The Boundaries of Medical Practice in Recent Years

Medical and technological advances continuously expand the preconceived boundaries in medical practice. Fifteen or twenty years ago, we could not have predicted how these advanced developments would impact our understanding in treating complex medical conditions, including those associated with cancer and advanced age. Hence, what once seemed beyond the limits of practice, even to the most skilled and technologically advanced practitioners, is now considered routine. However, despite new technology and the endless advances in medicine, there are still limitations on the human life. We do not live forever and eventually reach a point of decline in which attempts for treatment or finding a cure seem futile. The determination of futile care is a complex and sensitive ethical issue. This determination becomes even more complex when a patient cannot make a medically informed decision for themselves, when there is an absence of a living will, or when families and providers disagree about benefits from treatment… as is seen in the following case regarding Mrs. Selina Kyle.

Mrs. Selina Kyle is an 84-year-old woman who has advanced Alzheimer’s disease, is non-verbal, and has been bed-bound for several months in the nursing home in which she resides. She was diagnosed with lung cancer two years ago but did not respond to aggressive treatment, so the cancer has now metastasized. Recently, she developed pneumonia and was hospitalized but her status continued to deteriorate. Physicians realized that she needed intubation and mechanical ventilation to survive; however, given her incurable lung cancer, it was unlikely that Mrs. Kyle would ever be extubated. She has no advanced directives regarding life support, her husband is deceased, and the only family contact made was to her daughter that has never visited her in the hospital. This daughter has requested full treatment and the provider is frustrated, believing that further aggressive treatment is futile due to her decline from the cancer and the high probability that she will become ventilator dependent.

This is a common scenario in medical practice, where a provider must determine competency and help families decide when to stop aggressive treatment in favor of comfort care. The first ethical issue that must be addressed is respect for patient autonomy and informed consent. The main determinant of this principle is cognition, and any condition or treatment that affects cognition may potentially impair decision-making capacity.1 In the case of Mrs. Kyle, she has advanced Alzheimer’s disease which significantly affects her cognitive state, and she is subsequently nonverbal; therefore, due to this lack of capacity, she would be considered unable to make an informed decision. According to the 2018 Florida Statutes,2 “if an incapacitated or developmentally disabled patient has not executed an advance directive… health care decisions may be made for the patient by…an adult child of the patient, or if the patient has more than one adult child, a majority of the adult children who are reasonably available for consultation”. Thus, her health care proxy would be her daughter who has requested full treatment of her mother despite her mother’s declining state and the given medical advice.

First, and foremost, a consultation needs to be arranged with the daughter to determine her understanding of her mother’s prognosis and to provide enough information for an informed decision to be made on whether to continue life saving measures or transition to comfort care. The best effort should be made to arrange a consultation involving all immediate family. Secondly, we need to address the definition of futile care. Unfortunately, there is no uniform definition on futile medical care. “The American Medical Association (AMA) guidelines describe medically futile treatments as those having no reasonable chance of benefiting [the] patient … and The American Thoracic Society says a treatment is medically futile when it is highly unlikely to result in meaningful survival”.3 Any type of treatment will produce some type of effect on a patient, but what is important to consider is whether it coincides with the goals of treatment which follow the professional standards of care and benefit the patient. Futility is a patient-centered concept; therefore, the definition of futile intervention will evolve as the patient’s medical condition and goals change.4 During consultation with the family, the prognosis of the patient needs to be discussed, treatment goals that are in the best interest of the patient need to be determined, and all medically acceptable treatment options need to be reviewed so an informed decision is made.

Families tend to remain optimistic regarding a loved one’s health, even in the worst circumstances. This might lead to disagreements between the provider and the family.

If Mrs. Kyle’s daughter still wishes to continue with intubation and ventilation, the provider should be empathetic and allow her time to process all the given information but remain firm with the medical advice. In the case of Mrs. Kyle, her prognosis from her lung cancer is poor and she will continue decline regardless of interventions. If her heart stops, CPR might break her ribs and inflict more pain. With these thoughts in mind, even though families like to remain hopeful, they also do not want to see their loved ones suffer unnecessary and prolonged pain.3 After giving her time to reflect and providing guidance and reassurance, if she still wishes to continue with aggressive treatment then other providers and an ethics committee should be consulted. Ultimately, a transfer of care to another provider or facility may be necessary since providers should not be forced to practice medicine that conflicts with their morals or ethics.4

Medical futility will continue to be a source of debate, especially since there is no exact definition or criteria that can be created for the generalized population. Opponents of using medical futility are concerned that it gives unilateral decision-making power to medical providers. This is understandable if proper communication is not established, such as when providers speak in medical jargon to families without medical knowledge. Families need to understand how particular medical interventions will potentially help or hinder the medical goals of treatment and be reassured that their loved one will not be abandoned.3 Some opponents also argue that futility is a way to ration resources and reduce the costs for terminal care. Proponents reject this and argue that futility is determined as a professional consensus and is based on the best interest of the patient.4 This simply should not be a factor considering that health care providers make an oath to facilitate moral standards of care to their patients and to uphold the standards of professional ethics. Furthermore, with consensus of the medical team involved and/or an ethics committee, decision are based on the comfort and well-being of each individualized patient.

Ultimately, the goal in medicine and as a physician assistant is helping the sick and incorporating medical and ethical values in all medical decision making. I do not believe that health care providers have an obligation to offer treatments that will not benefit patients. This includes providing futile interventions that may cause further pain or inflict harm on the patient, giving false hope, and delaying palliative and comfort care. I will base my care on professional standards and ethics, scientific empirical research, and clinical knowledge and experience when making medical futility judgments. Moreover, I will be empathetic and sensitive when patients and families are faced with dilemmas of withholding or withdrawing futile interventions. I believe that if a provider’s medical decisions are guided by the ethical principles of beneficence, non-maleficence, and justice then ethically and morally viable decisions will be made regarding futile care. 

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