Medical futility, medical necessity. The-problem-without-a-name.
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Aged↗
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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↗
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↗
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 and the social context.
The concept of medical futility has come to be seen in some quarters as a value-neutral trump card when dealing with issues of power and conflicting values in medicine. I argue that this concept is potentially useful, but only in a social context that provides a normative framework for its use. This social context needs to include a broad consensus about the purpose of medicine and the nature of the physician-patient relationship.
Conflict, Psychological↗
Medically futile care: the role of the physician in setting limits.
In an effort to clarify the concept of "medically futile care," two types of futile care are identified: 1) care that produces no demonstrable effect; and 2) care that produces an effect that is believed by the speaker to be of no net benefit. It is the second type of futile care, when a patient or surrogate and the clinician disagree over the benefit that the patient will receive from an intervention, that is most interesting morally and that cannot properly be labelled medically futile. As such, decisions to limit access to care deemed futile should not rest with medical professionals. This Article argues for a limited duty of clinicians to provide life-prolonging and some other fundamental care that is equitably funded and desired by the patient while competent, even if the clinician believes that such interventions will produce no net benefit.
Adult↗
Medical futility: response to critiques.
Six years ago, we proposed a patient benefit-centered definition of medical futility that included both quantitative and qualitative components. We distinguished between an effect of a treatment that is limited to some part of a patient's body and a benefit that improves the patient as a whole. The quantitative portion of our definition stipulated that physicians should regard a treatment as futile if empirical data show that the treatment has less than a 1 in 100 chance of benefiting the patient. The qualitative portion of our definition stipulated that if a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, physicians should consider the treatment futile. In this paper, we clarify and modify our original proposal and respond to the following major criticisms: 1) Medical futility is simply an attempt to increase the power of the physician over the patient and to repeal recent hard-gained advances in patient autonomy; 2) no professional or societal consensus has been achieved about the definition of futility; 3) futility is a value-laden determination, the usurpation of which by medicine is inappropriate unless only a so-called value-free or strict physiologic definition of futility is used; 4) the concept of futility is not practically useful because empirical treatment data cannot be applied with certainty to any given patient; 5) futility undermines our pluralistic society and threatens, among other things, the free exercise of religion; and 6) because cost considerations will ultimately dictate all such decisions, futility is an unnecessary concept.
Beneficence↗
Medical futility: its meaning and ethical implications.
The notion of medical futility has quantitative and qualitative roots that offer a practical approach to its definition and application. Applying these traditions to contemporary medical practice, we propose that when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases a medical treatment has been useless, they should regard that treatment as futile. If a treatment merely preserves permanent unconsciousness or cannot end dependence on intensive medical care, the treatment should be considered futile. Unlike decision analysis, which defines the expected gain from a treatment by the joint product of probability of success and utility of outcome, our definition of futility treats probability and utility as independent thresholds. Futility should be distinguished from such concepts as theoretical impossibility, such expressions as "uncommon" or "rare," and emotional terms like "hopelessness." In judging futility, physicians must distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which appreciably improves the person as a whole. Treatment that fails to provide the latter, whether or not it achieves the former, is "futile". Although exceptions and cautions should be borne in mind, we submit that physicians can judge a treatment to be futile and are entitled to withhold a procedure on this basis. In these cases, physicians should act in concert with other health care professionals, but need not obtain consent from patients or family members.
Critical Care↗
Bioethical principles and care-based ethics in medical futility.
The process for solving ethical, legal, and moral dilemmas in the field of medicine is complex and time consuming. Frequently, the constraint of time forces the healthcare professional to make decisions quickly. When working with the cancer population, one faces, additionally, the dilemma of medical futility. Guidelines from the bioethical principles of autonomy, beneficence, nonmalificence, and justice help to address this dilemma. The use of care-based ethics allows healthcare professionals to establish trust, thus enabling patients and their families to be open to change and make realistic decisions. This article contrasts care-based ethical theory with justice-based ethical theory, using a case presentation to illustrate the importance of care-based ethics in making a moral decision to forgo medically futile treatment.
Aged↗
Restructuring the principle of medical futility.
This essay surveys the need for a clear and objective definition of medical futility. It is urged that once agreement is obtained for structuring operational guidelines for determining futility, a three-tier decisional structure can be developed for testing whether a given treatment falls within the scope of these guidelines. Under the first tier, the treating physician would be given the primary responsibility for making the determination to withhold treatment on the grounds of futility. While the physician would be under a duty not to prescribe treatment deemed futile, he would be obliged to inform the patient and his family of this decision, including the reasons for it, in order to allow, under the second tier, for an appeal to be taken by the patient or family to the hospital ethics committee. The third tier recognizes a right of limited appeal to the courts.
Clinical Protocols↗
Medical futility decisions and physicians' legal defensiveness: the impact of anticipated conflict on thresholds for end-of-life treatment.
Does legal defensiveness significantly influence physicians' assessments of medical futility, in ways that may adversely affect the rights of patients and their family members to make their own health care decisions at the end of life? This exploratory study addresses that question with attitudinal data from a survey of 301 physicians practicing in academic medical centers in Texas. The majority of respondents indicated that the probability of success defining futile treatment should hypothetically be lower for patients with potential to benefit more from life-sustaining medical intervention (e.g. typically patients who are sentient), and higher for patients with less potential to benefit (e.g. patients in a persistent vegetative state). That is to say, physicians normally perceive longer odds to be worth pursuing for greater potential gain - a position that seems logically consonant with patients' rational self-interest. However, physicians with an attitude of extreme legal defensiveness did not fit this pattern. Rather, they tended to define futility in a manner that would maximize the physician's latitude to justifiably oppose patient preferences for end-of-life treatment abatement. These findings suggest that some physicians assume an adversarial position in their consideration of medical futility issues - an attitude that anticipates conflict with terminally-ill patients or their surrogates. The analysis presented here is not definitive, but at least raises the question of whether some physicians may inappropriately use their prerogative over medical futility as a means to guard their professional autonomy against perceived threats.
Adult↗
Futile medical treatment and patient consent.
What are a physician's ethical responsibilities when a patient or surrogate demands futile life-saving treatment? Recent attempts to define medical futility have implications for physician responsibility and may create exceptions to acquiring patient consent. Wording is proposed for a "futility clause" for use in do-not-resuscitate policies.
Consensus↗
Medical futility and life-sustaining treatment decisions.
By focusing our attention on the questions of "what are we trying to achieve" and "are we able to do it", the discussion of medical futility has contributed an important dimension to the ethics of treatment decision making near the end of life. It is not simply enough to ask and answer the question of what the patient wants. Healthcare professionals have a responsibility to offer only those life-sustaining efforts that have a reasonable chance of being beneficial. Futility policies should permit treatment-limiting decisions to be made without the agreement of the patient or surrogate at times, but such policies should also provide opportunities to challenge a judgement of futility. Above all, such policies should not be used as a reason to avoid communication. Patients or surrogates need to be informed about what treatments are options and what are not. The futility criterion for limiting treatment should be recognized as a means of contributing to communication and discussion regarding benefits, harms and medical goals. It should not be permitted to bypass such discussions. The recognition of the significance of the concept of futility means that discussion needs to continue at another level as well. The questions of "what are we trying to achieve" and "are we able to do it" are not easily answered. It is especially important, we think, that those who are experienced in working with patients with neurological impairments contribute to the on-going reflection on what constitutes benefit or what is the appropriate use of life-sustaining interventions for such patients.
Adult↗
DNR orders and medical futility.
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Medical Futility↗