Page 35 - Deleware Medical Journal - September/October 2019
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ETHICS
The most common parameters which
futility were neurologic disability (85.4%), comorbidities (82.9%), acute organ failure(s) (82.9%), when desired care goals cannot be achieved (79.0%), and advanced age (65.4%). Curiously, despite such a large percentage focused on “desired goals,” only 62% address code status within 24 hours of admission to the ICU. criteria being used by acute care surgeons, there is a need for a clinically relevant acute conditions while also considering the quality of life in long-term outcomes.
DEFINING FUTILITY
The view of medicine and futility has changed dramatically over time. In
early medicine, a failure to heal was a defect of nature and not a failure of the physician or the treatment. Today, we
use empiric methods to evaluate for a distinction between the effect and the is important that we be able to recognize this distinction. That is, a treatment
may produce an effect, but it may not
be adequate to reach a desirable goal. In focal point, contemporary futility is often viewed by either “quantitative futility” or “qualitative futility.”
Quantitative futility looks at the particular
what percent chance of an outcome is considered adequate to be “futile” and
to a particular patient. In statistical analyses, we have arbitrarily picked 95%
is important to remember that with each decision made the patient will experience 100% of the outcome. It is easy for decision-making to become paralyzed
while focusing on the other 5% chance. Alternatively, qualitative futility attempts to determine an acceptable quality of life. to recognize an accepted outcome that can be generalized to all patients.4 In this with futility in both acute and chronic situations.
ACUTE FUTILITY
Acute futility includes situations with imminent mortality. One area that is commonly discussed is in traumatic cardiac arrest. A trauma patient presenting in cardiac arrest is a classic situation where decisions made, and actions taken, over just a few seconds scene in which many providers want
to “give the patient the best shot at survival” and “do everything,” which may include a resuscitative thoracotomy. It is only with more experience and after following patients and families beyond the trauma bay that one begins to ask the important question: is “everything” truly in the patient’s best interest?
The ACS Committee on Trauma
and the Eastern Association for the Surgery of Trauma provide guidelines
for resuscitative thoracotomies. Both agree that in penetrating trauma,
there is a role for a thoracotomy. They conditionally recommend the use of
a thoracotomy in blunt trauma if the patient has shown signs of life and conditionally recommend against it if
the patient has not shown signs of life.5,6 The research behind these decisions has shown repeatedly that a thoracotomy
in blunt trauma results in survival of 1-2% of patients. Alternatively, patients who are treated with closed-chest cardiopulmonary resuscitation in blunt traumas have a higher rate of survival, up to almost 6%.6,7,8
The quality of life in the few patients who do survive a resuscitative to consider. A meta-analysis addressing blunt-traumatic cardiac arrest outcomes was completed in 2014. This study showed that out of 1,269 patients, only 21 (1.5%) survived and had a broadly 9
A separate single-center study looking
at outcomes of 448 patients was able
to follow 16 survivors and found a
higher quality of life than previously reported. While there was a large number of patients lost to follow-up, 81% of
the 16 survivors were freely mobile
and functional and 75% had normal cognition. While it is unclear of the cause or chronicity, the study also recognized that 75% of survivors were unemployed and that daily alcohol (50%) and drug
use (38%) were common.10 While both of they do demonstrate that many of these patients have prolonged recovery times and that some survivors will have lifelong decreased quality of life.
As has been described above, there is
completing a thoracotomy in blunt- traumatic cardiac arrest. As such, many providers struggle with the decision
to either offer or limit a resuscitative thoracotomy and have sought other decision easier; often, the conversation will shift focus to that of educational decisions should be made with risks and who is present at the time.
Some may see the gray area in this decision-making process to be an opportunity for the surgical and emergency teams to gain experience so as to be better prepared for the next patient. In these instances, an unnecessary risk is placed on the care team. One recent multi-institutional
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