Futile. It’s a word not often heard in discussions with cancer patients or family members as test results are reviewed and next steps considered. But it may be key, as patients near the end of life, to debates about reducing costs and reducing suffering, dual objectives that so often go hand-in-hand.
As they weigh second-, third- or fourth-line options, should patients ask, "What is the likelihood this round of chemotherapy (or other aggressive treatment) will be futile? Would I gain function, time, or both? And at what physical and financial cost?"
All too often, the question isn’t even asked among colleagues during rounds, at hallway consults, or at the nursing station.
Then, when futile treatment fails and the inevitable family meeting transpires, often in the intensive care unit, the message to family members from the staff may be unclear.
Inevitably, the family member with the most assertive voice wins, more orders get written, and aggressive care continues.
At the City of Hope National Medical Center in Duarte, Calif., a novel project seeks to bring perspective to that process in the hopes of alleviating suffering, preserving patient dignity, and reducing the stress inherent in providing care that is "medically ineffective" through no fault of those ordering or administering that care.
Diane Morrison, licensed clinical social worker and manager of clinical social work, recently offered a snapshot of the Multidisciplinary ICU Team Family Meeting Project during a poster session at the annual meeting of the American Psychosocial Oncology Society.
Several years ago, a multidisciplinary steering committee was formed, made up of "physician champions" from the ICU and medical services, clinical social workers, nurses, and a chaplain. They designed a "shared accountability" strategy that brought goals and values to center stage in the ICU, hinging on structured family meetings.
Critically, a multidisciplinary premeeting is held, either in person or virtually, Ms. Morrison said in an interview after the meeting.
"The premeeting is used to make sure the medical staff is on the same page," she said.
Any disagreements about the course of care are aired and resolved. Details are organized, and expected "next steps" are considered. A primary spokesperson for the team is designated. Often, this will be the physician, but not always.
Perspectives of the family are shared to construct a culturally attuned scaffolding for the meeting to clarify that the patient’s life is ending.
During the meeting, speaking in a kind, professional, and unified voice, the team explains the patient’s medical condition, offers perspective on the role of supportive care and hospice, and provides support to the family or the patient as decisions are made.
As an added benefit, professionals extensively trained in family dynamics and end-of-life discussions lend help during the meetings to medical oncologists, hematologists, and surgeons.
Parents (24%), spouses (13%), siblings (16%), and offspring (26%) have attended the meetings, Ms. Morrison said. In just 5% of cases does the patient attend, a statistic that speaks to how far down the treatment road the case has progressed.
To administrators and budget-minded politicians, the results might as well be surrounded by flashing strobe lights. Among the roughly 100 patients who die in the ICU each year at the institution, the ICU stay was reduced by 4 days, from 14.2 days in 2010 to 10.3 days in 2012. (Approximately 1,850 patients are admitted each year to the ICU.)
But to Ms. Morrison, it’s not about money. It’s about better communication and more thoughtful attention to human values, dignity, and compassion.
Physician feedback has been strongly positive, with 19 of 22 participants agreeing or strongly agreeing that the family meetings have been useful in managing patients. Fully 18 of 22 felt that, by meeting the emotional and psychological needs of patients and caregivers, their time was protected to focus on duties related to their medical expertise.
Moreover, the program is believed to be reducing "moral distress" among nurses.
"We believe," concluded the poster, "that less time in futile care alleviates suffering for patients and family members. We also propose that less time spent providing medically ineffective care reduces stress on staff."
Dr. Freed is a psychologist in Santa Barbara, Calif., and a medical journalist.