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Case

Mr. Bruno is a 96-year-old man with advanced dementia complicated by recurrent pneumonia and a large Stage IV sacral decubitus ulcer admitted to the hospital with worsening agitation in the setting of MRSA bacteremia. At baseline he is nonverbal, bedbound, and incontinent. Mr. Bruno has had four hospitalizations in the past six months for urinary tract infections, wound infections and aspiration pneumonia.

During this hospitalization, he is found to be aspirating solids and liquids and a nasogastric tube is placed for administration of artificial nutrition. He later self-dislodges his nasogastric tube multiple times despite restraints and sedating medications. On the fourth attempt to re-insert the nasogastric tube, the patient experiences significant nasal trauma, and the team decides not to pursue further attempts. The medical team places Mr. Bruno on a dextrose drip for hypoglycemia. They worry that allowing him to eat will result in aspiration and because the patient is a full code, he would require intubation for respiratory distress.

Mr. Bruno does not have an advance directive and his daughter is his surrogate decision maker. His daughter shares that Mr. Bruno never discussed preferences for end-of-life medical care but would want “to live”. A family meeting is held and hospice is recommended, but his daughter requests that a percutaneous gastrostomy (PEG) tube be placed for long-term artificial nutrition. Additionally, his daughter requests all life sustaining measures be pursued including CPR and intubation in the event he further decompensates.

Questions

1. How do physicians determine whether a treatment is medically ineffective?
2. How should clinicians respond to requests for medically ineffective treatment?
3. What are the ethical and legal challenges in cases of medically ineffective treatment?
4. What strategies can be used to effectively navigate requests for medically ineffective treatment?

Learning Goals and Objectives

• Define medically ineffective treatment.
• Explore factors driving the delivery of medically ineffective treatment.
• Analyze potential harms associated with the provision of medically ineffective treatment.
• Review legal aspects of medically ineffective treatment in the context of the Maryland Healthcare Decisions Act.
• Propose practical approaches to reducing medically ineffective treatment at end-of-life.

References

American Geriatrics Society Ethics Committee and Clinical Practice and Models of Care Committee. American Geriatrics Society feeding tubes in advanced dementia position statement. (2014) J Am Geriatr Soc, 62(8):1590-3. doi: 10.1111/jgs.12924. Epub 2014 Jul 17. PMID: 25039796.

Bosslet, G. T. et al. (2015). An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. American Journal of Respiratory and Critical Care Medicine, 191(11), 1318-1330. doi:10.1164/rccm.201505-0924st

Davies N, et al. (2021). Enteral tube feeding for people with severe dementia. Cochrane Database Syst Rev.  Aug 13;8(8):CD013503. doi: 10.1002/14651858.CD013503.pub2. PMID: 34387363; PMCID: PMC8407048.

Maryland Attorney General – Health Care Decisions Act.

Neville, et al.  (2020). The community perspective on potentially inappropriate treatment. Annals of the American Thoracic Society, 17(7), 854-859. doi:10.1513/AnnalsATS.201912-890OC

Pope, T. M. (2011). Legal briefing: Futile or non-beneficial treatment. The Journal of Clinical Ethics, 22(3), 277. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2216799

Willmott, L. et al.  (2016). Reasons doctors provide futile treatment at the end of life: A qualitative study. Journal of Medical Ethics, 42(8), 496-503. doi:10.1136/medethics-2016-103370