Doctors must stop giving treatments that don’t help their patients, even if their families insist, the Israel Medical Association says in a paper addressing the treatment of terminal patients.
The paper tells doctors not to attempt resuscitation attempts or administer other treatments if they are known to be futile in advance. When the medical solutions prove ineffective, doctors should move on to supportive or palliative care, it says.
Resuscitation attempts or tests and treatments that won’t help the patient or prolong his life could be redundant and even harmful. “The futile treatment infringes on the patient’s right to put his affairs in order while he is still capable of doing so,” the paper says
The paper says doctors frequently administer treatment they know is futile for non-medical reasons, such as compassion or difficulty to give the bad news to the patient’s family.
The paper says there is no justification for carrying out resuscitation when the doctor knows it won’t help or prolong the patient’s life and in some conditions could even be seen as harmful.
“We must remember that the word ‘resuscitation’ means to the public at large to bring a dead man back to life,” the paper says. “A family asked whether to carry out resuscitation will mostly say ‘yes.’ If only because they might erroneously think that if they say ‘no’ to resuscitation they will lead to the death of the father, the mother or any dear person.”
The paper stresses however that this does not mean support for euthanasia, which is a criminal offense in Israel.
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Entitled “Terminal Patients and Futile Treatments” the paper lays out ethical principles doctors must act on while treating such patients. It says “the futile treatment infringes on the patient’s right to put his affairs in order before he is incapable of doing so, and denies his dear ones the right to say their farewells and get on with their lives.”
More than 30,000 people are diagnosed with cancer and 10,000 people die from it every year, alongside other patients with incurable diseases. Almost every Israeli family has dealt or is dealing with a close person suffering from a terminal illness. Dr. Tami Karni, chair of the Ethics Board, says “the ethical questions that have been raised in recent years about treating these patients have become frequent and required guiding principles.”
“Doctors often mix considerations of fear of legal suits with excess response to strange unprofessional requests by the patient’s families or relatives,” she says. The difficulty to give the patient and his family the bad news could also result in continued treatment which is known to be futile.
The principles deal with making sure the patient’s expectations are realistic, sharing the situation with the family and attempting to decide on the desired treatment in advance. The paper says the doctor should avoid hiding and embellishing the situation for the patient, and that his loyalty should be first to the patient, ahead of the family.
The main emphasis is on the doctor’s loyalty to his medical knowledge and professional judgement regarding the treatment’s effectiveness, even at the cost of giving up and giving the family the bad news.
Karni says that often the doctor’s professional decision is mixed up with the patient’s autonomy.
Sometimes the family is deluded, after looking in the Internet, into believing there’s a cure for their loved one. This undermines the relationship with the doctor and leads to loss of confidence in his professionalism and intentions. “When a doctor sees the treatment isn’t working and isn’t contributing to the patient he must stop it. Even if the family insists on continuing it,” says Karni.
Some doctors find it hard to confront the patient and his family and are led to carrying out examinations and treatments that not only don’t prolong the patient’s life but often lead to unnecessary adverse effects and even harm. The paper states that “when harm is caused by adverse effects and there’s no effect on the malignant tumor, or when there’s an operation that won’t solve incurable medical problems, act on the basis of the principle ‘first do no harm’. When there is fear that the treatment itself will shorten a patient’s life, it must not be administered.”
The paper stipulates that when the medical solutions run out, the doctor must move on to supportive treatment to improve the patient’s quality of life.