MEDICAL FUTILITY AND APPROPRIATE MEDICAL-CARE IN PATIENTS WHOSE DEATHIS THOUGHT TO BE IMMINENT

Often it is very difficult to make decisions involving the termination of aggressive cancer care in the case of patients who are no longer b enefiting, Among these patients, our ability to ''do everything possib le'' to continue life is in conflict with ''doing the right thing''; t he greatest benefit to these patients derives from delivering excellen t supportive care and assisting them in understanding and accepting en d-of-life issues. Furthermore, in a cost-conscious environment with li mited resources, all patients and. indeed, all of society, benefit whe n aggressive and often costly cancer care is limited to those patients who are likely to benefit, However. these issues are complex, blendin g treatment science and ethics, and thus, the physician frequently has no objective reference point on which to base the decisions. This pap er integrates the principles of ethics (respect for autonomy, benefice nce, nonmaleficence, and justice) and three difficult issues encounter ed by physicians in clinical decisionmaking in terminal cancer patient s in the American healthcare system, These issues include: medical fut ility and appropriate care, applications of outcomes research in clini cal decision-making, and impact of cost, particularly in a managed car e environment, on treatment choice, These topics are illustrated with reference to patients presenting to our emergency center with stage IV lung cancer and dyspnea, and the application of an outcomes model und er development to predict imminent death in these patients is discusse d, Outcomes models may provide patients. their families, and their phy sicians with objective data on which to base end-of-life decision-maki ng, Minimizing aggressive treatment of terminally ill patients may pro vide better life quality and will reduce costs during the patients' en d of life, Ethics plays a crucial role in integrating medical science, patient choice, and cost in making appropriate decisions.