Medical futility: a conceptual model

Lay views in Southern France of the acceptability of refusing to provide treatment because of alleged futility

AIM

To carry out a detailed study of existing positions in the French public of the acceptability of refusing treatment because of alleged futility, and to try to link these to people's age, gender, and religious practice.

METHOD

248 lay participants living in southern France were presented with 16 brief vignettes depicting a cancer patient at the end of life who asks his doctor to administer a new cancer treatment he has heard about. Considering that this treatment is futile in the patient's case, the doctor refuses to prescribe it. The vignettes were composed by systematically varying the level of four factors: likelihood of a positive effect, painfulness to the patient of the treatment, cost of the treatment, and attitude of the family.

RESULTS

Five main positions were identified. For 10%, refusing treatment was almost never acceptable. 35% judged acceptability in line with the level of painfulness. 19% judged acceptability consistent with an interaction between the painfulness of treatment and likelihood of positive effect. For 30% it was either almost always acceptable or always acceptable. 5% did not take a position.

CONCLUSION

A range of positions regarding the acceptability of refusing to provide treatment on the basis of perceived futility was observed. These positions have been analyzed in terms of what physicians and medical ethicists would see as the four principles of medical ethics. This description of lay people's positions in terms of the principles of medical ethics present clinicians with a conceptual tool to improve communication and shared decision making.

Medical futility is commonly encountered in small animal clinical practice

OBJECTIVE

To document veterinarians' perceptions and understanding of medical futility and determine the frequency with which medical futility occurs in small animal practice.

SAMPLE

477 veterinarians in small animal general and specialty veterinary practice.

PROCEDURES

A cross-sectional study was performed with a 25-question, web-based, confidential, anonymous survey distributed through various professional veterinary specialty associations.

RESULTS

Nearly all respondents (469/474 [99.0%]) believed that futile care occurs in veterinary medicine, and 42.4% (201/474) felt it occurred commonly (> 6 times/y). A similar percentage (471/475 [99.2%]) reported encountering futile care within their careers, and 85.0% (402/476) reported encountering it within the past year. A majority (293/477 [61.4%]) reported witnessing futile care occurring in both inpatient and outpatient settings. Most respondents disagreed or strongly disagreed (320/463 [69.1%]) with a statement that providing futile care is always wrong, and only 38 (8.2%) agreed or strongly agreed. Over 70% (329/464 [70.9%]) of respondents agreed that there are situations in which provision of futile care is appropriate.

CLINICAL RELEVANCE

The importance of reaching a consensus definition for medical futility in veterinary medicine is evident given the frequency with which such care is being provided. Most small animal specialist veterinarians will encounter futile care, and the establishment of an ethical framework to navigate questions surrounding medical futility may help reduce moral distress.

Applying futility in psychiatry: a concept whose time has come

Since its introduction in the 1980s, futility as a concept has held contested meaning and applications throughout medicine. There has been little discussion within the psychiatric literature about the use of futility in the care of individuals experiencing severe and persistent mental illness (SPMI), despite some tacit acceptance that futility may apply in certain cases of psychiatric illness. In this paper, we explore the literature surrounding futility and argue that its connotation within medicine is to describe situations where patients (or their substitute decision-makers) believe that interventions will almost certainly provide no meaningful benefit. We then provide two arguments in support of the use of futility within the care of individuals experiencing SPMI: that some SPMI can be considered a terminal illness, and that the risk-benefit ratio is a dynamic entity such that futility can help describe what Gillett calls the 'risk of unacceptable badness' when it comes to considering how an intervention might impact a patient's quality of life. We posit that capacity should not pose an obstacle to declaring futility when caring for individuals experiencing SPMI and explain how futility is not antithetical to recovery in mental health. Finally, we describe how using futility within psychiatric practice can allow for a reorientation of care by signalling the need to shift to a palliative approach.

Clarification and Mitigation of Ethical Problems Surrounding Withdrawal of Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is temporary life-support technology that provides time to rest the cardiac and respiratory system of critically ill people with acute, reversible medical conditions. Health care providers face emotional and challenging situations, where death may result, when withdrawing ECMO. A deepening of understanding of the ethical issues involved can aid clinicians in handling such difficult situations, leading to a possible mitigation of the moral problems. Toward this end, the ethical issues raised in the consideration of ECMO withdrawal are analyzed with respect to the ethical principles and concepts of autonomy, nonmaleficence/beneficence, medical futility, moral distress, and justice. In particular, these issues are considered in relation to how they affect and can be addressed by staff nurses and advanced practice nurses in the intensive care unit. Advanced practice nurses in particular can represent the voice of nurses to promote a healthier workplace in situations of moral distress related to stopping ECMO life-support technology and in developing clear and consistent guidelines for ceasing ECMO treatment, all leading toward clarification and mitigation of the ethical problems surrounding the withdrawal of this critical technology.

The value of life in English law: revered but not sacred?

Terms such as sanctity and inviolability have failed to provide a legally coherent or ethically sound principle upon which to determine the scope of the intrinsic value of life against extrinsic, quality-of-life considerations in a medical context. In their recent work, Margaret Brazier and Suzanne Ost introduce a new term, reverence for life, which they suggest may be more appropriate when attempting to navigate the murky waters of the meaning of life and the value that should be attached to it. They suggest that reverence should be utilised as an alternative that better reflects the nuances and the realities of the dilemma. This paper explores the existing difficulties before considering how the principle of reverence might provide a principled compromise over when the presumption in favour of preserving life should be rebutted.

Medical futility and the burns patient

Since its inception in the 1980s 'futility' has been a controversial concept. The history of this concept, its definition and application to burns care are discussed from the perspective of a burn surgeon. Although introduced as an objective (value-free) criterion, futility proves impossible to objectivate and judgements about the value of human life always play a role. The roles of the patient, the doctor, the 'politician' and society at large in futility-decisions are discussed.

Medical futility in the care of non-competent terminally ill patient: nursing perspectives and responsibilities

BACKGROUND

Debate continues on the use of medical technology to prolong life independent of the quality of the outcomes. As a consequence, acute care nurses often find themselves in situations where they are asked to carry out physician's orders, in the context of a patient's deteriorating condition, which may be at odds with professional and personal ethical standards. This can cause nurses to become distressed when struggling with the ethical dilemmas involved with medical futility.

PURPOSE

This paper is a perspective on nursing considerations of our Code of Ethics and the concept of medical futility in acute nursing care. The utility of the Code is examined through a clinical vignette.

METHOD

A database search using the keywords medical futility and acute care limited to 2008 to 2012 and a secondary hand search of these references identified thirty journal publications. The Code of Ethics was examined via a clinical scenario pertinent to an acute environment.

FINDINGS

This paper examines the ethical principles that underpin nursing and illustrates how the code of ethics may serve as sign posts when faced with caring for a terminally ill patient that is inappropriately managed.

CONCLUSION

Understanding how individual nurses may address ethical dilemmas when faced with medical futility can better enable the nurse to fulfil their role as patient advocate, health promoter and alleviator of suffering. Ongoing education and communication to decrease any ambiguity or anguish associated with a patient's impending death optimises apt outcomes.

End of life issues in the intensive care units

A structured discussion of End-of-Life (EOL) issues is a relatively new phenomenon in India. Personal beliefs, cultural and religious influences, peer, family and societal pressures affect EOL decisions. Indian law does not provide sanction to contentious issues such as do-not-resuscitate (DNR) orders, living wills, and euthanasia. Finally, published data on EOL decisions in Indian ICUs is lacking. What is needed is a prospective determination of which patients will benefit from aggressive management and life-support. A consensus regarding the concept of Medical Futility is necessary to give impetus to further discussion on more advanced policies including ideas such as Managed Care to restrict unnecessary health care costs, euthanasia, the principle of withhold and/or withdraw, ethical and moral guidelines that would govern decisions regarding futile treatment, informed consent to EOL decisions and do-not-resuscitate orders. This review examines the above concepts as practiced worldwide and looks at some landmark judgments that have shaped current Indian policy, as well as raising talking points for possible legislative intervention in the field.

Ethics seminar: the hospice patient in the ED: an ethical approach to understanding barriers and improving care

Emergency physicians (EPs) are asked to evaluate and treat a growing population of hospice patients who present to the emergency department (ED) for a number of important reasons. Hospice patients pose unique ethical challenges, and "best practices" for these patients can differ from the life-preserving interventions of usual ED care. Having a solid understanding of professional responsibilities and ethical principles is useful for guiding EP management of these patients. In end-of-life care, EPs need to recognize that there are barriers and complexities to the best management of hospice patients, but they need to commit to strategies that optimize their care. This article describes the case of a hospice patient who presented with sepsis and end-stage cancer to the ED. Patient, system, and physician factors made management decisions in the ED difficult. The goal in the ED should be to determine the best way to address terminally ill patient needs while respecting wishes to limit interventions that will only increase suffering near the end of life.

Knowing when to stop: futility in the ICU

PURPOSE OF REVIEW

Decisions to withdraw or withhold potentially life-sustaining treatment are common in intensive care and precede the majority of deaths. When families resist or oppose doctors' suggestions that it is time to stop treatment, it is often unclear what should be done. This review will summarize recent literature around futility judgements in intensive care emphasising ethical and practical questions.

RECENT FINDINGS

There has been a shift in the language of futility. Patients' families often do not believe medical assessments that further treatment would be unsuccessful. Attempts to determine through data collection which patients have a low or zero chance of survival have been largely unsuccessful, and are hampered by varying definitions of futility. A due-process model for adjudicating futility disputes has been developed, and may provide a better solution to futility disputes than previous futility statutes.

SUMMARY

Specific criteria for unilateral withdrawal of treatment have proved hard to define or defend. However, it is ethical for doctors to decline to provide treatment that is medically inappropriate or futile. Understanding the justification for a futility judgement may be relevant to deciding the most appropriate way to resolve futility disputes.

Medical futility: a commonly used and potentially abused idea in medical ethics

Hospital doctors frequently invoke the idea of medical futility in making decisions regarding end-of-life care. This concept of futility will be reviewed and the differing definitions and how it relates to other important principles in biomedical ethics discussed.

Too much of a good thing is wonderful? A conceptual analysis of excessive examinations and diagnostic futility in diagnostic radiology

It has been argued extensively that diagnostic services are a general good, but that it is offered in excess. So what is the problem? Is not "too much of a good thing wonderful", to paraphrase Mae West? This article explores such a possibility in the field of radiological services where it is argued that more than 40% of the examinations are excessive. The question of whether radiological examinations are excessive cries for a definition of diagnostic futility. However, no such definition is found in the literature. As a response, this article addresses the issue of diagnostic futility in five steps. First, it investigates whether the concept of therapeutic futility can be adapted to diagnostics. A closer analysis of the concept of therapeutic futility reveals that this will not do the trick. Second, the article scrutinizes whether there are sources for clarifying diagnostic futility in the extensive debate on excessive radiological examination. Investigating the debate's terms and definitions reveals a disparate terminology and no clear concepts. On the contrary, the study uncovers that quite different and incompatible issues are at stake. Third, the article examines a procedural approach, which is widely used for settling controversies over utility by focusing on the role of the professionals. On scrutiny however, a procedural approach will not solve the problem in diagnostics. Fourth, a value analysis reveals how we have to decide on the negative value of excessive examinations before we can measure excess. The final and constructive part presents a definition of diagnostic futility drawing upon the lessons from the previous analytical steps. Altogether, too much radiological examination is not a good thing. This is simply because radiological examinations are not unanimously good. Excessive radiological examinations can be defined, but not by one simple general and value-neutral definition. We have to settle with contextually framed value-related definitions. Such definitions will state how bad "too much of a good thing" is and make it possible to assess how much of the bad thing there is. Hence we have to know how bad it is before we can tell how much of it there is in the world.

Reviving the conversation around CPR/DNR

This paper examines the historical rise of both cardiopulmonary resuscitation (CPR) and the do-not-resuscitate (DNR) order and the wisdom of their continuing status in U.S. hospital practice and policy. The practice of universal presumed consent to CPR and the resulting DNR policy are the products of a particular time and were responses to particular problems. In order to keep the excesses of technology in check, the DNR policies emerged as a response to the in-hospital universal presumed consent to CPR. We live with this historical concretion, which seems to perpetuate a false culture that the patient's wishes must be followed. The authors are critical of the current U.S. climate, where CPR and DNR are viewed as two among a panoply of patient choices, and point to UK practice as an alternative. They conclude that physicians in the United States should radically rethink approaches to CPR and DNR.

Futility clarified

Futility is easily defined as uselessness. The mistaken appearance that it cannot be defined is explained by difficulties applying it to particular cases. This latter problem is a major goal of clinical training and cannot be solved in a pithy statement.

What limits for acute care in the elderly?

PURPOSE OF REVIEW

This review aims to address the important question of the increasing life expectancy and the aging population in the healthcare system today. We try to give some elements that will help the reflection about the ethical stakes balancing the necessity of care in the increasing number of elderly patients and the limited resources available, in the special context of acute care.

RECENT FINDINGS

There is growing evidence that the chronological age itself is not a reliable marker of bad prognosis or of mortality. The new concept of frailty may better correlate with the aging process of the elderly. The frailty index is an integrative approach considering the multiple factors impacting on the aging individual. Applied in the practical arena, it might become a useful tool for clinicians.

SUMMARY

Aging implies many biological modifications at molecular, cellular, organic levels as well as of the behavior. Some aspects of these processes and their consequences on health are described. The frailty concept is detailed, and its potential interest explained. We conclude that the measurement of aging phenomenon, including the frailty index, may help us to better assess the true health and the required therapeutics of elderly patients.