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Back to Module 9: Medical Futility Introduction to Medical Futility

Introduction to Medical Futility

• Questions for Consideration
• Common Responses

Definitions of Medical Futility

• The Nature and Limitation of Futility Definitions
• Is This Really a Futility Case?
• Types of Futility Conflicts

Objectives of this Module

Introduction to Medical Futility

• Patient or surrogate requests therapy that the physician does not think is beneficial
• Clear, unequivocal medical futility is rare
• Conflict resolution is often the issue
• Physician may be pursuing unrealistic or unwanted plans
• Proxy may have difficulties in performing role
• Misunderstandings about prognosis
• Personal factors such as distrust or guilt
• Values differences
• Understanding the conflict may allow resolution
• Fair process for conflict resolution is recommended for intractable difficulties

For Example

Imagine a case involving a patient in a vegetative state, whose life is being supported mechanically, and whose family insists that "everything be done"

Questions for Consideration

• How should physicians approach this type of situation?

• How might the physician better understand the reasons for the family’s seemingly irrational request?

• Are there techniques that are useful for ensuring that both parties feel they have been supported and understood?

• In those rare instances where a mutually acceptable resolution is not possible, how should the physician balance his or her own concerns with those of the patient and family, and those of the health care system?

• Ultimately, what is the physician’s responsibility in providing futile care?

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Common Responses

• Frustration and distress

• Health care team may feel that the family is:

• Unreasonable
• Wasting scarce economic resources
• Causing increased pain and suffering prior to patient's ultimate demise

• Physicians may distance themselves from the family

• Accuse family members of ulterior motives
• Argue that nonprofessionals should not be allowed to make "medical decisions"

• Patient and/or family

• Already stressed by the realities of life-threatening illness
• May feel isolated, misunderstood, or abandoned
• React by suggesting that the health care team does not "care" about their loved one
• Impute financial, racial, or other prejudices to the team

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Definitions of Medical Futility

• Won’t achieve the patient’s intended goal
• Serves no legitimate goal of medical practice
• Ineffective more than 99% of the time
• Does not conform to accepted community standards

The Nature and Limitation of Futility Definitions

Evidence

In the majority of situations in which death is imminent, consensus is reached and life-sustaining interventions are not provided. Investigators using the SUPPORT study database found only 32 patients (0.7%) of 4301 whose prognosis for survival was less than 1% on their third hospital day who did not have a DNR order in the medical record

Examples

• life-sustaining interventions for patients in a persistent vegetative state


• resuscitation efforts for the life-threateningly ill


• use of chemotherapy in patients with far advanced cancer


• use of antibiotics or artificial hydration for patients who are in advanced stages of the illness

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Is This Really a Futility Case?

• Unequivocal cases of medical futility are rare

For Example

Attempt to resuscitate a patient who is decapitated. In this situation, CPR would be futile according to all conceivable definitions

• Miscommunication or value differences are more common

• Conflict over treatment; not clear how to reach resolution


• One view--physicians should neither offer nor provide therapy that is unlikely to work, or will only result in a poor quality of life


• Violate professional integrity
• Offer false hope
• Inflict harm without possible benefit


• Other perspective-- why should physician values override patient and family values, especially when those values are religiously based?

• Case resolution - an important principle

• Difficult to differentiate "futile" therapy from "low-yield" therapy


• Case-by-case basis for defining futility recommended by AMA’s Council on Ethical and Judicial Affairs


• Need to find a fair process of resolution more important than futility definition

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Types of Futility Conflicts

• Disagreement over goals

For Example

One party wishes to preserve life "at all costs" while the other party concludes that preserving life is not a worthwhile goal

• Disagreement over benefit

For Example

Pursue a therapy that is highly unlikely to achieve the agreed upon goal (i.e., a "miracle") while the other party does not believe the chances of success are high enough to continue treatment

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Objectives of this Module

• List factors that might lead to futility situations
• Understand how to identify common factors
• Understand how to communicate and negotiate to resolve conflict directly
• Understand the steps involved in fair processes to resolve intractable conflict

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