Whether it’s an outpatient clinic visit or a prolonged hospital stay in the intensive care unit (ICU), patients who have been deemed to have decision-making capacity have the right to refuse treatment. A physician often assesses four criteria in determining capacity:
- Does the patient understand the treatment?
- Does the patient understand how the treatment applies to their situation?
- Can the patient reason out their circumstances?
- Can the patient express a choice?
Oftentimes patients can decide certain aspects of their care (yes, I’ll take antibiotics for pneumonia) but not others (why do I need an invasive catheterization to assess the extent of coronary artery disease?) Of course, patients have a right to refuse treatment, which often clashes with a physician’s goal to promote wellness.
The 30-day mortality rate following surgery (or 1-year mortality after transplant) crudely reflects how “successful” an operation was. What if that patient was kept on life support in the ICU for 30 days and made DNR/DNI on the 31st day? What if a patient had cardiac arrest one week after a heart transplant with catastrophic neurological consequences requiring lifelong mechanical ventilation? Is it fair to push the family towards transferring the patient to long-term acute care (LTAC) hospital (at least for a year) to deem the transplantation a success?
At the end of the day, it’s really up to the patient, medical proxy, advanced directive, etc. However, I feel like, in the world of transplant surgery, there might be a little more coercion to pursue long-term care rather than realizing the futility of medical care. Loved ones of patients who have fallen victim to difficult post-operative courses are extremely vulnerable and need to be guided accordingly.
Hospitals will always try to make their metrics look good in a society driven by numbers and outcomes. Excellent outcomes = more surgeries = more money. But what about the family who opted to take a healthcare professional’s advice and pursue ECMO, continuous dialysis, mechanical ventilation, tracheostomy, gastrostomy, and every other conceivable modality to stay alive? Having to see their loved one in such a debilitating, often vegetable-like state every single day… when in reality… their substituted judgment may have preferred a do-not-resuscitate (DNR), do not intubate (DNI), withdrawal of care, comfort care, or some other less intense method of care?
End-of-life care is an essential facet of healthcare. Every person should make their wishes clear and legally document them in a form that no other party could exploit because, unfortunately, it happens. 🙁
