Factors Influencing Potentially Futile Treatments at the End of Life in a Multiethnic Asian Cardiology Setting: A Qualitative Study

Background. Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood. Aim. This study aimed to explore clinicians’ perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting. Design. We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed. Results. A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment. Conclusion. Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Choosing wisely: protocols, priorities and a postcard

Can a young doctor without training in communication skills use empathy as a compass for making ethical decisions? This narrative reflects on a young boy left alone with a paralysed dying father after six months of ‘free’ but futile treatment. Protocols should be weighed against prognosis and priorities when the disease is incurable.

Ethical and Legal Issues

The sections of this chapter discuss both evaluation and management of legal and ethical aspects of the physician assistant (PA) profession, taking into consideration that the PA practice flows out of an interconnected relationship between the PA, the physician, and the patient. PAs are called to fulfill not only the law when practicing but also rise to uphold ethical principles. There are a variety of situations a provider can encounter throughout a career. Some topics are present in every patient encounter, such as confidentiality and informed consent. Some topics may only be present in certain cases, such as advanced directives and futile treatment. Nevertheless, the provider should be knowledgeable about each of these legal and ethical situations and understand the evaluation and management of them.

Frequency and Severity of Moral Distress in Nephrology Fellows: A National Survey

<b><i>Introduction:</i></b> Moral distress is a negative affective response to a situation in which one is compelled to act in a way that conflicts with one’s values. Little is known about the workplace scenarios that elicit moral distress in nephrology fellows. <b><i>Methods:</i></b> We sent a moral distress survey to 148 nephrology fellowship directors with a request to forward it to their fellows. Using a 5-point (0–4) scale, fellows rated both the frequency (never to very frequently) and severity (not at all disturbing to very disturbing) of commonly encountered workplace scenarios. Ratings of ≥3 were used to define “frequent” and “moderate-to-severe” moral distress. <b><i>Results:</i></b> The survey was forwarded by 64 fellowship directors to 386 fellows, 142 of whom (37%) responded. Their mean age was 33 ± 3.6 years and 43% were female. The scenarios that most commonly elicited moderate to severe moral distress were initiating dialysis in situations that the fellow considered futile (77%), continuing dialysis in a hopelessly ill patient (81%) and carrying a high patient census (75%), and observing other providers giving overly optimistic descriptions of the benefits of dialysis (64%). Approximately 27% had considered quitting fellowship during training, including 9% at the time of survey completion. <b><i>Conclusion:</i></b> A substantial majority of nephrology trainees experienced moral distress of moderate to severe intensity, mainly related to the futile treatment of hopelessly ill patients. Efforts to reduce moral distress in trainees are required.

Dealing with Futile Treatments Based on the Humanistic Approach

: Medical futility is one of the most common controversial topics in medicine, medical ethics, and philosophy of medicine. Every day, doctors are dealing with patients who are in a condition that must have a decision about requested futile treatment with their own beliefs, opinions, and different demands. This is an important issue that must be taught during teaching courses. Therefore, it is good to provide general policies for teaching how to make the best decision, establishing better communication between doctors and patients, and maintaining their Autonomy. On the other hand, with the interference and expansion of humanistic and holistic attitudes in the treatment of patients, it must be considered that at all treatment levels, especially decisions related to end-of-life, it is better to involve this point of view in our policies. In the present article, we tried to give a general conclusion of general policy and present standards for a humanistic policy by analyzing various countries’ policies and expressing their bugs.

Η μάταιη θεραπεία (futile treatment): Ιατρική και θεολογική προσέγγιση

This is a medical and theological approach of Futile Treatment, an issue that raises severe medical and bioethical dilemmas. We discuss the difficulties in establishing objective criteria to discontinue treatment and present the theological views on the subject with emphasis to orthodox theology. This paper aims to contribute to the subject and also rise a debate in Greece.

Pulsatile varicose veins: an uncommon presentation of a common condition

Varicose veins of the lower limbs are common. However, pulsatile varicose veins are unusual. They could be an indicator of a sinister underlying pathology, such as severe cardiac dysfunction. It is easy to miss these rare cases during clinical workup, which can result in futile treatment with potentially dangerous consequences. In this report, we describe 2 cases of pulsatile varicose veins that highlight different etiologies and management strategies for this condition.

Inappropriate hemodialysis treatment and palliative care

The paper discusses inappropriate (futile) treatment by analyzing the casuistics of palliative patients in the terminal stage of illness who are hospitalized at the Department of Internal Medicine and Geriatrics of the Faculty hospital with policlinic (FNsP). Our research applies the principles of palliative care in the context of bioethics. The existing clinical conditions of healthcare in Slovakia are characteristic of making a taboo of the issues of inappropriate treatment of palliative patients. Inductive-deductive and normative clinical bioethics methods of palliative care and ethical strategy are applied for defining issues found in inappropriate hemodialysis treatment. An algorithm of hemodialysis treatment requires the definition of those lege artis criteria which, in the context of a patient’s autonomy and his/her decision, precondition the avoidance of the situation in which hemodialysis treatment is inappropriate (futile). Futile treatment in a terminal condition is ethically inappropriate medical treatment that extends the suffering of patients and their relatives. Its definition is determined by the relevant legislation and the methods of bioethics. An active palliative strategy is aimed at managing the process of incurable diseases in the patient’s bio-psycho-socio-spiritual continuity in the process of special bioethics. The global bioethical objective of general bioethics for palliative care is based on the paradigm of social harmony and solidarity in the context of an authentic modus of the patient’s existence as a constitutive principle for the phenomenon of the patient’s being to finite being (death).