Futile Care or Best Practice?
I worked with a patient this weekend that made me question some of the things I automatically do. He is a 16-year-old boy with a severe head injury. All of his physicians are in agreement that his prognosis is poor. I was consulted for family training and positioning. Prior to going into the room his nurse warned me. The mother has unrealistic expectations and believes her son will fully recover.
The PROM exercises were no problem. The problem was the request to replace one of his multipodus boots. The original had become soiled and was thrown away. I saw no problem with it. Proper positioning and pressure relief are necessary to prevent skin breakdown and the assorted problems that come with them. Just because someone has a poor prognosis doesn't mean he will die in the immediate future.
Not everyone agreed with me. The regular NICU therapist was shocked that he'd been issued the original pair. She doesn't issue them to patients with poor prognoses. She felt it was a waste of resources. She was upset the soiled one had been thrown away and didn't want me to replace it. There is some logic to that. Putting something on a patient who won't be ambulating and has a poor prognosis might not be the best use of resources. We only have so many available. Taking one might result in someone else not getting one in a timely fashion.
I replaced the boot. A pressure sore would only complicate an already-complicated hospital course. But the conversation made me think. When did we start deciding who deserved best practice versus adequate practice? When did cost become more important than outcome? Why should he be denied the boot because someone else might need one? I'm not advocating putting him on caseload and following the rest of his hospitalization. That wouldn't be the best use of resources. However, I see no problem with doing something to prevent further complications that we know he is at high risk for.
It really isn't our place to ration therapy based on subjective judgments. Part of our code of ethics is to provide the best reasonable care possible. To me that means every time with every patient. Unless patients are actively dying they deserve our best efforts appropriate for their condition. I can make a good case in this instance. If we start basing treatment decisions on things other than best practice and patient outcomes, our profession begins to suffer.
Unless instructed otherwise, doctors must do everything possible. Shouldn't that hold for us as well?