Medical Futility and Relating to Patient Families

Vignette #1 deals with medical futility and the physician’s relationship to the patient’s family: Actors: Nurse, Family Member, Physician Scene: Family Member, Mrs. Crane, is seated. The nurse enters. Mrs. Crane stands, eager for news. Nurse: Mrs. Crane? Mrs. Crane nods: Yes. Nurse: Have a seat. I’ve been going over Frank’s situation with the nurse that took care of him last night. It is clear that he will need dialysis because his kidneys are still not working. Water and toxic substances are beginning to build up in his body. He had a repeat brain wave test, an EEG, late yesterday and still there is little activity. As you know Frank has not regained consciousness since his operation two weeks ago, and there has been no change overnight. The prognosis is not good. Mrs. Crane wipes her eye and tries to keep her composure: We aren’t surprised. We all talked yesterday. You know…about Frank. He really fought the good fight. We all wanted to hear something else…a miracle, I guess, but we all knew that the end was near when Frank came into hospital. Physician enters: Good morning Miss Flynn, Mrs. Crane. Nurse Flynn: Good morning Doctor. I was just updating Mrs. Crane on her husband’s condition, that his kidneys are failing and that his repeat EEG shows minimal activity. Mrs. Crane and the family understand that Frank is at the end of his life. Physician: Oh! Oh! Wait a minute. Let’s not give up just yet. There are still things we can do to try to save him. Admittedly, his life will not be like it was before, but it’s not over. We can start dialysis. We can continue to support his breathing with the respirator. He will need a tracheostomy in the next two or three days. I just wrote orders for total parenteral nutrition so that he doesn’t starve. The situation is not hopeless. Mrs. Crane: My husband didn’t want this. None of the family wants this for him. Can you just keep him comfortable? Physician: I know all of these tubes and treatments are frightening but they help him stay alive. Look, just trust me that more can be done. The actors freeze momentarily to mark the end of the vignette. Some questions to stimulate about 10 minutes of small group discussion for the first vignette are: What are the issues for the family member? What are the issues for the physician? Underlying motivation and belief about each of their decision making processes? What does the family member need? What is behind the difference in approach of the physician compared to the nurse? What did you agree with or disagree with regarding the physician’s response? Some questions to stimulate about 10 minutes of discussion by all participants about the first vignette are: What was the most important theme for your discussion group? What made it so important? Whose opinions should dominate medical decision making? Why? How should care-givers respond when there is a disparity in treatment goals? Best practices will come out of these dialogues. Writing the best practices on a flip chart keeps the ideas in front of the participants.