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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 9: Medical Futility
    Introduction to Medical Futility

    Introduction to Medical Futility Definitions of Medical Futility 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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