1 ECONOMIC CONSIDERATIONS IN DETERMINING FUTILE CARE HOW MUCH CAN WE AFFORD?

2 STANDARDS FOR RESOURCE ALLOCATION  ARBITRARY.  PERSONAL WEALTH.  RESOURCE LOTTERY.  SOCIAL LOTTERY.  AGE???  NATURAL.  FINITUDE.  BENEFIT TO PATIENT.  PATIENT SELF-RESTRAINT IN DECISIONS.  AGE???

3 POSSIBLE LIMITATIONS ON RESOURCE EXPENDITURES I FFFFUTILE TREATMENT. CCCCOSTWORTHY TREATMENTS. SSSSUFFICIENT BENEFITS FOR BURDENS. RRRREALISTIC ASSESSMENT OF BENEFITS. WWWWEIGHING ALTERNATIVES. RRRREIMBURSEMENT. SSSSOCIETAL PRIORITIES.

4 POSSIBLE LIMITATIONS ON RESOURCE EXPENDITURES II  PATIENT’S SELF-RESTRAINT.  PATIENT’S VALUES.  PATIENT’S/SURROGATE’S PARTICIPATION IN DECISION MAKING.  EXERCISE OF AUTONOMY.  RIGHT TO REFUSE TREATMENT.  CHOICES AMONG ALTERNATIVES.  IMPORTANCE OF INFORMED CONSENT.

5 DETERMINATION OF BENEFITS FOR PATIENTS  CLEARLY BENEFICIAL.  NO BENEFIT (FUTILE).  BURDENS OUTWEIGH BENEFITS (INADVISABLE).  COSTWORTHINESS.  IMPORTANCE OF REALISTIC ASSESSMENT OF BENEFITS.

6 BENEFITS  THE POSITIVE RESULT FOR A FUNCTIONAL IMPROVEMENT IN THE QUALITY OF LIFE OR THE ACHIEVEMENT OF A PARTICULARLY DESIREABLE GOAL WHICH AN INDIVIDUAL WILL EXPERIENCE AS THE RESULT OF A HEALTHCARE INTERVENTION.  COMPLETE RECOVERY.  REMISSION OF DISEASE PROCESS.  IMPROVED QUALITY OF LIFE.  COMFORT.  RESTORATION OF CONSCIOUSNESS.  IMPROVED PERFORMANCE ACTIVITY.  RETURN TO A PREVIOUS LEVEL OF FUNCTIONING.  MAINTENANCE OF A MINIMALLY DECENT QUALTIY. OF LIFE  FIGHTING A DISEASE.  EXPERIENCING A LESS DISTRESSING DYING.  COST/RESOURCE SAVINGS.  [CONTINUED BIOLOGICAL EXISTENCE].

7 BURDENS  THE SUFFERING ONE MUST ENDURE AS THE RESULT OF AN INTERVENTION; IT MAY TAKE A PHYSICAL, PSYCHOLOGICAL, SPIRITUAL, OR MORAL FORM.  TOO PAINFUL.  TOO DAMAGING TO BODILY SELF AND FUNCTIONING.  TOO PSYCHOLOGICALLY REPUGNANT TO THE PATIENT.  TOO RESTRICTIVE OF PATIENT’S LIBERTY AND PREFERRED ACTIVITIES.  TOO SUPPRESSIVE OF PATIENT’S MENTAL LIFE.  TOO EXPENSIVE.

8 CRITERIA FOR CPR  TO PREVENT SUDDEN, UNEXPECTED DEATH.  COROLLARY: DNR WHEN DYING IS EXTENDED PROCESS AND/OR EXPECTED.  PRESUMPTION GENERALLY IN FAVOR OF CPR.  BEST INTERESTS OF PATIENT.  COST OF CPR ATTEMPT???  [CARDIAC ARREST OCCURS WITH EVERY DEATH].

9 CPR AND THE ELDERLY  SUCCESS RATE FOR CPR ABOUT 33%-40% ACROSS ALL AGES AND CONDITIONS.  = 12.4% TO DISCHARGE.  = 10.2% TO DISCHARGE.  90+ = 0% TO DISCHARGE.

10 CRUZAN  ACCIDENT.  JANUARY 25,  DIAGNOSIS.  POSSIBLE AUGUST,  COST – REHABILITATION HOSPITAL.  $130,000 – PER YEAR.  $910,000 – 1983 –  SAVINGS FROM TIMELY DECLARATION OF FUTILITY.  $845,000.  30 YEARS  $3.9 MILLION.

11 SCHIAVO  ATTEMPTS AT REHABILITATION.   COST - ???  DIAGNOSIS OF PVS.  1996/  $50,000 PER YEAR???  SAVINGS FROM DECLARATION OF FUTILITY.  $450,000.

12 MRS. H.  HISTORY OF INCREASINGLY SERIOUS ALLERGIES.  JANUARY – JULY.  INCREASING EDEMA RESISTENT TO TREATMENT.  AUGUST – 9 DAYS IN ICU.  KIDNEY FAILURE – DIALYSIS AND PLASMAPHERESIS.  LIVER FAILURE.  LEAKY CAPILLARY SYNDROME.  DISORIENTATION.  HYPERALIMENTATION; DNR.  NINTH DAY.  DIAGNOSIS = THROMBOCYTOPENIA PUPURA.  AGGRESSIVE TREATMENTS STOPPED.  PALLIATIVE CARE.  TWELFTH DAY.  DEATH.  TWELVE-DAY COST = $193,000+

13 FORMULA WITHOUT NUMBERS  GOOD ETHICS = GOOD MEDICINE = GOOD LAW = GOOD ECONOMICS.

14 GE = GM = GL = GE  GOOD ETHICS.  FULL ATTENTION TO THE PATIENT’S BEST INTERESTS,  ESPECIALLY AS IDENTIFIED BY THE PATIENT THROUGH THE EXERCISE OF AUTONOMY;  APPROPRIATE UTILIZATION OF CLINICIANS IN HELPING PATIENTS IDENTIFY THOSE BEST INTERESTS.

15 GE = GM = GL = GE GGGGOOD MEDICINE. LLLLEADS TO A PROPER THERAPEUTIC RESPONSE; WWWWITHIN THE OVERALL CONTEXT OF THE PATIENT’S VALUES AND PRIORITIES; EEEEXERCISING SOUND CLINICAL JUDGMENT; AAAAND ACCEPTABLE STANDARDS OF PROFESSIONAL MEDICAL PRACTICE.

16 GE = GM = GL = GE  GOOD LAW.  PROTECTING THE PATIENT’S RIGHTS TO INFORMATION AND SELF- DETERMINATION;  PROTECTING THE INTEGRITY OF THE CAREGIVER IN FOLLOWING THE STANDARDS OF ACCEPTABLE MEDICAL PRACTICE.

17 GE = GM = GL = GE  GOOD ECONOMICS.  MAY LEAD TO PATIENT-INITIATED RESTRAINT;  A REALISTIC ASSESSMENT OF BENEFITS IN THE UTILIZATION OF HIGH-COST TECHNOLOGICAL INTERVENTIONS;  REDUCING EXPENDITURES BY THE PATIENT, INSURERS, AND HEALTHCARE INSTITUTIONS.