Chest
Volume 119, Issue 6, June 2001, Pages 1944-1947
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Ethics in Cardiopulmonary Medicine
Motivating Factors in Futile Clinical Interventions

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With modern medical technology, it is now possible to sustain life for prolonged periods in critically ill patients, even when there is no reasonable hope of improvement or achieving the goals of therapy. Such futile and medically inappropriate interventions may violate both the ethical and medical precepts generally accepted by patients, families, and physicians. In this study, we sought to determine who was primarily responsible for such interventions, the nature of their motivation, and the role of a timely bioethical consultation. In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 ± 32 years (mean ± 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (χ2 5 degrees of freedom = 26.7, p < 0.001). When the bioethics consultation resulted in cessation of the therapy, patients died in a median of 2 days as opposed to 16 days if therapy continued (p < 0.001).

Section snippets

Materials and Methods

In 1995, a formal Bioethics Program was instituted at Cedars-Sinai Medical Center. One of its principal functions has been to encourage, organize, and document bioethical consultations. The patient, the patient's family, or any member of the health-care team may request such consultations. The consultation is performed by a specially trained and specially privileged team consisting of a physician, a nurse, and a social worker. Meetings are held with families and health-care providers in an

Clinical Features

The average age of the patients was 73.5 ± 32 years (mean ± 2 SD). Fifty-seven percent of the patients were female, and the remaining 43% were male. The religious makeup was as follows: Jewish, 43%; Catholic, 15%; no religion, 15%; unknown, 12%; other, 8%; and Protestant, 7%. Fifty-seven percent of the patients were admitted with a degenerative disease process, 21% with an inflammatory process, 16% with a neoplastic disorder, and the remaining 6% were admitted secondary to a traumatic event or

Discussion

Our study is unique in evaluating futile and medically inappropriate care on a practical rather than a theoretical basis. We sought to minimize the ambiguity in the definition of futile or medically inappropriate care by selecting patients who died during the hospital stay without a period of marked improvement. This care is most often given to elderly patients with degenerative disease processes. This is not surprising given that these are the patients most likely to have disorders where the

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