Medical futility, medical necessity. The-problem-without-a-name.
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Medical futility.
"Medical futility" may be provisionally defined as a medical conclusion that a therapy is of no value to a patient and should not be prescribed. The current debate about medical futility is one of the most important and contentious in medical ethics. Proponents believe that allowing physicians to determine and withhold futile therapies can be done without disturbing the current paradigm of medical ethics which respects patient autonomy with regard to informed consent and the right to refuse treatment. Others conclude that medical futility is simply an unacceptable form of medical paternalism. Some adopt a middle position that doctors can predict medical futility; they believe that attempting this does not necessarily justify imposing decisions to forgo life-sustaining therapy on patients. Regardless of its policy outcome, this important debate is leading to a reexamination of the nature of a patient's entitlement to health care and of the ends of medicine. It has two aspects. A definitional debate examines the concept of medical futility and its derived clinical criteria. A second debate considers the nature of the authority and procedures to act on the conclusion that a therapy is futile by withholding or withdrawing treatment.
Decision Making↗
Medical futility and care of dying patients.
In this article, I address ethical concerns related to forgoing futile medical treatment in terminally ill and dying patients. Any discussion of medical futility should emphasize that health professionals and health care institutions have ethical responsibilities regarding medical futility. Among the topics I address are communicating with patients and families, resolving possible conflicts, and developing professional standards. Finally, I explore why acknowledging the futility of life-prolonging medical interventions can be so difficult for patients, families, and health professionals.
Beneficence↗
Medical futility and appropriate medical care in patients whose death is 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 benefiting. Among these patients, our ability to "do everything possible" to continue life is in conflict with "doing the right thing"; the greatest benefit to these patients derives from delivering excellent supportive care and assisting them in understanding and accepting end-of-life issues. Furthermore, in a cost-conscious environment with limited resources, all patients and, indeed, all of society, benefit when aggressive and often costly cancer care is limited to those patients who are likely to benefit. However, these issues are complex, blending treatment science and ethics, and thus, the physician frequently has no objective reference point on which to base the decisions. This paper integrates the principles of ethics (respect for autonomy, beneficence, nonmaleficence, and justice) and three difficult issues encountered by physicians in clinical decision-making in terminal cancer patients in the American healthcare system. These issues include: medical futility and appropriate care, applications of outcomes research in clinical decision-making, and impact of cost, particularly in a managed care 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 under development to predict imminent death in these patients is discussed. Outcomes models may provide patients, their families, and their physicians with objective data on which to base end-of-life decision-making. Minimizing aggressive treatment of terminally ill patients may provide better life quality and will reduce costs during the patients' end of life. Ethics plays a crucial role in integrating medical science, patient choice, and cost in making appropriate decisions.
Adenocarcinoma↗
Disability versus futility in rationing health care services: defining medical futility based on permanent unconsciousness--PVS, coma, and anencephaly.
All societies must ration health care services in the face of unlimited demand. The concept of medical futility may appear to be an uncontroversial means by which to ration services. Depending upon how it is applied, however, limiting services based on alleged medical futility may violate prohibitions against disability-based discrimination. In particular, use of medical futility to require removal of life-sustaining interventions has been held to violate the Americans with Disabilities Act. The ADA protects both people with disabilities who are conscious and people in unconscious states, such as permanent vegetative state (PVS), coma, and anencephaly. Ultimately, as the number of people in permanently unconscious states increases, our society will have to recognize that consciousness is an essential characteristic defining human beings and determining whether a legal right to unlimited life-sustaining intervention should apply. This article proposes to define medical futility to preclude life-sustaining interventions after a stated period of permanent unconsciousness and to redefine the end of life consistently as neocortical death.
Anencephaly↗
Medical futility and nursing.
Defining medical futility is central to the efforts of clinicians and ethicists who seek to identify the limits of patient autonomy. This article is a critique of current efforts to define and then use policies of medical futility to justify refusing requests for treatment and care that have no perceived medical benefit. After exploring the current definitions of medical futility in the bioethics and clinical literature, comparisons of the advantages and disadvantages of the following three options are provided: allowing patients to decide all but physiologic futility, allowing clinicians to decide futility, and pursuing negotiated compromise. The third option--negotiated compromise--is recommended. A role is developed for nurses in preventing and resolving conflict about futile treatment.
Decision Making↗
Fruitful or futile: intensive care nurses' experiences and perceptions of medical futility.
The study sought to investigate the perceptions and experiences of nurses practising in adult intensive care units (ICUs) with regard to medical futility. A qualitative exploratory descriptive design was used, providing a framework which enabled information to be gathered on a relatively undefined phenomena. Data were gathered via semi-structured interviews with seven intensive care nurses. Findings concluded that there is no 'one size fits all' definition of medical futility. To arrive at the decision whether treatment is futile, participants want to understand patients' views on treatment limitation. In some ICUs, 'the decision' about whether to cease or continue treatment is unilaterally made by medical staff, raising concerns about value laden judgement. Nurses experience frustration with having to administer treatment with which they do not agree and may actually leave intensive care nursing because of their moral conflict. There are opportunities for nurses to have input into 'the decision', but they must have a cogent and articulate approach to be heard. Once treatment is deemed to be futile, nurses play a key role in treatment withdrawal and can have a significant impact on the patient and family experience if they manage the situation well; this nursing role in medically futile situations and treatment withdrawal is detailed. 'Medical futility' is not easily defined. Understanding patients' views about treatment limitation is important in deciding whether treatment is medically futile. To do this, an inclusive decision making process should be developed by ICUs which incorporates nursing and family input. Experienced ICU nurses can have a significant impact on the management of futile cases; they need to share their understanding of the processes surrounding medical futility and assist junior nurses in negotiating the difficult challenges encountered in decision making and treatment withdrawal.
Adult↗
Medical futility in the natural attitude.
Medical futility has a long history going back to Plato but continues to be a controversial topic. Patients, families, and health professionals are faced with decisions about which treatments and interventions may be futile, but such questions as who decides; how do competing values get resolved; what value is placed on human life; how are decisions balanced according to reason and, in some circumstances, faith; and who decides effect, benefit, and burdens of treatments are often difficult to answer. The naïve reality of medical futility is explored in the natural attitude to expose presumptions and facts related to both physiologic (fact-based) and evaluative (value-based) futility components. Highlights from the bioethical and clinical literature, a review of 3 landmark cases, and implications for nursing practice are presented. This natural attitude description could serve as what ought to be bracketed for a future phenomenology.
Adult↗
A broader look at medical futility.
This paper attempts to provide a descriptive theoretical overview of the medical futility debate. I will first argue that quantitative data cannot alone resolve the medical futility debate. I will then examine two aspects of medical futility, which I call the prospective and immediate, respectively. The first involves making prospective factual and value judgments about the efficacy of proposed medical interventions, while the latter involves making value judgments about ongoing medical conditions where the clinical data are clear. At stake is the nature and scope of individual rights. Thus, I maintain there is an undeveloped aspect to the medical futility debate and, briefly, analyze two political perspectives which give rise to different understandings of medical futility. The view that I will defend is that only a system with defined collective goals can accommodate a normative concept of medical futility. These larger questions are the value options which if unaddressed, may be settled by default of economic grounds.
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Medical futility.
The debate on medical futility can lead to a fresh revisiting of the doctor-patient relationship and with it a restoration of common sense and reality to society's grasp of the powers and limits of medicine. In my view, the duty of the physician is to attempt that which is of therapeutic benefit to the patient. Nothing less and nothing more.
Cross-Cultural Comparison↗
The attitudes of patients with advanced AIDS toward use of the medical futility rationale in decisions to forego mechanical ventilation.
BACKGROUND: The medical futility rationale asserts that physicians need not offer their patients therapies that have zero or close to zero probability of success. The rationale is controversial, but it is used in practice. OBJECTIVE: To examine the attitudes of patients with advanced acquired immunodeficiency syndrome (AIDS) toward the medical futility rationale as it might apply to their medical care. METHODS: We conducted a cross-sectional study with interviewer-administered questionnaires. Fifty-seven patients with advanced AIDS (C3 stage AIDS and a CD4 cell count <100/microL) were recruited from academic and private clinics. MAIN OUTCOME MEASURE: Whether patients believe it is acceptable for physicians to withhold mechanical ventilation, without offering it, if physicians determine the intervention is futile. RESULTS: Sixty-one percent of patients (n=35) believed that it was definitely acceptable for their physician to not offer mechanical ventilation if the physician judged this intervention to be futile, and 26% (n= 15) believed this was probably acceptable. Less than 10% of patients (n= 5) said not offering therapy judged futile was definitely not acceptable. Patients who were less likely to prefer mechanical ventilation in different hypothetical health states were significantly more likely to accept decisions on the basis of futility (P=.003). Health-related quality of life, patient satisfaction with medical care, and patient-clinician communication about end-of-life care were not associated with attitudes toward medical futility. CONCLUSIONS: Although the majority of patients with advanced AIDS accept the medical futility rationale, a substantial minority do not. Acceptance of this rationale was associated with wanting less life-sustaining treatment. Physicians invoking the medical futility rationale and hospitals using policies incorporating the medical futility rationale should take into account this diversity in the attitudes toward medical futility.
Acquired Immunodeficiency Syndrome↗
Medical futility. Committee on Bioethical Issues of the Medical Society of the State of New York.
The term futile is used in many different ways. It is therefore difficult to decide whether a procedure or treatment such as CPR or hemodialysis or blood transfusion would be futile in a given case. The AMA's guidelines on the appropriate use of DNR orders state that DNR decisions should be made openly. Institutions should have policies and physicians should elicit the patient's preferences about CPR. For physicians, the question is no longer whether we should discuss DNR orders with our patients; instead, the issue is how to do so with compassion and caring. Physicians should share with patients their judgment about what medicine can and cannot do. Then physicians must "make decisions about when to withhold or limit resuscitation openly" in honest and trusting conversation between doctor and patient. Often CPR is an exercise in futility. The medical profession should be vested with the authority to make futility decisions if they are the product of open discussion and shared deliberation between physician and patient, family, or surrogate. Rationing, triage, and medical futility in relation to AIDS patients require careful deliberation and consideration. What was considered medically futile five years ago for an AIDS patient may be appropriate care nowadays. The need for appropriate use or non-use of life-sustaining therapy for the elderly, the terminally ill, patients with AIDS and other incurable illnesses is evident to patients, health care providers, policy makers, and the public. CPR should only be administered if it is expected to confer lasting benefit to the patient. However, if 10% of elderly patients benefit from CPR in the case of out-of-hospital cardiac arrest, how can one consider this procedure futile? Although communication between physician and patient about difficult treatment limitation decisions has markedly improved in recent years, it remains a problem, largely because open dialogue with patients and families about futility is a demanding emotional and intellectual task. The medical profession is charged with setting standards for the proper implementation of judgments regarding futility.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiopulmonary Resuscitation↗
Judging medical futility: an ethical analysis of medical power and responsibility.
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Ethics, Medical↗
Use of the medical futility rationale in do-not-attempt-resuscitation orders.
OBJECTIVE: To describe the use of the medical futility rationale in do-not-attempt-resuscitation (DNAR) orders written for medical inpatients. DESIGN: Structured interviews with medical residents. METHODS: Second- and third-year internal medicine residents (n = 44) were telephoned weekly and briefly interviewed about each patient who received a DNAR order in the preceding week. SETTING: Two university-affiliated hospitals: a veterans affairs medical center and a municipal hospital. PATIENTS: One hundred forty-five medical inpatients for whom DNAR orders were written during their hospitalization. RESULTS: Residents stated that the medical futility rationale applied for 91 patients (63%), but this rationale was invoked independent of patient or surrogate choice for only 17 patients (12%). Of the 91 patients for whom futility applied, both quantitative futility (low probability of success) and qualitative futility (poor quality of life if cardiopulmonary resuscitation [CPR] were performed) applied to 45 (49%), quantitative futility alone to 30 (33%), and qualitative futility alone to 16 (18%). Residents report that they discussed resuscitation issues with all communicative patients for whom the medical futility rationale was invoked. Among patients for whom quantitative futility applied, residents' predictions of the probability that patients would survive to hospital discharge after CPR varied from 0% (for 60% of patients) to 75%. For 32% of these patients, residents predicted survival at 5% or more. Logistic regression modeling showed that the presence of organ failure (odds ratio [OR], 8.9; 95% confidence interval [CI], 3.3 to 23.9), the residents' estimates of the probability of surviving CPR (OR, 0.94; 95% CI, 0.88 to 0.99), and nonwhite race (OR, 2.7; 95% CI, 1.1 to 6.3) were associated with the determination of quantitative futility. In one third of the cases where qualitative futility applied, residents made the judgment of qualitative futility without discussing quality of life with communicative patients. Logistic regression modeling showed immobility (OR, 3.2; 95% CI, 1.1 to 9.0) and age > or = 75 years (OR, 0.3; 95% CI, 0.1 to 0.8) to be associated with the determination of qualitative futility. CONCLUSIONS: While residents did not appear to use the medical futility rationale to avoid discussing DNAR issues with patients, we found evidence of important misunderstandings of the concepts of both quantitative and qualitative futility. If the futility rationale is to be applied to withholding or withdrawing medical interventions, practice guidelines for its use should be developed, and education about medical futility must be incorporated into medical school, residency training, and continuing medical education programs.
Cardiopulmonary Resuscitation↗
Medical futility: definition, determination, and disputes in critical care.
Physicians may employ the concept of medical futility to justify a decision not to pursue certain treatments that may be requested or demanded by patients or surrogates. Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient's medical condition. Medical futility remains ethically controversial for several reasons. Some physicians summarily claim a treatment is futile without knowing the relevant outcome data. There is no unanimity regarding the statistical threshold for a treatment to be considered futile. There is often serious disagreement between physicians and families regarding the benefits to the patient of continued treatment. Medical futility has been conceptualized as a power struggle for decisional authority between physicians and patients/surrogates. Medical futility disputes are best avoided by strategies that optimize communication between physicians and surrogates; encourage physicians to provide families with accurate, current, and frequent prognostic estimates; assure that physicians address the emotional needs of the family and try to understand the problem from the family's perspective; and facilitate excellent palliative care through the course of the illness. Critical care physicians should support the drafting of state laws embracing futility considerations and should assist hospital policymakers in drafting hospital futility policies that both provide a fair process to settle disputes and embrace an ethic of care.
Aged↗
Experts' attitudes towards medical futility: an empirical survey from Japan.
UNLABELLED: BACKGROUND The current debate about medical futility is mostly driven by theoretical and personal perspectives and there is a lack of empirical data to document experts and public attitudes towards medical futility. METHODS: To examine the attitudes of the Japanese experts in the fields relevant to medical futility a questionnaire survey was conducted among the members of the Japan Association for Bioethics. A total number of 108 questionnaires returned filled in, giving a response rate of 50.9%. Among the respondents 62% were healthcare professionals (HCPs) and 37% were non-healthcare professionals (Non-HCPs). RESULTS: The majority of respondents (67.6 %) believed that a physician's refusal to provide or continue a treatment on the ground of futility judgment could never be morally justified but 22.2% approved such refusal with conditions. In the case of physiologically futile care, three-quarters believed that a physician should inform the patient/family of his futility judgment and it would be the patient who could decide what should be done next, based on his/her value judgment. However more than 10% said that a physician should ask about a patient's value and goals, but the final decision was left to the doctor not the patient. There was no statistically significant difference between HCPs and Non-HCPs (p = 0.676). Of respondents 67.6% believed that practical guidelines set up by the health authority would be helpful in futility judgment. CONCLUSION: The results show that there is no support for the physicians' unilateral decision-making on futile care. This survey highlights medical futility as an emerging issue in Japanese healthcare and emphasizes on the need for public discussion and policy development.
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["Medical futility": the doctor caught between the demands for and the limitations of treatment].
The term medical futility is applied to justify withholding treatments in patients who are likely to gain minimal benefit. Futility refers to limiting the moral obligation to provide medical treatment on the basis of clinical efficacy. Current discussions about the meaning of medical futility revolve around two distinct but related concerns. Firstly, whether it is possible to define medical futility in a way that enables objective assessment. Secondly, who should determine when a treatment is futile. In this article we summarize the debate about futility and discuss the relevance of this concept.
Decision Making↗
Do-not-resuscitate orders and medical futility.
This report addresses the difficult situation in which a patient or surrogate decision maker wishes cardiopulmonary resuscitation to be attempted even though the physician believes that resuscitation efforts would be futile. It also reviews current controversies surrounding the subject of do-not-resuscitate (DNR) orders and medical futility, discusses the complex medical, legal, and ethical considerations involved, and then offers recommendations as a guide to clinicians and ethics committees in resolving these difficult issues. Conflicts over DNR orders and medical futility should not be resolved through a policy that attempts to define futility in the abstract, but rather through a predefined and fair process that addresses specific cases and includes multiple safeguards. As it examines these issues, the report focuses on the Veterans Health Administration (VHA). Current national VHA policy constrains physicians from entering a DNR order over the objection of a patient or surrogate even if the physician believes cardiopulmonary resuscitation to be futile. The VHA National Ethics Committee recommends that VHA policy be changed to reflect the opinions expressed in this report. The National Ethics Committee, which is composed of VHA clinicians and leaders, as well as veterans advocates, creates reports that analyze ethical issues affecting the health and care of veterans treated in the VHA, the largest integrated health care system in the United States. This report does not change or modify VHA policy.
Cardiopulmonary Resuscitation↗