Pediatric Patients — Do We Try Too Hard?

A two-year-old child is brought into the emergency department on a warm summer day after having been found floating in a backyard swimming pool. The paramedics who deliver the child state that the child had no vital signs (blood pressure, pulse, respirations) when they arrived at the scene. After hooking the child to a monitor, they only got a flat line (isoelectric activity, indicating absence of any electrical and certainly absence of mechanical activity in the heart).

This is still true on his arrival in the emergency department, despite approximately 20 minutes of advanced life-support activities (drugs, ventilation, defibrillation when appropriate). Physical exam demonstrates a flaccid child without any signs of cardiac activity or neurological function. Nevertheless, resuscitation is continued for another 45 minutes. When the child still does not respond, resuscitation efforts are finally terminated. The cost of the in-hospital portion of the resuscitation is $2550, the prehospital care is another $750.


Comment: Unlike most adult deaths, the deaths of children seem to affect profoundly the emergency department personnel. The results of prolonging the resuscitative effort often helps lessen the pall that otherwise might hang over the medical personnel for several days.

Also, the remarkable recovery that children make to other serious injuries (especially head injuries that adults might not survive) make it seem reasonable on a gut level to "try hard" to resuscitate all children. Is the effect on the medical personnel worth the cost of the treatment? We may claim, alternatively, that it is not the benefit to the medical personnel that matters but rather it is the benefit to the child that determines what to do.

But this also raises difficult questions. In this case, if the child survives (which is extremely unlikely), he would be profoundly brain-damaged, and probably would be institutionalized for the rest of his life. Should extreme resuscitative measures be taken in order to maintain the life of a "vegetable?"

Commentary

The tragic death of a child is a trying emotional situation for medical caregivers as well as for the family of the child. That situation is made even more difficult when it is accompanied by failure of efforts to resuscitate the patient or to administer other forms of life-preserving treatment. In such cases, the medical team bears the double burden of witnessing the death of a very young patient and experiencing the helplessness and frustration of their own failed efforts.


It is not surprising, then, to learn that attempts to resuscitate children often continue beyond any reasonable probability of success. Such efforts appear to be motivated by two different factors: (a) the remote possibility that continuing the attempt at resuscitation could succeed in reviving the patient, a possibility based on those rare instances in which children have made unprecedented recoveries; and (b) the measure of relief felt by the medical personnel in the knowledge that they did "everything possible" by making a truly heroic effort to combat a tragic death.

VALUE OF PSYCHOLOGICAL COSTS TO MEDICAL PERSONNEL


To inquire whether the psychological benefits to the medical personnel are worth the cost of the treatment — in this case, $3300 — is to pose a thorny cost-benefit question. How can emotional costs and benefits be given a monetary value? Is it even meaningful to try to cast these value judgments in financial terms?

Yet such questions are frequently asked, typically in reference to the monetary costs involved in caring for terminally ill patients in order to confer the benefit to the patient and family of gaining a few more weeks or months of life. In the latter cases, the envisaged benefit is to the patient or family, while the costs are borne by the insurance pool, taxpayers, the hospital, or some combination of these. There is no agreed-upon method for making this type of cost-benefit assessment, much less those in which the presumed benefit accrues not to the patient but to the medical personnel administering treatment.


On the assumption that such cost-benefit analyses are meaningful, however, it is important to conduct the analysis as accurately as possible. If the in-hospital portion of the resuscitation is assessed at $2550 for the 45-minute period, an accurate appraisal would require that the cost of resuscitative efforts of appropriate duration be subtracted from the total cost.

The remainder would then be the cost of the "excessive" portion of resuscitation. It is that additional cost of "trying too hard" that should be questioned in performing a cost-benefit analysis. Even though 20 minutes of advanced life-support activities were conducted prior to arrival at the emergency department, the attempt at resuscitation in the hospital would still proceed for at least another 20 minutes, and probably for 30, based on currently accepted medical standards governing the length of time for cardiopulmonary resuscitation.

The correct computation for the cost-benefit analysis would then leave the cost of 15 minutes of in-hospital resuscitation as the dollar amount to be used in determining whether the effect on the medical personnel is "worth the cost of the treatment." The artificiality of these computational maneuvers is an inevitable feature of almost any attempt to perform an accurate cost-benefit analysis. This is only one among a number of reasons why many ethicists shun cost-benefit analysis as a proper method for arriving at sound conclusions to moral problems.

COSTS AND BENEFITS TO THE PATIENT AND FAMILY


The discussion so far has focused on the cost side of the cost-benefit analysis. What about the benefits? In the case of the drowned two-year-old child, there is no conceivable benefit to the patient.

The remote possibility that prolonged resuscitation could result in restoring biological life cannot be viewed in terms of a positive value to the child, since the neurological damage would be so profound as to render the individual incapable of any human interaction. Life can only properly be seen as a benefit to an individual when the capacity for having distinctly human experiences is present. To exist as a "vegetable" is to fall below the line at which life can be a benefit to the survivor.


If the child did survive as a "vegetable," however, the monetary costs of that survival would be much in excess of the initial $2550 for the in-hospital portion of the resuscitation. Placement in a public or private facility would entail years of financial expense to society or to the family, on behalf of an individual who could not benefit from rehabilitation or other treatment that might be administered to a patient with less severe neurological damage.

These long-term financial costs, added to that of the initial resuscitation, present a distinctly unfavorable cost-benefit ratio, one that could hardly justify the emotional relief gained by the medical personnel from their heroic efforts to reverse a tragic death.

Another cost — a nonmonetary one — must also be factored in. That is the emotional cost to the parents of the child in having to endure the prolonged and continuing agony of its survival in a less-than-human state. Even if the parents did not plan to incur the expense of placement in a private facility, the nonmonetary costs to them would be considerable. In either case — if their child could not be resuscitated or survived in a vegetative state — the parents would most likely endure a lifetime of guilt.


That guilt would no doubt lessen over time but might well persist longer and with greater intensity if the child lived. Survival in an institution would serve as a constant reminder of the tragedy, prolonging both grief and guilt. In the doubly unlikely event that the child survived and the parents decided against institutionalization, the financial costs would be reduced but only at the expense of even greater emotional costs to them.

Assuming again that the task of assessing and comparing nonmonetary costs and benefits is a meaningful one, the conclusion is compelling that the positive effect on the medical personnel as a result of their making prolonged, heroic resuscitative efforts cannot be worth the financial and other costs of the treatment, if the child were to survive.

WITHHOLDING VERSUS WITHDRAWING TREATMENT


Is the same conclusion equally compelling in the more likely event that the child is not successfully resuscitated? The answer is not so clear. All too often in discussions of ethical issues in medicine, the consequences for medical personnel of decisions to treat aggressively, to administer routine therapy, or to forego treatment altogether are ignored.

One familiar exception occurs in discussions of whether withholding treatment is morally different from withdrawing treatment already begun. The most common answer offered by ethicists to this quandary is that no justifiable moral difference exists between these two circumstances. Yet most health care workers report that there is an undeniable psychological difference, one that feels very much like a morally significant difference to the personnel administering care.


The President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research, in its report entitled Deciding to Forego Life-Sustaining Treatment, addressed this issue noting that physicians who allow com­petent patients to refuse a life-sustaining treatment are frequently troubled about stop­ping a treatment that has already been started.

The Commission observed that the "withdrawal of treatment may be more anguishing than withholding it in the first place, but that does not make it morally different." In concluding that "neither law nor public policy should mark a difference in moral seriousness between stopping and not starting treatment," the Commission apparently judged the emotional consequences for the medical personnel to be minimally relevant, at best, as an ethical consideration.

Whether the difference between withholding treatment and withdrawing it is a moral one, or a purely psychological one, depends in part on whose interests are to be morally relevant in the medical setting. If the only consequences that can properly be viewed as morally relevant are those that affect the patient (and perhaps also the patient's family, albeit to a lesser extent), the psychological effect on medical personnel can be discounted as not relevant to the ethics of treatment.


If, however, the ethics of different treatment decisions is a function of the consequences for everyone who stands to be affected, the effect of treatment decisions on medical personnel must be taken into account, although perhaps given a lesser weight than the effects on patient and family. According to classical utilitarian theory (the most prominent ethical viewpoint that bases moral rightness on the consequences of actions), the interests of everyone who stands to be affected must be taken into account in assessing the rightness or wrongness of an action.

However, there is reason to question whether the utilitarian approach in its traditional form is applicable to the medical setting. The ethics of medical practice has long held that the interests of the patient take precedence over those of others who are affected by medical decisions. Should the effects on others be included in the moral equation?

MORAL RELEVANCE OF OTHERS THAN THE PATIENT


To resolve this issue, it is necessary first to recall the purpose of medicine. Although a number of subordinate ends are no doubt served by the practice of medicine, its chief purpose lies in ministering to the sick or injured.

The goals of treatment are typically cited as preserving and prolonging life, curing disease, relieving suffering, and providing comfort to the hopelessly or terminally ill. These aims may sometimes conflict, as is widely acknowledged, but despite the dilemmas that arise as a result of such conflicts, the chief function of medicine is to serve the health-related needs of patients.


This is not, of course, to argue that patients or families can dictate a course of medical treatment or nontreatment that is unacceptable to physicians or other caregivers. The responsibilities of medical personnel include upholding proper standards of care and acting in accordance with the dictates of their own moral principles. In cases where the moral viewpoints of physicians and patients diverge, the physician is obligated to seek another caregiver whose moral precepts more nearly accord with those of the patient.

To argue, however, that the function of medicine is primarily to serve the needs of patients and secondarily those of the family (when patients are incapable of speaking for themselves) is to claim that the emotional effects on medical personnel are not normally compelling factors in treatment decisions.

The question of whether the effect on the medical personnel is worth the cost of excessive resuscitative efforts for the two-year-old child calls for a decision about what factors determine the moral rightness or wrongness of a situation.


The effect on the emergency department team, although surely a matter of emotional concern and profes­sional morale and thus of some moral relevance, should nonetheless not count as decisive factors in reaching an ethical decision about what steps should be taken in treating patients, whether in the emergency department or elsewhere. But that conclusion can be reached without having to undertake the somewhat artificial computation involved in assessing benefits against the monetary costs of a prolonged resuscitation.

OPTIONS


A properly conducted analysis of moral situations on the basis of their consequences must consider all available options and their probable results. The option of prolonging resuscitative efforts beyond a reasonable time is not the only means of lessening the pall that hangs over the medical personnel in such cases.

Other means include holding a conference soon after the unfortunate episode, to review the steps taken and evaluate their appropriateness given the patient's medical condition and prognosis, and providing counseling services and support for the emergency department team, in the recognition that their work regularly involves stress and difficulty coping with the emotional effects of unsuccessful efforts. Although steps like these will not entirely eliminate the staff's troubled feelings following the death of a young patient (or a patient of any age, for that matter), they can serve as a recognition of the emotional toll the practice of medicine takes on a conscientious professional staff.

COST CONTAINMENT INAPPROPRIATE AT BEDSIDE


There is, finally, a general issue of considerable importance raised by this case and the question of whether the extra time spent in resuscitation is "worth it." That issue is the increasing tendency to raise cost considerations in the clinical setting or at the bedside, when they should properly be matters of policy in the hospital or in the de­partment or unit.

The current concerns about containing costs in medical practice are laudable, and there are surely many areas in which budgets can be reduced, unnecessary tests and procedures eliminated, prolonged hospital stays shortened, and methods found to trim undue financial expenses. But a disturbing tendency is emerging on the part of cost-conscious physicians, house officers and, especially, medical students who hear so much about the excessive costs of medical practice.


That tendency is to think that the proper place to act as society's fiscal gatekeepers is at the bedside. Nothing could be more pernicious for the role of physicians as advocates of their patients. It is most inappropriate to judge that a resuscitative effort for a patient is or is not worth it because of the monetary cost of that resuscitation.

This is not to claim that a discussion of the costs of resuscitation is inappropriate. It is rather to argue that the place for that discussion is at the level of policy in the emergency department and not on an individual case-by-case basis. The appropriateness of a prolonged resuscitative effort is, indeed, an ethical question, but that should not be confused with a question about costs.

Although it is probably morally unsound to waste money in any situation, the problem should be dealt with as a matter of emergency department policy. If medical personnel occasionally violate departmental policy, in an attempt to assuage their feelings of helplessness and frustration, they should not be faulted morally because of the incremetal costs incurred by the prolonged resuscitation.

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