As much of the most vocal debate over the U.S. health reform bill focuses on non-existent death panels, a new study suggests that many people in charge of making decisions for incapacitated, very sick people are usually not convinced by what doctors say anyway.

Specifically, the study found that when doctors say an incapacitated, very sick person shouldn't receive more medical treatment because he or she will die soon anyway, people in charge of making decisions for that patient were often skeptical.

We found a great deal of skepticism about whether physicians can actually predict with certainty that a patient will not survive, Dr. Douglas B. White, who conducted the research while at the University of California, San Francisco, told Reuters Health. White now directs the Program on Ethics and Critical Care Medicine at the University of Pittsburgh Medical Center.

Physicians frequently use the so-called futility rationale -- or the argument that further medical treatment is not appropriate because it will not extend a person's life -- to help loved ones make decisions about care.

To see how people on the receiving end of this information perceive it, White and his colleagues interviewed 50 people acting as decision-makers for incapacitated patients being treated in intensive care units.

The researchers presented the decision-makers with a hypothetical situation in which a physician told them their loved one had absolutely no chance to survive the hospitalization. Thirty-two of the study participants, or 64%, said they wouldn't believe the doctor.

In-depth interviews identified four main rationales for these doubts: being skeptical that physicians can predict the future; wanting to see for themselves whether additional treatment would indeed be futile; wanting more sources of information, for example a second opinion from another physician; and believing that God might intervene.

The researchers also asked study participants about whether they would decide to continue life support based on a patient's chances of survival. Thirty-two percent said they would want to continue treatment if the patient had less than 1% chance of survival, while 18% said they would want treatment to continue if the patient had no chance of survival.

The people who questioned the futility hypothesis based on their religious beliefs were four times as likely as people who didn't have doubts to say they would want to continue life support for someone with a very poor prognosis, White and his colleagues found. However, those whose doubts were based on secular considerations were no more likely to want continued life support in this situation than people who didn't doubt a doctor's predictions.

Doctors often use the futility rationale in situations where, for example, they believe the risks of treatment outweigh the potential benefits, or the costs to society are too high, White said. These are important differences in what doctors mean by futility that often go unnoticed and go unspoken but have quite large ethical implications, he said.

At the end of the day, he added, physicians and health care providers need to be very careful to not put their view of what's a life worth living on to patients who may have very different views.

When a decision-maker has religious reasons for questioning the futility of treatment, the researcher said, doctors should seek help from a chaplain or other representative of that person's religion early on to help mediate the conflict, while getting opinions from several doctors may help when decision-makers' doubts are secular.

SOURCE: CHEST, July 2009.

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