Futile Therapy versus Worthy Dying: Anthropological and Ethical Arguments

Nowadays, issues related to the final stages of life stand more and more at the centre of problems relating to life and health, which result, for example, from the demographic situation in highly developed societies. In the last decades of the twentieth century, an explosion of therapeutic possibilities in the field of technical medicine has caused such questions to be voiced more and more frequently: Should humans try to live as long as possible, or should they live as long as they can with dignity and then die with dignity? Despite the seemingly obvious answer, there is still considerable medical and social resistance to the policy of discontinuing futile therapy. There are probably many reasons for this situation, but one of the most important factors is that this is regarded as a form of euthanasia. This means that ineffective therapy administered to a terminally ill patient is prolonged, even when it increases their suffering and prolongs their agony. Therefore, it is reasonable to examine the relevant arguments for the right approach to treating a terminally ill person. The starting point should begin with the empirical facts about patients who are in the last stage of their life, and where there is reasonable doubt about the benefits of the treatment they are receiving. Since normative conclusions should not be directly derived from empirical data, it is necessary to collect anthropological arguments first. It is only the concept of what a human being is that is fundamental to the applied bioethics, according to which we can formulate ethical conclusions. Finally, theology will come to the fore and it can bring new perspectives on death and what is beyond death boundaries.

Etyczne warunki rezygnacji z uporczywej terapii

Death is an inevitable phenomenon, but it can be experienced with dignity. For this reason, people are continually seeking decent ways to die. One of these is avoiding or moving away from so-called aggressive medical treatment if it doesn’t provide the dying with any therapeutic benefit and only generates costs and prolongs suffering. Consensual, inevitable death has been practiced in medicine since the time of Hippocrates, although at the same time we can see a tendency towards the opposite, uncompromising fight to the end. This trend is sometimes justified by the exceptional value of human life, which demands both the patient’s and doctor’s heroism. Since the Middle Ages, it has been a widely accepted practice to limit the care for human life to the use of so-called, ordinary, and proportionate remedies. The acceptance of this principle also means withdrawing futile therapy.

Improving quality of early breast cancer care with a predictive test for taxane response.

146 Background: Patients (pts) with high-risk early breast cancer (BC) frequently have adjuvant taxane (TAX) treatment, but only 22% experience benefits in disease-free survival and many experience toxicities which impact quality of life (QoL) and increase costs. Research is underway to develop biomarkers which predict TAX response and hence identify pts who will benefit from the regimen and pts who will not, avoiding futile treatment and associated toxicities. Methods: A predictive economic model estimated the potential avoided toxicities and related costs of testing 100 BC pts with a biomarker to guide therapy selection compared to no pretesting. The no biomarker test group all received AC-T (AC-T) (doxorubicin 60mg/m2, cyclophosphamide 600mg/m2, followed by weekly paclitaxel 80mg/m2) for 12 weeks ($572). The model included rates and costs of 3 associated side effects (average $2024/patient): neutropenia (14%), thrombocytopenia (1%), and peripheral neuropathy (1%). In comparison, all pts were biomarker tested ($950) pre-treatment initiation and only those with biomarker overexpression were treated with AC-T versus AC, accruing the appropriate related costs plus the biomarker test cost. The model assumed the biomarker test was 70% to 90% predictive of expression. Results: The model found the biomarker group identified 55 to 70 non-expressing pts who would likely not have an increased benefit from the addition of TAX. For this group, 55% to 70% of the 3 AE toxicities and the associated impacts on QoL would be avoided producing $110,505 to $142,078 cost offsets. Between $25,792 and $60,304 of treatment expenditures could be avoided and better used. Budget neutrality occurred when neutropenia rates were reduced to 7%. The biomarker group identified 30–45 expressing pts who likely would benefit from AC-T. Conclusions: Applying a biomarker test to identify BC pts likely to respond to TAX may improve quality of care, particularly for non-expressers who could avoid QoL decrements of futile therapy and instead be managed with a less toxic and more beneficial therapy. Further development of such a biomarker should assess all pt impacts and healthcare system costs for both biomarker-identified expressers and non-expressers.

The expanded role of palliative procedures with minimally invasive tumor ablation techniques

19548 Background: To effectively and appropriately manage the debilitating symptoms of advanced cancer, physicians must balance the potential promise of palliative interventions against requirements to avoid toxic or futile therapy. Ablative technologies are increasingly used for the local destruction of tumors. This study examines the outcomes of ablative procedures performed with palliative intent. Methods: Minimally invasive ablative procedures (microwave and radiofrequency) to explicitly palliate symptoms of advanced cancer were identified from all procedures performed. Patients were observed for >90 days or until death. Results: There were 175 palliative ablative procedures performed in 129 patients from 1999 to 2004. Ablations were performed most commonly for pain (90%) caused by metastatic (90%), locally advanced (5%), and locally recurrent (5%) disease. Primary malignancies treated were lung (31%), colorectal (14%), renal (11%), breast (9%), sarcoma (9%) and other (26%). Symptom improvement or resolution within 30 days was achieved in 69% (89/129). Median duration of symptom control was 315 days. Recurrence of the primary symptom occurred in 46% (59/129) while treatment of additional symptoms was needed in 22% (29/129). Palliative ablative procedures were associated with postoperative morbidity (25%) and mortality (7%). A postoperative complication reduced the probability of symptom improvement to 25% (p<0.001). Effective symptom relief was associated with improved overall survival (median 408 days vs. 161 days, p<0.001). Conclusions: In carefully selected patients, relief of symptoms following palliative ablative procedures can be expected, but new or recurrent symptoms limit durability. As observed in other palliative procedures, potential benefits are minimized by postoperative complications. Optimal management for these patients with advanced cancer, who are often not suitable candidates for operation, requires the highest level of multidisciplinary care. No significant financial relationships to disclose.