Physicians Should Not Always Pursue a Good "Clinical" Outcome

Increasingly, hospitals are using so-called futility policies to address medical goals that are centered not just on the prospect of mending the organs, but on whether the outcome will actually benefit the patient. The University of California, San Diego Medical Center, for example, defines a treatment as futile when it "has no realistic chance of providing a benefit that the patient would ever have the capacity to perceive and appreciate, such as merely preserving the physiologic functions of a permanently unconscious patient, or has no realistic chance of achieving the medical goal of returning the patient to a level of health that permits survival outside the acute care setting."

The policy goes on to assert that the physician's obligation is to provide optimal comfort care, namely "care whose intent is to relieve suffering and provide for the patient's comfort and dignity. It may include analgesics, narcotics, tranquilizers, local nursing measures, and other treatments including psychological and spiritual counseling. . . .[A]lthough a particular treatment may be futile, palliative or comfort care is never futile."

Beginning about fifteen years ago, the topic of medical futility became a matter of stormy contention in medicine. Some critics even argued that the term "medical futility" should be abandoned altogether. But as one critic acknowledged: "The commonsense notion that a time does come for all of us when death or disability exceeds our medical powers cannot be denied. This means that some operative way of making a decision when 'enough is enough' is necessary. . . . [S]ome determination of futility by any other name will become a reality."¹

Physicians are trained to achieve good clinical outcomes. Unfortunately, many physicians interpret that to mean good physiologic outcomes in the organ system of their specialty. The cardiologist wants to help the patient maintain a strong cardiac output, a nephrologist wants to make sure the patient's kidney function is adequate, and the pulmonologist concentrates on lung capacity and viability.

Patients reasonably assume they, too, have a vested interest in promoting good clinical outcomes. Usually, good clinical and patient outcomes are completely aligned. Indeed, the vast majority of physicians and patients have an accurate mutual understanding of the ultimate objective—to improve the patient's quality of life as soon as possible. Regrettably, though, as medicine becomes ever more complex and specialized, at times a patient's organ, rather than the patient, becomes the focus of attention. A variety of effective interventions can help sustain one organ even as others fail. From a specialist's perspective, prolonging organ function in such a case represents a significant professional challenge. It tests the technical knowledge, skill, and experience of physicians who are energized by the opportunity to demonstrate to themselves, colleagues, patients, and families that the potential benefit of persistent medical and surgical treatment should never be underestimated. To some physicians, then, successfully sustaining a patient who needs constant support and may not even survive hospitalization with a reasonable quality of life is a testament to medical progress.

Implicit in this view is that death is necessarily a bad clinical outcome. Some say that Americans view death as optional. Death means failure. But in fact, in many situations, good patient outcomes should be valued more highly than good clinical outcomes. The difference between the two is more than semantics. When medical treatment no longer fulfills a patient's expressed preferences and the patient is terminally ill, a good death should be viewed as an acceptable and appropriate outcome. Under these circumstances, a good death becomes a preferred patient outcome, instead of aggressive treatment to achieve a good clinical outcome as measured by organ function. Death is not necessarily a medical failure; conversely, causing or allowing a bad death is not only a medical failure, but also an ethical breakdown.