Towards a just, courageous, and honest resolution of the futility debate

Treatment withdrawal of the patient on end of life: An analysis of values, ethics and guidelines in palliative care

AIM

Family surrogate decision-making during the later stage of a patient's life may sometimes result in conflict and emotional distress among the parties involved. The present article aims to promote ethical end-of-life decision-making among healthcare professionals in a view to eliminating any misunderstanding that may arise while meeting the care needs of the patient.

DESIGN

A case study involving a request for treatment withdrawal by the family of a patient on end of life.

METHODS

This paper draws upon a scenario encountered during practice to analyse the moral commitments in delivering high-quality end-of-life care with much emphasis on pre-existing palliative care guidelines for adults.

RESULTS

Healthcare professionals are bound by the principle of beneficence, non-maleficence, autonomy and justice. Although the use of guidelines may be tenable, decisions often take into consideration the patient's choice and then weighed against the moral values of healthcare specialists and those required in the profession.

Futility, conscientious refusal, and who gets to decide

Most discussions of medical futility try to answer the Futility Question: when is a medical procedure futile? No answer enjoys universal support. Some futility policies say that the health care provider will answer this question when the provider and patient (or surrogate decisionmaker) cannot agree. This raises the Decision Question: who has the moral authority to decide what to do in cases where futility is disputed? I look for a procedural answer to this question, an answer that does not turn on whether a given party happens to answer the Futility Question correctly. I argue that these policies get it right; the provider should decide because providers have a right of conscientious refusal that extends to refusing procedures on grounds of futility. This is a procedural answer because providers have this right even if they are sincerely mistaken about whether a procedure is futile.

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.

"There is power in the blood": a case discussing ethical issues of utility of resources

The allocation of medical resources is often a great concern in the United States. This article discusses a case concerning utility of resources in a patient with a terminal disease. We assert that the goals of treatment tailored to an individual patient should be made at the bedside by a fiduciary (physician) in conjunction with the patient's preferences and values. There is great responsibility in making these decisions and it is critical that they be made at the bedside with the patient and family clearly aware of the goals of treatments and informed of treatment limitations.

Do parents or surrogates have the right to demand treatment deemed futile? An analysis of the case of Baby L

Do parents or surrogates have the right to demand treatment deemed futile? An analysis of the case of Baby L The purpose of this discussion paper is to address and analyse the ethical issues arising from the following questions: Do parents or surrogates of newborn infants have the right to demand treatment deemed 'futile'? Should the religious beliefs of the infant's parents be given special consideration when deciding on the correct course of action? The case of Baby L, an infant born with severe disability will be used to aid the analysis. It is argued that health care providers have no obligation to provide 'futile' treatment based on the surrogates' right to autonomy, but an obligation may arise from a duty of benevolence. However, acting from a duty of benevolence can ignore considerations of justice and fairness and does not always prompt the right course of action. Any decision regarding treatment options will involve ranking the beliefs and values of the parents or surrogate against the integrity of the health care team and the interest of society as a whole. The consequences of continuing or discontinuing life-sustaining treatment for the infant, the parents and the health care team will also be considered and examined.

The role of futility judgments in improperly limiting the scope of clinical research

In medical research, the gathering and presenting of data can be limited in accordance with the futility judgments of the researchers. In that case, research results falling below the threshold of what the researchers deem beneficial would not to be reported in detail. As a result, the reported information would tend to be useful only to those who share the valuational assumptions of the researchers. Should this practice become entrenched, it would reduce public confidence in the medical establishment, aggravate factionalism within the research community, and unduly influence treatment decisions. I suggest alternative frameworks for measuring survival outcomes.

The eclipse of the individual in policy (where is the place for justice?)

Several inquires about healthcare over the past several decades have shown that the evolution of healthcare practices exhibit their own microcosm of local and political influences. Likewise, other studies have shown clearly the ways in which both external and internal institutional factors establish the sectors within which healthcare is delivered. Although restrictions have always been present in some form, it seems obvious that whatever the precise form of healthcare delivery that results from current changes in its organization, there are going to be broader restrictions not only on the choices that providers will be able to make about individual patients' care and needs, but also regarding the character of their clinical judgments. Indeed, there are already reports of instances where physicians' contracts with managed care organizations forbid them to disclose the existence of services not covered by a plan.

Medical ethics--when to stop treatment

Several misunderstandings regarding the question of when to stop treatment are examined by considering two frameworks for sorting out the different dimensions of the question. One framework addresses what is meant, and what is not meant, by 'stopping treatment'. The other plots various strategies of stopping treatment on a continuum of increasing degrees of invasiveness. While significant disagreements remain at important points, there is evidence of an emerging consensus in Western medicine: (1) that palliative care and counselling through the dying process should be increased whenever curative or life-sustaining treatment is curtailed; (ii) that any treatment that is not curative, but merely life-sustaining, should be stopped whenever a patient makes an authentic request to have it stopped; (iii) that genuinely futile treatment should not be offered even if requested; (iv) that much more thought and discussion is required to achieve a workable agreement about the definitions of 'futile' and 'inappropriate' treatment; and (v) that assistance in dying, although profoundly problematic, is no longer unthinkable.