by David Magnus, PhD and Norm Rizk, MD
This issue’s target article by Kirby (2016) raises an incredibly important and challenging set of issues: Whether, when, and how should limits be placed on patient access to intensive medical care? What are limits of shared decision making? Is bedside rationing ever appropriate? Kirby’s move away from bedside rationing to a mesolevel approach is novel and interesting. However, as some of the commentaries note, the question of whether there are limits to what will be offered to patients and their families often has to be made at the bedside.
Consider the following cases:
- An 84-year-old man with altered mental status, severe aortic stenosis, congestive heart failure, coronary artery disease, and chronic kidney disease presents with increased difficulty breathing. Standard medical management of the patient’s heart failure is no longer working. His desperate family asks for a surgical consult to consider whether there are any surgical interventions (including a ventricular assist device) that would give the patient a chance to live longer. The cardiology team and the cardiothoracic surgeons all agree that there is a small chance (different physicians vary in their estimate, but it ranges from 5 to 20%) that the patient will have his life prolonged by the surgery, but a very high chance he will die either during surgery or from postoperative complications. Considering his background state of health, likely quality of life, and the risks and benefits, the surgeons (with support from the cardiologists) decide that the burdens of treatment outweigh the benefits and decide that the patient is not a surgical candidate.
The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.