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“I had to hold my tongue on multiple occasions from saying, “just because there is a surgical option, doesn’t mean you have to do it… I felt in many family meetings, it was presented to the parents as “this is what we need to do to save your baby” and there was a lack of “these are all the options we have right now.”
“Infant had several episodes over the first week of life that could have allowed parents to change care path, but were encouraged instead to continue on with support.”
The above quotes represent a glimpse into the view of different imperatives at the bedside. Crucially, this view stems from bedside nurses or RTs. For the first part of this post, we will delve into just what an imperative is: the technological imperative and the research imperative. The last part of this post will discuss the so-called window of opportunity.
An imperative, in general, refers to an action or duty that someone cannot avoid. In healthcare, we discuss different imperatives and their impact on care delivered to patients. We will start this discussion with the technological imperative.
The technological imperative refers to the use of technology to maintain life. Importantly, this refers to, at times, cases wherein palliative care may be more appropriate. An economist, Victor Fuchs, first described the technological imperative and coined the term in 1968. Fuchs, and others, described the differences in what can be done versus what should be done, noting that what can be done is clearer. That what can be done is clearer is not surprising. The ability to do something to a patient does not depend on your values or the patient's values. The technology exists with possible manipulations on the patient without concern for the human values.
The should part of the above conundrum is many times harder to decipher. Medical care dictates that the patients receive the best care that is technically available. The expectation of using the best and newest technology is often informed by the patient's wishes or their families. Many patients perceive high-quality of care as directly related to the use of highly sophisticated services. Patients propagate the technological imperative by valuing high-quality care that we've already defined as, for some, the use of highly sophisticated technology. It follows then that any reduction of technology would equate to less quality care for some patients.
The technological imperative speaks to the modern, consumer-driven model of healthcare delivery. In such a model, providers view the patient's autonomy (or the parents' authority) as the primary principle worthy of respect and life's preservation as a primary goal. This viewpoint reflects a more medical view, but the sense that death in the face of advanced technology is a failure is not limited to physicians.
More explicit definitions include:
An image of high-quality medicine that is predicated on a scientific approach to problems, with modern technology providing the instruments with which that approach is practiced
The tendency of the health care system to favor technologically-sophisticated elements in the allocation and use of resources
The pressure to perform a procedure because it can be done
Not addressed above is the segregation between what should be done and what can be done. The technological imperative suggests healthcare providers should do everything given it does not consider the healthcare provider's values or the patient's values. Obviously, we do not exist in such a universe though it may seem as if we do at times. In cases where the outcome is unclear, the technological imperative suggests healthcare providers ought to use technology to prolong life. This proclamation may not be a direct interpretation of the technological imperative but, instead, an acknowledgment that it is easier to do where ambiguity exists than do not. While no morally different than never starting technology in the first place, stopping technology is often more complicated.
Below is a brief video discussing death and healthcare and how the view of death has changed.
The research imperative assumes death is the principal evil of human life. The message of the imperative is that if healthcare cannot eliminate death itself, perhaps researchers can eliminate death causes one by one? This viewpoint leads to a view of death as an accidental event and not an inevitability. The line between death and living has been blurred, inexorably leading healthcare providers to view those who die as having not cared for themselves, received poor care, or because they had genetically unhealthy parents.
The view is that research will cure whatever disease someone died of this year, perhaps in a few years. If only they became sick two years later! The research imperative fights against fatalism, giving up hope, and that we cannot wield nature. What if the research imperative focused on improving the conflict often seen at the end of life?
The research imperative could focus on the prevention of premature death. For example, in the NICU setting, the research could and is, focusing on the birth of premature infants. Such a focus would lessen the burdens of disease and lessen the suffering of parents whose infants are admitted to the ICU. Dr. Callahan, mentioned above in the video, takes this view further, stating scientists should spend research dollars on causes of death that cause death before the age of 65. Such a view would remove spending from diseases predicted to bring about death at an age older than 65 but open up funds for diseases predicted to kill those younger (our babies in the NICU included).
Another view of Dr. Callahan is that treatments or ideals that compress morbidity ought to be funded instead of funding interventions that only prolong life. The compression of morbidity refers to the shortening of time that a person is in poor health before death. In this view, science may not prolong life per se, but science would shorten the time of being acutely ill before death. Regrettably, our healthcare institution is not geared toward the concepts of prevention and health promotion necessary for such an ideal.
When death is imminent, instead of seeking to continue prolongation, Dr. Callahan argues that the healthcare provider should avoid the patient experiencing a tragic death. Dr. Callahan views the prevention of death as an equal value to the avoidance of a horrible death. In this view, preserving life at all costs should not be viewed as a value greater than a peaceful death. This viewpoint opens the door for good palliative care, the topic of our next module.
References:
Callahan D. Death and the research imperative. NEJM. 2000;342
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