TREATMENT OPTIONS

recep — Thu, 26 Mar 2009 17:05:58 +0000

Developing a list of treatment options for a patient is a central component of good decision making. Two assumptions help in developing options for a patient. First, although society’s financial concerns are an issue, the choices made with a particular patient are ordinarily assumed to have negligible effects upon society as a whole, neither greatly changing costs nor depleting other resources. For example, choosing to dialyze an elderly, disabled patient is usually assumed to have no major effect upon the availability of dialysis to others. Although society’s financial concerns usually do not limit the options for a particular patient at a particular time, financial concerns may exclude certain options for everyone. Second, all available options, including forgoing specific treatment, should be considered. Thus, a patient with an embolic stroke will have at least the options of (1) having only supportive care for comfort and function, (2) having further diagnostic studies to better assess the risks of recurrence, and (3) receiving anticoagulation therapy. Proceeding directly to full diagnosis and treatment without considering the merits of forgoing specific diagnosis and treatment often is not the best choice.
Decision making may be inappropriately simplified by either-or choices, in which one option is held to be unacceptable. An example is the notion that a provider must always give “ordinary” treatments but that “extraordinary” or “heroic” efforts need not be made. One might also be permitted to “allow a patient to die” but not to “kill a patient.”
Relying on such either-or choices misleadingly reduces a complex situation to simple moral alternatives. This approach is a poor substitute for one in which choices are made to advance the patient’s best interests—as the patient defines them. Advancing the patient’s interests may involve stopping a treatment; deciding not to use the usual array of interventions, such as antibiotics or feeding tubes; or giving medications that may lead to an earlier death while relieving symptoms.
Appeal to the common distinction between ordinary and extraordinary treatments is made in cases in which some question exists about the obligation to treat. This use of the distinction raises two problems. First, rapidly changing technologies and views about which practices are indicated constantly alter a descriptive definition of ordinary care. Second, and more serious from an ethical point of view, noting that a practice is common is irrelevant to deciding whether it is morally right.
The terms ordinary and extraordinary are used in a variety of ways— to indicate whether treatment is usual, complex, artificial, expensive, or available. Care that is extraordinary in the sense that it is rare might be morally required for a limited time in an unusual case. For example, a patient appropriately may be given ventilator support in dire circumstances precipitated by an unexpected complication of experimental therapy, even though thelikelihood of survival is so poor that a ventilator might not be used otherwise.
Ordinary and extraordinary are useful terms to express one’s conclusions about the ethical evaluation of a situation, but they do not define the appropriateness of treatment. The terms are helpful only when used to indicate whether the burdens imposed by a treatment are disproportionate to its benefits. Thus, when a patient prefers death to prolonged suffering, even treatment with antibiotics may be considered extraordinary.
Many physicians express reservations about withdrawing treatment when, all other things being equal, they would not have had doubts about withholding treatment. There are often powerful psychological inhibitions against stopping treatment, but there is usually no moral difference between not starting treatment and stopping it once it has started. Attempting a treatment may help determine whether it provides a benefit. Admitting that the treatment is not achieving the desired benefit is more painful (and stopping it often entails more documentation than not starting it would have), but such problems can usually be mitigated by having planned end points of therapeutic trials. Such planning is as necessary for the use of nasogastric feeding tubes as it is for more complicated interventions, such as dialysis or repeated blood transfusions. In each case, the best decision cannot be known until after treatment is initiated. Simply put, a physician need not continue a course of treatment that is not working merely because that treatment was started.
Certain prudent steps should be taken whenever care involves an action that may shorten the patient’s life, for example, administering high-dose narcotics for pain or respiratory distress, forgoing antibiotics or feeding tubes, or agreeing to withhold a life-sustaining transfusion or radiation treatment. (1) The physician must be sure that the plan is correctly assessed; for instance, the prognosis should be diligently evaluated. (2) Respected colleagues (including nurses, social workers, and clergy) should be asked to evaluate the situation. If they disagree with
the plan, usually it should be reassessed and implementation delayed. (3) The physician must try to determine whether the patient agrees with the plan (or would have agreed were the patient competent). (4) The decision-making process should be carefully documented. (5) The physician might arrange for a formal review by an ethics or patient care committee or for a court review. This last step is emotionally and financially costly and usually unnecessary if the first four steps are followed.

health articles » TREATMENT OPTIONS

TREATMENT OPTIONS