Remarkable advances in technology have made it possible for medical teams at major centers such as UCLA to save the lives of patients who in years past would have had little to no chance for survival. In some cases, such treatments carry the hope of restoring very sick patients to relatively normal lives. But such scenarios can also raise difficult ethical questions, particularly when a treatment has a low likelihood of success but a substantial chance of leaving the patient with an unacceptable quality of life. In such cases, it’s important for patients and their families to talk with their doctors ahead of time so that decisions can be made that are consistent with each patient’s clearly stated care goals, says Neil Wenger, MD, director of the UCLA Health Ethics Center.
“All of these wonderful advances dramatically increase our responsibility as physicians to ensure that patients and those making decisions for them are fully informed about the pros and cons of using that technology,” Dr. Wenger explains.
“To make informed decisions on whether to receive these treatments, patients and their families should understand not only what benefits might come, but alsothe future outcomes if they don’t benefit in the way that’s anticipated.”
Many of these advanced technologies aim at rescue, which means that under normal circumstances, Dr. Wenger explains, without the treatment the patient would die — usually from the failure of an organ. For example, there might be a small-to-moderate chance that with a ventricular-assist device (an artificial heart), a particularly ill patient could be kept alive until an organ became available for transplant.
“Under those circumstances, one is shooting for an uncertain or perhaps even improbable benefit, with a high likelihood that the ‘miracle’ won’t happen and decisions will need to be made about future treatments,” Dr. Wenger notes. “Frequently, those decisions need to be made when the patients can’t talk to us. Therefore, the use of advanced technology necessitates an in-depth and detailed discussion with the patient or the people making decisions for the patient about the purpose of the technology, what will happen if the technology doesn’t achieve the intended goal, and how the patient would feel about that.”
This makes high-quality conversations between the treating team and the patient and patient’s family particularly important. Dr. Wenger says such discussions should clearly and compassionately identify the spectrum of potential treatments, conveying the likelihood that each approach will be successful and what that success would mean — as well as the potential adverse outcomes and the health states they would produce — to determine the patient’s preferences and goals.
“These are difficult conversations,” Dr. Wenger says. “When you’re trying to rescue someone, the last thing that person wants to focus on is what life will be like after a massive stroke. “However, without such conversations beforehand, a patient might end up undergoing unwanted life-sustaining treatment.”