The ethical dilemma of medical futility: the case of Mr. X.

Mr. X is a 52-year-old Hispanic man who was admitted to the intensive care unit (ICU) for congestive heart failure. He had mitral valve disease with repair in 1999 and underwent a heart valve replacement in February 2001. Mr. X has a history of renal disease that was diagnosed in 1999 and was treated for a gastric ulcer in 2000. He also has chronic gout. He was diagnosed with multiple myeloma in 2003 and received melphalan and prednisone chemotherapy, resulting in a partial response. His medical record indicates that he had been considered for a clinical trial prior to his current illness. Several months ago, he developed a partial paraplegia secondary to compression fracture of T5 and underwent surgery to reduce the tumor burden on his spinal cord. For the past two months, he has been treated for acute renal failure secondary to the myeloma and respiratory insuffi ciency related to pulmonary disease. Mr. X is currently in multiple organ failure with the following diagnoses listed in his medical record: respiratory failure, congestive heart failure secondary to chronic atrial fi brillation with recent cardiac arrest, history of mitral valve regurgitation following mitral valve replacement, cardiomyopathy, positive fl uid balance, renal insuffi ciency, liver insuffi ciency, chronic anemia, superimposed pneumonia, pulmonary hypertension, underlying parenchymal pulmonary disease, gout, and gastric ulcers. Consultants from oncology, neurology, pulmonology, cardiovascular services, gastroenterology, nephrology, endocrine medicine, infectious disease, and nutrition are managing his current care. A cardiologist at a neighboring hospital cared for Mr. X for approximately nine years prior to transferring services to the current medical facility after he was diagnosed with cancer. Mr. X’s wife works at a nearby hospital. She has used all of her available leave time and has negotiated her work schedule with her employer to be able to briefl y visit Mr. X in the ICU each morning, and then she returns to the hospital after work. Mr. X has two sons who both work and have no paid leave time. Their visits to the hospital are infrequent and brief. The nurses have been fl exible with the family regarding visiting hours because of their diffi culties managing work and family responsibilities. Mr. X’s wife has commented repeatedly on her complete faith in the cardiologist who cared for her husband for many years at what she refers to as “the heart institute.” She has hinted continually that she would like his prior cardiologist to be consulted or believes that her husband should be transferred to the heart institute. She believes that his cancer is not the cause of his decline and that his problems are related to his heart condition; therefore, the cardiologist might be able to intervene as he has in the past. She acknowledges that prior to this admission, Mr. X “had not been doing well” since his discharge earlier in the year following treatment for pneumonia. She said that his activity level had decreased until he was mostly either in bed or in a chair, and he was not able to independently manage activities of daily living. She has not called the cardiologist herself to inquire about a transfer. The nurses and physicians explained to Mrs. X that her husband is currently too ill to transfer to another facility, even if the cardiologist would agree to accept his case. The ICU physician has not disclosed that he already had contacted the cardiologist to review Mr. X’s history, and the cardiologist expressed that he is unwilling to accept the case or visit the patient on consult because he believes that he has nothing more to offer. Mrs. X repeatedly expressed her admiration and confi dence in the prior cardiologist, so the ICU physician felt uncomfortable telling her that the cardiologist refused to visit her husband and was not willing to speak about a transfer. The physician stated that he did not want to undermine a long-standing physician-family relationship; he rather would just let the cardiologist discuss his reasons for declining the case if the wife should decide to call him. During the past week, Mr. X has been intubated and repeatedly failed attempts to be weaned from the ventilator. His condition has never stabilized, and his health status is decliningrapidly. Although the physicians and nurses have kept Mrs. X completely informed of his declining health, she expresses that she “knows he would want everything done to keep him alive.” The sons defer to their mother regarding medical decisions. Mr. X did not have an advance directive. His wife acknowledges that Mr. X never directly discussed his healthcare wishes with his family or his physician, but she knows that he has “fought hard against the cancer” and that “he would not ever just give up.” Mr. X currently is unresponsive and has towels positioned around his face to absorb the continual bleeding from his mouth. The nurses are making efforts to keep Mr. X comfortable and also have reinforced to Mrs. X that he does not seem to be responding to current treatment. When the subject of withdrawing mechanical ventilation (terminal weaning) was mentioned, Mrs. X