Human Exceptionalism

We Shouldn’t Have to Pay Doctors to Talk

I oppose Futile Care Theory–aka medical futility–because it authorizes the unilateral withholding of wanted efficacious treatment.

What is efficacious? A proper understanding would be treatment that accomplished its purpose. Hence, a ventilator facilitates respiration and helps keep the patient alive. 

Futile care is when–in the above example–the wanted ventilator is removed because it is working–not because it isn’t–based on the perceived quality of the patient’s life.

This is sometimes called “qualitative futility.” In other words, in qualitative futility the patient is being declared futile, which is why the efficacious treatment is withdrawn. That’s why it presents such an acute danger to ethical medical practice. 

But there is also something known as physiological futility, that is, a situation when the intervention objectively does not provide efficacious benefit. To use an extreme example, no doctor should perform an appendectomy for an ear ache. 

From this story in the LA Times, it appears that some Alzheimer’s medications don’t work at the end stages of the disease. From the story:

Alzheimer’s disease drugs, which are virtually ineffective in patients with severe dementia, were the questionable medications most commonly given to nursing home patients with advanced disease.

Prescriptions for Alzheimer’s drugs such as donepezil (better known by its commercial name, Aricept), rivastigmine (Exelon), and memantine (Namenda) are commonly initiated for patients in the early stages of the disease and may slow the rate at which they become unable to care for themselves.

There’s little evidence they improve memory or mental performance in people in late stages of the disease, however.

Should doctors refuse such medication in end stage patients, even if wanted? It depends on the meaning of the term, “little evidence.”

But the bigger point is that it should never–or only very rarely–come to disputation. Most families will not want their loved ones to undergo greater discomfort for no or very minor efficacious gain. Ongoing dialogue is the best way to avoid such unfortunate outcomes and avoid futility disputes.

This is why I am worried that the varying plans to pay doctors for these communications–once a year or once every five years, whatever–miss the mark. If we bureaucratize these essential and ongoing dialogues, the doctor/patient/family relationship could easily become sclerotic.  

Better to raise doctor’s general pay in the understanding that their overall compensation includes end–of-life talks whenever they are needed and wherever they occur. 


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