineffective” and “medically inappropriate,” which themselves are debatable.

“Consider going toe to toe in the emergency department, where somebody says, ‘Do everything,’ and you know with every fiber of your being [that] it’s the wrong thing to do,” he said. “You are at risk. The courts haven’t gotten behind you; the legislature hasn’t gotten behind you.”

Before physicians will be able to withhold or withdraw care with confidence in such situations, certain events must occur, according to Dr. Sullivan. “We need a social mandate; we need society to move on this issue. We need clear-cut legislation, and that legislation probably has to be federal,” he said. Finally, “we need immunity – civil, criminal, disciplinary.”

For now, “you’ve got to back your patient off the conflict,” he recommended. “There are systems in place to bring people away from conflict and into agreement, and there we can all do the right thing.”

Panelist Dr. Jerome R. Hoffman, a professor of emergency medicine at the University of California, Los Angeles, contended that medically futile care is a societal issue and noted that it begs a larger question: “Do we as individuals have the right to demand unlimited resources from our society?”

He pointed to starkly different societal attitudes on and approaches to allocating shared health care resources between Europe and the United States.

“In Europe, they call this having choices – we are going to choose among different therapies; we are going to choose the one that makes sense because it’s rational, it gives us a bang for our buck, and we can afford it,” he commented. “In America, we don’t call it choices; we call it rationing.”

Drawing on his own life experiences, Dr. Hoffman offered his opinion that in the United States, “we sort of believe that we can control everything and that – why not – we should be immortal. ... We can fix everything,” he said. “Part of what goes along with that is the notion that if we didn’t fix it [and] the outcome was bad, the process must have been bad, and somebody’s got to be to blame.”

Dr. Hoffman agreed that resolving the controversy around medical futility will require discussion as a society.

“I honestly believe that law doesn’t drive society; society drives law,” he concluded. “If we want to fix this ... we have to get the society thinking about this; we have to get the society to decide that there’s a better way. And when we do, the laws will follow.”

Panelist Dr. Arthur R. Derse, director of the center for bioethics and medical humanities and a professor of bioethics and medical humanities and emergency medicine at the Medical College of Wisconsin, Milwaukee, advised emergency physicians to follow their professional judgment in cases of medical futility.

“Whether or not to offer or perform an emergency medical treatment or procedure in a given situation is actually a professional medical determination,” he asserted. “So even if the family says, ‘Do everything,’ it’s your implementation of medical judgment as to whether or not it is going to be done.”

Most litigated futility cases have pertained to persistent vegetative state, according to Dr. Derse. “The number of emergency physicians who have been found to be in violation of EMTALA by not providing medical treatment that they considered would not work is – well, we don’t have a number,” he said. “It’s certainly not a lot, because we don’t know about any,” although the risk cannot be entirely ruled out, he acknowledged.

Dr. Derse offered a set of recommendations for emergency physicians when it comes to approaching these difficult cases, which he abbreviated as the “5 C’s.”

Namely, he recommended carefully defining futility; being cognizant of codes, policies, and laws supporting futility determinations; exercising well-grounded clinical judgment; communicating with patients, families, and caregivers; and continuing to care for the patient.

“Even when withdrawing or withholding treatment that you think is ineffective, you still need to attend to the care of the patient,” he commented on the last point. “Obviously, we know that ‘do not resuscitate’ does not mean ‘do not care.’?”

Panelist Dr. Gregory L. Larkin, professor of emergency medicine and section chief for international emergency medicine and global health at Yale University in New Haven, Conn., noted that survey data show emergency physicians are conflicted when it comes to providing futile care. “The bottom line is that we docs provide this kind of care all the time, even though we don’t believe in it,” he said.

Aggressive end-of-life treatment may be not only ineffective, but also harmful to patients and families alike, Dr. Larkin reminded attendees. “We are called on to be a profession the public can trust to protect them from harms, and there are harms worse than death,” he commented, noting, for example, that some family members are traumatized by witnessing such treatment.

When it comes to resource use, “I think we have an affirmative duty to be stewards of the resources, even though it is a societal issue,” he commented. “We are often the best judge of what should be used and not used in the ED setting. Rationing is part of our job; we do it at the bedside. A lot of ethicists don’t like that; they think it’s wrong. But they have never worked in an ED.”

Stewardship is especially important for emergency physicians, as they are often the front door to the health care system, according to Dr. Larkin. Moreover, he cautioned, new legislative mandates are coming that could have dire consequences for the specialty.

“We will be, as emergency physicians, part of these shared accountability schemes, where repeat visits will not be paid for and the use of resources will be restricted,” he noted. “I guess if we don’t continue to try to steward resources, we are going to be closing more and more emergency departments.”

Dr. Larkin recommended a judicious approach to communication in cases of medical futility. “When you talk to patients and families, try to be more affirmative about what you will do, not what you will withhold,” he advised. “And don’t put [an intervention] on the menu if you don’t think it’s appropriate. ... Don’t even bring it up, is my humble but strong opinion.”

For example, physicians can focus on how aggressively they will manage the patient’s pain, anxiety, and other symptoms. “When you have a positive and affirmative, goal-oriented discussion with families, you give them back a sense of control,” he commented.

“We need to lead by example,” Dr. Larkin concluded, encouraging emergency physicians to have an advance directive in place for themselves. “I think for us to be credible leaders in this issue, we need to embrace that as well.”

LAS VEGAS – Emergency physicians should weigh the benefits and harms of life-sustaining medical treatments that are likely to be ineffective or simply prolong the dying process, especially when patients have comorbidities such as dementia, according to an expert panel.

The panel took up the divisive issue of providing “medically futile” care to patients in emergency departments at the annual meeting of the American College of Emergency Physicians.

Panel moderator Dr. Gregory L. Henry, a past president of ACEP and adjunct clinical professor of emergency medicine at the University of Michigan, Ann Arbor, offered an economic perspective, pointing to the escalating cost of health care against the backdrop of staggering national debt.

He noted that patients have a steadfast belief in autonomy and self-determination when seeking care, but the matter of how to pay for this care is unresolved.

“Spending other people’s money is always easy, but spending the money that indentures the yet-unborn is cowardly and immoral, and that’s exactly what we are doing,” Dr. Henry commented.

The default in emergency departments is often to stabilize patients with poor prognoses and let their fate play out in the intensive care unit, he said. But emergency physicians should reflect on their role in starting this “cascade of expensive care rolling down the hill,” he said.

“Everybody in this room who is practicing must decide: Are you just following orders, or are you an independently thinking individual?” he challenged those in attendance. Furthermore, emergency physicians must ask themselves whether they serve only individual patients or larger society.

“It takes no intelligence or courage to stick in a tube, intubate, start IVs, give pressors, raise blood pressure on a 90-year-old who is demented,” Dr. Henry commented. “It takes some courage to take one step back and say, ‘What’s the point?’?”

Although discussion of medical futility by emergency physicians is imperative, he advocated taking up the issue with other specialties, and contended that resolution will require input of society as a whole. Finally, “as this discussion goes forward, I want to see the politician brave enough to lead it.”

Panelist Dr. Daniel J. Sullivan, president of Sullivan Group Risk Management Consulting and assistant professor in the emergency medicine department at Cook County–Rush Medical College in Chicago, noted that courts have established a personal negative right to care, whereby patients can refuse life-sustaining treatment, but they have declined to rule on a potential positive right to care, whereby patients can demand care even when their physicians believe it is futile. In the latter case, the courts have deferred to patient autonomy and self-determination, and cited preemption by federal laws such as EMTALA (Emergency Medical Treatment and Active Labor Act) and the Americans with Disabilities Act.

All 50 states have passed futility statutes that provide immunity to physicians in such situations. But “most of them don’t work,” Dr. Sullivan observed, because they refer to care in terms such as “medically ineffective” and “medically inappropriate,” which themselves are debatable.

“Consider going toe to toe in the emergency department, where somebody says, ‘Do everything,’ and you know with every fiber of your being [that] it’s the wrong thing to do,” he said. “You are at risk. The courts haven’t gotten behind you; the legislature hasn’t gotten behind you.”

Before physicians will be able to withhold or withdraw care with confidence in such situations, certain events must occur, according to Dr. Sullivan. “We need a social mandate; we need society to move on this issue. We need clear-cut legislation, and that legislation probably has to be federal,” he said. Finally, “we need immunity – civil, criminal, disciplinary.”

For now, “you’ve got to back your patient off the conflict,” he recommended. “There are systems in place to bring people away from conflict and into agreement, and there we can all do the right thing.”

Panelist Dr. Jerome R. Hoffman, a professor of emergency medicine at the University of California, Los Angeles, contended that medically futile care is a societal issue and noted that it begs a larger question: “Do we as individuals have the right to demand unlimited resources from our society?”

He pointed to starkly different societal attitudes on and approaches to allocating shared health care resources between Europe and the United States.

“In Europe, they call this having choices – we are going to choose among different therapies; we are going to choose the one that makes sense because it’s rational, it gives us a bang for our buck, and we can afford it,” he commented. “In America, we don’t call it choices; we call it rationing.”

Drawing on his own life experiences, Dr. Hoffman offered his opinion that in the United States, “we sort of believe that we can control everything and that – why not – we should be immortal. ... We can fix everything,” he said. “Part of what goes along with that is the notion that if we didn’t fix it [and] the outcome was bad, the process must have been bad, and somebody’s got to be to blame.”

Dr. Hoffman agreed that resolving the controversy around medical futility will require discussion as a society.

“I honestly believe that law doesn’t drive society; society drives law,” he concluded. “If we want to fix this ... we have to get the society thinking about this; we have to get the society to decide that there’s a better way. And when we do, the laws will follow.”

Panelist Dr. Arthur R. Derse, director of the center for bioethics and medical humanities and a professor of bioethics and medical humanities and emergency medicine at the Medical College of Wisconsin, Milwaukee, advised emergency physicians to follow their professional judgment in cases of medical futility.

“Whether or not to offer or perform an emergency medical treatment or procedure in a given situation is actually a professional medical determination,” he asserted. “So even if the family says, ‘Do everything,’ it’s your implementation of medical judgment as to whether or not it is going to be done.”

Most litigated futility cases have pertained to persistent vegetative state, according to Dr. Derse. “The number of emergency physicians who have been found to be in violation of EMTALA by not providing medical treatment that they considered would not work is – well, we don’t have a number,” he said. “It’s certainly not a lot, because we don’t know about any,” although the risk cannot be entirely ruled out, he acknowledged.

Dr. Derse offered a set of recommendations for emergency physicians when it comes to approaching these difficult cases, which he abbreviated as the “5 C’s.”

Namely, he recommended carefully defining futility; being cognizant of codes, policies, and laws supporting futility determinations; exercising well-grounded clinical judgment; communicating with patients, families, and caregivers; and continuing to care for the patient.

“Even when withdrawing or withholding treatment that you think is ineffective, you still need to attend to the care of the patient,” he commented on the last point. “Obviously, we know that ‘do not resuscitate’ does not mean ‘do not care.’?”

Panelist Dr. Gregory L. Larkin, professor of emergency medicine and section chief for international emergency medicine and global health at Yale University in New Haven, Conn., noted that survey data show emergency physicians are conflicted when it comes to providing futile care. “The bottom line is that we docs provide this kind of care all the time, even though we don’t believe in it,” he said.

Aggressive end-of-life treatment may be not only ineffective, but also harmful to patients and families alike, Dr. Larkin reminded attendees. “We are called on to be a profession the public can trust to protect them from harms, and there are harms worse than death,” he commented, noting, for example, that some family members are traumatized by witnessing such treatment.

When it comes to resource use, “I think we have an affirmative duty to be stewards of the resources, even though it is a societal issue,” he commented. “We are often the best judge of what should be used and not used in the ED setting. Rationing is part of our job; we do it at the bedside. A lot of ethicists don’t like that; they think it’s wrong. But they have never worked in an ED.”

Stewardship is especially important for emergency physicians, as they are often the front door to the health care system, according to Dr. Larkin. Moreover, he cautioned, new legislative mandates are coming that could have dire consequences for the specialty.

“We will be, as emergency physicians, part of these shared accountability schemes, where repeat visits will not be paid for and the use of resources will be restricted,” he noted. “I guess if we don’t continue to try to steward resources, we are going to be closing more and more emergency departments.”

Dr. Larkin recommended a judicious approach to communication in cases of medical futility. “When you talk to patients and families, try to be more affirmative about what you will do, not what you will withhold,” he advised. “And don’t put [an intervention] on the menu if you don’t think it’s appropriate. ... Don’t even bring it up, is my humble but strong opinion.”

For example, physicians can focus on how aggressively they will manage the patient’s pain, anxiety, and other symptoms. “When you have a positive and affirmative, goal-oriented discussion with families, you give them back a sense of control,” he commented.

“We need to lead by example,” Dr. Larkin concluded, encouraging emergency physicians to have an advance directive in place for themselves. “I think for us to be credible leaders in this issue, we need to embrace that as well.”