Keith M. Swetz, Christopher M. Burkle, Keith H. Berge, and William L. Lanier
Mayo Clinic Proceedings, 2014
Open and honest communication may help limit some futile treatments
Futile medical care and disagreements constitute the main ethical health-related challenges patients and caregivers face. An aging population and ever-expanding treatment and technology options may lead to misdirected, inappropriate and unwanted medical interventions. Common concepts, language and controversies are provided below.
What is the definition of medical futility?
Futile is defined as “serving no useful purpose; completely ineffective.” However, “medical futility” is often slanted to reflect the definer’s point of view.
Definitions may consider experience and quantity (“in the last 100 cases, a medical treatment has been useless”). This consideration relies on a value judgment of “useless” or “useful.” Physiologic futility examines whether a treatment or technology effectively meets its intended purpose on a given patient. Although it may be easier to identify, the “intended purpose” for a patient may not be the one that the physician considers in use.
The authors settled on the non-comprehensive definition: “excessive (in terms of effort and finances) medical intervention with little prospect of altering a patient’s ultimate clinical outcome.”
How do challenges in prognostication contribute to medical futility?
Scoring systems have been developed to predict the likelihood of a patient’s survival, but they fail to determine when an individual therapy is futile for an individual patient. Interestingly, the most accurate measure of individual patient survival is the opinion of the experienced Intensive Care Unit (ICU) physician as documented in the hospital record’s narrative notes. Clinicians and available prognostic tools are limited in their ability to predict outcomes for an individual; this may lead to uncertainty and the continuation of treatments with marginal effectiveness.
What and who are the principal movers encouraging medical care that may be considered futile?
The medical record documentation of “unrealistic family expectations” was found to be the best predictor of prolonged and expensive ICU care in patients unlikely to survive. These expectations may stem from cultural or spiritual values, personal convictions or inaccurate interpretation of unclearly presented medical information.
The popular media has been cited as depicting unrealistic outcomes of CPR (75% survival compared to the actual 10-15%) and sensationalism surrounding “miracles”- these are usually the result of inaccurate diagnosis.
Finally, a treatment and technological imperative may lead physicians and patients to feel obligated to use any intervention because they are at their disposal.
What are the financial arguments that may encourage or discourage the provision of medically futile care?
Chronic critical illness and multi-organ failure, previously not compatible with survival, can now be associated with extended and indefinite survival if sustained by heroic measures and technological advances.
Meanwhile, a recent study found that 11% of ICU patients were receiving care considered to be futile, and the Institute of Medicine estimates that up to 30% of U.S. health care expenditures may not be indicated.
As the U.S. population ages, Medicare and Medicaid will become the primary means of paying for healthcare. This process may place healthcare professionals in the position of being “stewards” of limited funds when the wishes of patients are pitted against those of society. One way health care reimbursement reform can affect health care delivery is by restricting potentially futile care and reappropriating the saved funds.
What are the core legal concerns that influence the provision of medically futile care?
There are many examples in which legal decisions, legislative actions and executive decisions have either encouraged or discouraged the delivery of futile care without facing the issue of medical futility directly.
Practitioners’ decisions to terminate end of life treatment may be in conflict with states’ desire to preserve the lives of citizens.
Furthermore, withholding potentially life-sustaining treatment has been found in violation of the Americans with Disabilities Act. In contrast, the parents of a child born with a life-threatening disability requested that the child not be forced to undergo further surgical intervention and allow to die. This request led to an executive mandate that children with disabilities be provided necessary life-sustaining treatments.
The lack of legal consensus on end of life futility disputes dictates that strong efforts to resolve these disagreements should best take place outside of the judicial arena.
Does the definition of medical futility differ depending on the type of patient?
Medical futility weighs the clinical benefit of an intervention or the lack thereof with how it affects the goals of care. Certain vulnerable groups require attention- such as minors, those with disabilities, the elderly and the economically deprived. Clinical ethics committees are often used as advisors or arbiters, but they may be biased if employed by the healthcare institution. Members may not have sufficient medical knowledge to make these life and death decisions.
Do the standards of appropriate vs. futile medical care change with time?
Treatments once viewed as medically futile may no longer be considered as such, and those once viewed as beneficial may now be seen as futile. Advances in medications and technology are associated with a learning curve to determine those patients who may benefit.
How does one adjudicate outside the legal system whether medical care is futile and whether such care should be continued or stopped?
Most futility disputes are resolved through collaboration and effective communication involving family members, other surrogate decision makers and health care professionals. Failure of these initial attempts at communication accounts for the greatest number of requests for ethics committee intervention.
Other resources that may be used include consultation with a hospital clinical practice committee, the hospital legal counsel or other colleagues with experience in the area. In rare circumstances, the courts are asked to intervene.
How does one adjudicate within the legal system whether medical care is futile and whether such care should be continued or stopped?
The need for legal intervention generally suggests that stakeholders support widely disparate views. Most legal cases involve a surrogate health care decision maker- who may be burdened by a mistrust of healthcare professionals, unrealistic healthcare expectations, strong religious beliefs, inability to tolerate the emotional burden of their decision and immunity for the costs and consequences of their decisions.
The concept that physicians should not be required to offer treatments of questionable benefit is generally supported, but it is viewed variably in the law. The role of courts has mostly been to assign a surrogate decision maker or determine the validity of surrogate decisions as consistent with patient values. Legal intervention is rare, but it often gains much media attention.
How does one prevent medical futility?
The authors present practical considerations regarding how to approach situations that may be viewed as futile:
- Encourage medical care that is given on the basis of evidence from the best available medical research.
- Allow room for individual patient variability.
- Create more effective communication tools, appropriately engage in goal setting, and re-establish clinicians’ role in making recommendations over simply asking what the patient wants.
Read the study here