Model Policy on “Non-beneficial Treatment”

[Click here to go to SDCMS' Bioethics Commission "Model Hospital Policy on Non-beneficial Treatment and Conflict Resolution."]

For most of us, facing the imminent death of a beloved family member can be the most heart-wrenching experience of our lives. Because most people still die in hospitals, they are usually receiving aggressive, life-sustaining treatments prior to death. Families have to grapple with decisions regarding withholding and withdrawing such support to allow their family member to die. These situations, unfortunately, often result in conflict between families and the healthcare team.

While no policy will ever make these decisions easy, they can certainly help guide clinicians through a difficult situation by establishing guidelines and standards of practice. There is ongoing debate within the bioethics field regarding who determines the point of futility and how that determination is reached, but the consensus of clinicians is that we must be able to set limitations of treatment based on our clinical experience and expertise. Expecting distraught family members to make such emotionally laden decisions, in my opinion, increases their burden of suffering as they are trying to come to terms with a major loss. My experience has been that some family members feel compelled to “demand everything” as a way of expressing their love and devotion to their family. In the majority of cases, they do in the end accept limitations set by a caring, communicative clinician.

Some physicians use the rationale of legal liability when they continue treatment they feel is no longer beneficial but that the family demands. Last year, we had one of our University of California lawyers review all of the cases filed against University of California Medical Centers, and she did not identify one successful lawsuit based on limitation of life-sustaining treatment based on futility determination. Thus, I am convinced that our fears are way out of proportion to reality and result in excessive, burdensome treatment.

The San Diego Bioethics Commission, chaired by Lynette Cederquist, MD, (USCD), and Paula Goodman-Crews, LCSW (Kaiser Permanente), was developed within the San Diego County Medical Society with a vision of bringing together San Diego’s medical community to develop standards in bioethics practices. So far, our commission has representation from UCSD, Kaiser Permanente, Sharp Grossmont, Sharp Coronado, the Veterans Health Administration, Rady Children’s Hospital, Sharp Grossmont, Sharp Memorial, Sharp Mission Park, Scripps Mercy, Edgemoor, Navy Medical Center, San Diego Hospice, Silverado Hospice, Scripps La Jolla, and Palomar Medical Center. The first issue the commission has tackled is “non-beneficial treatment,” also referred to as “medical futility.” This is an issue with which every hospital and every ethics committee wrestles on a regular basis.

In a recent review of UCSD’s ethics consultations, close to 50 percent of consults were requested because of conflicts surrounding perceptions of medical futility or medically ineffective treatment. This has been identified by all of the commission’s participants as a major source of conflict, especially intractable cases that are not remediated by ethics facilitation. The nearly universal consensus has been that when faced with cases where physicians have determined treatment is non-beneficial, but the patient or surrogate continues to insist on treatment, most physicians continue treatment. Physicians tend to default to continuation of treatment even if their institution’s policies support withdrawal of non-beneficial treatment. We believe that by developing a community standard to guide policy, each individual institution’s policies and practices will be better enforced.

Last year, after input from all the members of the commission, we adopted our first model policy: “Model Hospital Policy on Non-beneficial Treatment and Conflict Resolution.” This is a major step toward establishing a community standard. Bioethics Commission members will now be able to take this policy back to their individual institutions, with the added force of community consensus.