Title: Policy On Treatments That Are Harmful or Ineffective
Purpose: To ensure that medical treatment always respects the dignity and integrity of both the patient and any involved health professionals.
Policy Statement: The goal of medicine is to benefit the patient, and the process of delivering medical care should always respect the dignity and integrity of both the patient and the health care practitioner.
It is the policy of the Beth Israel Deaconess Medical Center that no patient should be forced to undergo, nor should any physician or health professional be forced to provide, a treatment that is ineffective or harmful. A medical treatment is ineffective if there is no reasonable likelihood that it will achieve a medical benefit to the patient. A medical treatment is harmful if the likely suffering or risk of other harm caused by the treatment grossly outweighs any medical benefit to the patient.
In undertaking the care of a patient, a BIDMC physician will offer all available medical treatments that have a reasonable likelihood of benefit without an overwhelming burden of suffering. If a point is reached when no further medical treatment offers any reasonable hope of benefit without an inordinate risk of suffering, the physician will continue to care for the patient, ensuring that any suffering is minimized and the patient’s dignity is respected.
Procedure(s) for Implementation:
Patients, families and providers generally agree in applying these principles of medical care to achieve patient-centered goals. In rare cases, significant disagreements may arise over whether a treatment is ineffective or is harmful. In such circumstances, if all efforts to achieve agreement fail, the following series of steps is recommended, each in a timeframe appropriate to the patient’s clinical situation, and with documentation in the medical record:
- The attending physician should seek a formal, independent second opinion from a physician not currently engaged in the patient’s treatment. If the consulting physician concludes that treatment is not ineffective and not harmful, the attending physician may choose to provide that treatment or the consulting physician (or another who is willing to do so) may take over care of the patient.
- If the attending and consulting physicians agree that the treatment is ineffective and/or harmful, the patient or family should be offered the opportunity to seek transfer to a facility willing to provide that treatment. The patient or family should be encouraged to seek support and assistance from a BIDMC Patient Relations Representative and/or Social Worker in this and any subsequent steps described below.
- Chief(s) of the relevant medical or surgical service(s) or their designees not involved in the patient’s care
- Chair of the Ethics Advisory Committee (EAC) or designee
- Representative of the Patient Care Assessment Committee (PCAC)
- Senior Vice President of Patient Care Services or designee
- Director of Social Work or designee
- Director of Pastoral Services or designee
- Chief of Psychiatry or designee
- Chief Operating Officer or designee
- Others deemed appropriate by the committee or its chair
The EAC representative will serve as moderator and chair of the committee. A quorum will consist of a minimum of four members, including at least two physicians, since the committee’s core task is to determine, on medical grounds, whether the treatment under consideration is ineffective or harmful. The quorum must include at least one representative of the relevant medical or surgical service(s), and the representative of PCAC.
The committee will consult with the following parties:
a. The attending physician, who should explain the basis for deeming the treatment to be ineffective and/or harmful. Other members of the treatment team should be asked to add details or to offer different perspectives and interpretations.
b. The patient and/or family spokesperson(s), who should explain the patient’s perspective regarding the treatment under consideration, including hopes or expectations of benefit and views about possible harm(s). A BIDMC Patient Relations Representative and/or Social Worker should be available to the patient and/or family before, during, and after this step.
Following as free an interchange of perspectives as possible, the committee will meet alone to determine whether the treatment is ineffective or harmful.* If the committee does not conclude that the treatment is ineffective or harmful, it may offer suggestions for identifying BIDMC staff that may be willing to assume responsibility for the patient’s care. If the committee does conclude that the treatment is ineffective or harmful, it may offer suggestions to the involved clinical service(s) and BIDMC administration regarding steps that may be taken to ensure that BIDMC staff are not forced to provide the treatment.
One or more representatives of the committee will communicate the committee’s conclusion, any related suggestions, and its reasoning to the concerned parties, with documentation in the medical record.
If the patient or family are not in agreement with a determination by the committee that the treatment is ineffective or harmful, and are unable or unwilling to arrange for transfer to another facility, they should be informed of their options for seeking, within a reasonable timeframe, court involvement. Unless there are legal barriers to doing so, however, BIDMC administration shall take steps to support implementation of the committee's conclusion.