The cost of health care at the end of life accounts for a high proportion of total health care costs in the United States. The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006. This indicates how little progress has been made in containing these costs, though doing so will be important to promote a financially sustainable health care system. These expenditures also (...) highlight the prospect that efforts to reduce health care costs overall are likely to disproportionately affect the care patients receive at the end of life. (shrink)

Professionalism requires that physicians uphold the best interests of patients while simultaneously insuring just use of health care resources. Current articulations of these obligations like the American Board of Internal Medicine Foundation's Physician Charter do not reconcile how these obligations fit together when they conflict. This is the problem of dual agency. The most common ways of dealing with dual agency: “bunkering”—physicians act as though societal cost issues are not their problem; “bailing”—physicians assume that they are merely agents of society (...) and deliver care typically based on a strongly consequentialist public health ethic; or “balancing”—a vaguely specified attempt to uphold both patient welfare and societal need for judicious resource use simultaneously—all fail. Here I propose how the problem of dual agency might begin to be addressed with rigor and consistency. Without dealing with the dual agency problem and getting more specific about how to reconcile its norms when they conflict, the expectations of professionalism risk being written off as cute, nonbinding aphorisms from the medical profession. (shrink)

Objective Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient9s life. Design Semistructured in-depth interviews. Setting Three large tertiary public hospitals in Brisbane, Australia. Participants 96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling. (...) Results Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the _main_ reasons for futile care. Conclusions Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level. (shrink)

This article reports the findings of a qualitative study that explored the organizational influences on moral distress for health professionals working in pediatric intensive care units across Canada. Participants were recruited to the study from PICUs across Canada. The PICU is a high-tech, fast-paced, high-pressure environment where caregivers frequently face conflict and ethical tension in the care of critically ill children. A number of themes including relationships with management, organizational structure and processes, workload and resources, and team dynamics were identified. (...) This study provides a rare and important multi-disciplinary perspective on this topic and the findings have implications for administrators and leaders who seek to improve the moral climate of healthcare delivery. (shrink)

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in (...) Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment. (shrink)

Although rationing of scarce health-care resources is inevitable in clinical practice, there is still limited and scattered information about how physicians perceive and execute this bedside rationing (BSR) and how it can be performed in an ethically fair way. This review gives a systematic overview on physicians’ perspectives on influences, strategies, and consequences of health-care rationing. Relevant references as identified by systematically screening major electronic databases and manuscript references were synthesized by thematic analysis. Retrieved studies focused on themes that fell (...) under three major headings: (i) conditions and influences of BSR, (ii) strategies of BSR, and (iii) consequences of BSR. The range of themes indicates that physicians’ rationing behavior is highly variable, strongly influenced by context-related factors, and consists mainly of implicit rationing strategies. Torn between patient advocacy and the obligation to contain costs, physicians experience various role conflicts. The development of explicit rationing strategies seems necessary to avoid arbitrary BSR and allow a fair allocation of health-care resources. (shrink)

In 1989, Helga Wanglie, 86 years old, broke her hip. This began a medical downhill course that a year later caused her health care providers to conclude that she would not benefit from continued medical treatment. It would be futile, and therefore, should not be provided. Her husband disagreed, and the conflict eventually led to a lawsuit. The Wanglie case touched off an extended debate in the medical and bioethical literature about medical futility: what it means and how useful the (...) concept is in making ethical decisions about starting or stopping treatment. (shrink)

"Written by a well-known and respected author, this book reflects careful scholarship by someone who has extensive experience in the field and creative insights.

Research councils, agencies, and researchers recognize the benefits of team-based health research. However, researchers involved in large-scale team-based research projects face multiple challenges as they seek to identify epistemological and ontological common ground. Typically, these challenges occur between quantitative and qualitative researchers but can occur between qualitative researchers, particularly when the project involves multiple disciplinary perspectives. The authors use the convergent interviewing technique in their multidisciplinary research project to overcome these challenges. This technique assists them in developing common epistemological and (...) ontological ground while enabling swift and detailed data collection and analysis. Although convergent interviewing is a relatively new method described primarily in marketing research, it compares and contrasts well with grounded theory and other techniques. The authors argue that this process provides a rigorous method to structure and refine research projects and requires researchers to identify and be accountable for developing a common epistemological and ontological position. (shrink)