Frailness and Chronic Illness
When deciding about new medical intervention in very ill patients, it is helpful to distinguish between two different types of cases:
- “End-of-life” illness: Patients who have a definite, incurable disease process that is progressively worsening and will eventually be fatal. Doctors have diagnosed a specific, terminal disease, such as advanced cancer. Medical treatment might slow the disease’s progression, but we can nonetheless predict within a certain period of time that death will occur.
- Acute Critical Illness: In this case, there is no clear terminal diagnosis. Nonetheless, various factors indicate a very low probability of surviving the episode and returning to a reasonable level of functioning. These might include:
i) Severe, underlying chronic illness, which compromises the patient’s ability to handle a new problem (such as life-threatening influenza).
ii) An older body that has grown particularly frail, as indicated, for example, by muscle weakness and/or weight loss, and now has become threatened by a new, acute illness.
At times, stabilizing such patients may require aggressive interventions, such as: Intubation, surgery, dialysis, chemotherapy, and a feeding tube.
Doctors will typically take several variables into account when assessing the probability of the patient emerging intact from such interventions. These include:
- Diagnosis: What’s the medical problem, and how reversible might it be?
- Patient Condition: Given the patient’s condition (age, frailness, severity of illness, health history, cognitive status), how likely is it that their body can recover?
Many times these factors coalesce into a highly complex scenario in which multiple physical or cognitive conditions (“comorbidities”) coexist. A patient, for example, might have kidney failure, moderate dementia, and pneumonia all at once. Another could have those ailments and be additionally hampered by congestive heart failure, loss of appetite, or COVID-19. Despite all of these factors, in these cases there is often no specific terminal diagnosis because no factor definitively points to such a declaration. As with many healthcare dilemmas, decisions must be made without total certainty.
Doctors can try to estimate the chances of survival from a given intervention and in what state a person might recover. At the same time, there’s always a risk that an aggressive intervention on a frail person may be overall ineffective and just lead to unnecessary suffering.
May a frail patient elect not to undergo an aggressive intervention that may be ineffective and lead to suffering?
Generally speaking, there are a three approaches within contemporary rabbinic literature:
- The patient should undergo such treatments. Given the lack of a terminal diagnosis, a person should take any necessary steps to extend their life as long as such interventions are not deemed medically futile.
- A person should be encouraged to take such treatments but is not required to do so. Given their frailty, unstable condition, and the potential negative consequences of an intervention, they may choose to focus their treatments on supportive care and comfort while living the rest of their life to the fullest that they can, if that is what they prefer.
- A person in such a circumstance has the prerogative to take either course of action. A patient may forego treatment in situations in which reasonable people might conclude that the downsides outweigh the benefits.
Each circumstance should be evaluated on a case-by-case basis. Decisions may also be made at the time of initial treatment to stabilize a critical illness but then revisited regarding further treatments down the line. It should be noted, however, that some decisions (such an intubation) may become harder to revisit if forgoing further treatment actually entails withdrawing treatment. (See here).
Who Can Make This Decision?
Ideally, this decision should be made by the patient themselves. If the patient lacks sufficient cognition, a family member or health-care proxy can decide to decline treatment based on the previously expressed directives of the patient, or, if necessary, by analyzing what the patient would want to be done in such a case (“substitute judgment”).
The Ematai advance healthcare directive and conversation guide can help families discuss these choices before a moment of an acute crisis so they can make the best decisions for that individual in an informed manner.