Futile medical care
Encyclopedia
Futile medical care refers to the belief that in cases where there is no hope for improvement of an incapacitating condition that no course of treatment is called for. It is distinct from the idea of euthanasia
because euthanasia involves active intervention to end life, while withholding futile medical care does not encourage, nor speed the natural onset of death. The difference is of utmost importance to physicians who have taken and who adhere to the traditional Hippocratic oath
, and have thus taken a professional vow that under no circumstances will they "prescribe a deadly drug nor give advice which may cause [a patient's] death."
One could say that it is impossible to reach a firm definition of futile medical care, because this would depend upon universal agreement about the point at which there is no further benefit to intervention, and different involved parties may always disagree about the amount and type of benefit under discussion. For instance, a cancer patient may be willing to undergo yet more chemotherapy with a very expensive medication for the benefit of a few weeks of life, while medical staff, the insurance company, and close relatives may all feel otherwise, for different reasons.
A 2010 survey of more than 10,000 physicians in the United States found respondents divided on the issue of recommending or giving "life-sustaining therapy when [they] judged that it was futile", with 23.6% saying they would do so, 37% saying they would not, and 39.4% selecting "It depends".
benefit comes from such care. Futile care also prolongs the grieving process and frequently raises false hope. Also, futile care can be very difficult on caregivers, who may see themselves as forced to act against the best interests of their patient.
Secondly, in a setting of limited resources, futile care involves the expenditure of resources that could be used by other patients with a good likelihood of achieving a positive outcome. For instance, in the case of Baby K
, attempts to transfer the infant to other centers were unsuccessful because there were apparently no unoccupied pediatric
ICU
beds in the region. Many critics of that case insist that the medical expenses used to keep the anencephalic child on life support for 2+ years could have been better spent on awareness and prevention efforts for her condition.
is not possible or practical are easily identifiable as being completely futile, many other situations are less clear. For instance, should surgeons attempt a heroic clinical rescue in a 99-year-old unconscious patient with a ruptured abdominal
aortic aneurysm
, even though survival with a good outcome would be so very unlikely as to warrant publication of the case as a clinical case report? What is actually true is that various bleak clinical scenarios will vary in their degree of futility. Another example: when elderly patients sustain large third degree burns, mortality can be very high. This is similarly true for elderly patients sustaining massive trauma
.
The last four decades has seen the clinical community make impressive efforts at improving the quality of their prognostic efforts. As a result, simple but imprecise rules of thumb like “percent mortality = age + percent burn” have now given way to very sophisticated algorithms based on multiple linear regression
and other advanced statistic
al techniques. These are complex clinical algorithms that have been scientifically validated and have considerable clinical predictive value, particularly in the case of patients suffering severe burns.
While one intent of such algorithms is to provide high-quality prognostic information to aid patients and families in making difficult decisions, it takes little imagination to see how they could be used to guide resource allocation in a setting of limited resources.
Usually such prognostic algorithms produce an estimate of the probability of the patient surviving. While clinicians faced with difficult clinical scenarios where the probability of survival is, say, 30% might be expected to mount a valiant effort, when the chance of survival falls well below 1%, most clinicians would be expected to focus on palliative and comfort measures rather than attempting aggressive clinical measures. In a study of patients so severely burned that survival was clinically unprecedented, during the initial lucid period (before sepsis and other complications set in) patients were told that survival was extremely unlikely (i.e., that death was essentially inevitable) and were asked to choose between palliative care and aggressive clinical measures. Most chose aggressive clinical measures. This suggests that the will to live
in patients can be very strong even in hopeless situations.
As another practical clinical example that occurs very frequently in large hospitals, it can sometimes be problematic to decide whether or not to continue resuscitation when the resuscitation efforts following an in-hospital cardiac arrest have been prolonged. Clinicians often want to know when continuing resuscitation in such settings is futile. A recent study in the Journal of the American Medical Association
has validated an algorithm developed for these purposes.
As medical care improves and affects ever greater varieties of chronic conditions, questions of futility will continue to arise. A relatively recent response to this difficulty in the United States is the introduction of the hospice
concept, in which palliative care
is initiated for someone thought to be within about six months of death. Numerous social and practical barriers exist that complicate the issue of initiating hospice status for someone unlikely to recover.
that should be able to be purchased just like cruise vacations or luxury automobiles, as long as the purchaser of the clinical services has the necessary funds and as long as other patients are not being denied access to clinical resources as a result. In this model, Baby K
would be able to get ICU care (primarily ventilatory care) until funding vanished.
With rising medical care costs and an increase in extremely expensive new anti-cancer medications, the same issues of equity often arise in treatment of end-stage cancer.
Euthanasia
Euthanasia refers to the practice of intentionally ending a life in order to relieve pain and suffering....
because euthanasia involves active intervention to end life, while withholding futile medical care does not encourage, nor speed the natural onset of death. The difference is of utmost importance to physicians who have taken and who adhere to the traditional Hippocratic oath
Hippocratic Oath
The Hippocratic Oath is an oath historically taken by physicians and other healthcare professionals swearing to practice medicine ethically. It is widely believed to have been written by Hippocrates, often regarded as the father of western medicine, or by one of his students. The oath is written in...
, and have thus taken a professional vow that under no circumstances will they "prescribe a deadly drug nor give advice which may cause [a patient's] death."
One could say that it is impossible to reach a firm definition of futile medical care, because this would depend upon universal agreement about the point at which there is no further benefit to intervention, and different involved parties may always disagree about the amount and type of benefit under discussion. For instance, a cancer patient may be willing to undergo yet more chemotherapy with a very expensive medication for the benefit of a few weeks of life, while medical staff, the insurance company, and close relatives may all feel otherwise, for different reasons.
A 2010 survey of more than 10,000 physicians in the United States found respondents divided on the issue of recommending or giving "life-sustaining therapy when [they] judged that it was futile", with 23.6% saying they would do so, 37% saying they would not, and 39.4% selecting "It depends".
Arguments against providing futile medical care
Arguments against futile care generally center on two issues. First, futile care has no possibility of achieving a good outcome and serves only to prolong death. No physical or spiritualSpirituality
Spirituality can refer to an ultimate or an alleged immaterial reality; an inner path enabling a person to discover the essence of his/her being; or the “deepest values and meanings by which people live.” Spiritual practices, including meditation, prayer and contemplation, are intended to develop...
benefit comes from such care. Futile care also prolongs the grieving process and frequently raises false hope. Also, futile care can be very difficult on caregivers, who may see themselves as forced to act against the best interests of their patient.
Secondly, in a setting of limited resources, futile care involves the expenditure of resources that could be used by other patients with a good likelihood of achieving a positive outcome. For instance, in the case of Baby K
Baby K
Baby K was an anencephalic baby who became the center of a major U.S. court case and a debate among bioethicists.-Prenatal assessment:...
, attempts to transfer the infant to other centers were unsuccessful because there were apparently no unoccupied pediatric
Pediatrics
Pediatrics or paediatrics is the branch of medicine that deals with the medical care of infants, children, and adolescents. A medical practitioner who specializes in this area is known as a pediatrician or paediatrician...
ICU
Intensive Care Unit
thumb|220px|ICU roomAn intensive-care unit , critical-care unit , intensive-therapy unit/intensive-treatment unit is a specialized department in a hospital that provides intensive-care medicine...
beds in the region. Many critics of that case insist that the medical expenses used to keep the anencephalic child on life support for 2+ years could have been better spent on awareness and prevention efforts for her condition.
Issues in futile care considerations
The issue of futile care in clinical medicine generally involves two questions. The first concerns the identification of those clinical scenarios where the care would be futile. The second concerns the range of ethical options when care is determined to be futile.Assessment of futility
While scenarios like providing ICU care to the brain dead patient or the anencephalic patient when organ harvestingOrgan harvesting
Organ harvesting refers to the removal, preservation and use of human organs and tissue from the bodies of the recently deceased to be used in surgical transplants on the living...
is not possible or practical are easily identifiable as being completely futile, many other situations are less clear. For instance, should surgeons attempt a heroic clinical rescue in a 99-year-old unconscious patient with a ruptured abdominal
Abdomen
In vertebrates such as mammals the abdomen constitutes the part of the body between the thorax and pelvis. The region enclosed by the abdomen is termed the abdominal cavity...
aortic aneurysm
Aneurysm
An aneurysm or aneurism is a localized, blood-filled balloon-like bulge in the wall of a blood vessel. Aneurysms can commonly occur in arteries at the base of the brain and an aortic aneurysm occurs in the main artery carrying blood from the left ventricle of the heart...
, even though survival with a good outcome would be so very unlikely as to warrant publication of the case as a clinical case report? What is actually true is that various bleak clinical scenarios will vary in their degree of futility. Another example: when elderly patients sustain large third degree burns, mortality can be very high. This is similarly true for elderly patients sustaining massive trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
.
The last four decades has seen the clinical community make impressive efforts at improving the quality of their prognostic efforts. As a result, simple but imprecise rules of thumb like “percent mortality = age + percent burn” have now given way to very sophisticated algorithms based on multiple linear regression
Linear regression
In statistics, linear regression is an approach to modeling the relationship between a scalar variable y and one or more explanatory variables denoted X. The case of one explanatory variable is called simple regression...
and other advanced statistic
Statistics
Statistics is the study of the collection, organization, analysis, and interpretation of data. It deals with all aspects of this, including the planning of data collection in terms of the design of surveys and experiments....
al techniques. These are complex clinical algorithms that have been scientifically validated and have considerable clinical predictive value, particularly in the case of patients suffering severe burns.
While one intent of such algorithms is to provide high-quality prognostic information to aid patients and families in making difficult decisions, it takes little imagination to see how they could be used to guide resource allocation in a setting of limited resources.
Usually such prognostic algorithms produce an estimate of the probability of the patient surviving. While clinicians faced with difficult clinical scenarios where the probability of survival is, say, 30% might be expected to mount a valiant effort, when the chance of survival falls well below 1%, most clinicians would be expected to focus on palliative and comfort measures rather than attempting aggressive clinical measures. In a study of patients so severely burned that survival was clinically unprecedented, during the initial lucid period (before sepsis and other complications set in) patients were told that survival was extremely unlikely (i.e., that death was essentially inevitable) and were asked to choose between palliative care and aggressive clinical measures. Most chose aggressive clinical measures. This suggests that the will to live
Will to live
The will to live is a psychological force to fight for survival, particularly when one's life is threatened by an injury or disease such as cancer. Some physicians believe that it plays an important role in one's chances of survival. There are significant correlations between the will to live and...
in patients can be very strong even in hopeless situations.
As another practical clinical example that occurs very frequently in large hospitals, it can sometimes be problematic to decide whether or not to continue resuscitation when the resuscitation efforts following an in-hospital cardiac arrest have been prolonged. Clinicians often want to know when continuing resuscitation in such settings is futile. A recent study in the Journal of the American Medical Association
Journal of the American Medical Association
The Journal of the American Medical Association is a weekly, peer-reviewed, medical journal, published by the American Medical Association. Beginning in July 2011, the editor in chief will be Howard C. Bauchner, vice chairman of pediatrics at Boston University’s School of Medicine, replacing ...
has validated an algorithm developed for these purposes.
As medical care improves and affects ever greater varieties of chronic conditions, questions of futility will continue to arise. A relatively recent response to this difficulty in the United States is the introduction of the hospice
Hospice
Hospice is a type of care and a philosophy of care which focuses on the palliation of a terminally ill patient's symptoms.In the United States and Canada:*Gentiva Health Services, national provider of hospice and home health services...
concept, in which palliative care
Palliative care
Palliative care is a specialized area of healthcare that focuses on relieving and preventing the suffering of patients...
is initiated for someone thought to be within about six months of death. Numerous social and practical barriers exist that complicate the issue of initiating hospice status for someone unlikely to recover.
Options for futile care
The second issue in futile care theory concerns the range of ethical options when care is determined to be futile. Some people argue that futile clinical care should be a market commodityCommodity
In economics, a commodity is the generic term for any marketable item produced to satisfy wants or needs. Economic commodities comprise goods and services....
that should be able to be purchased just like cruise vacations or luxury automobiles, as long as the purchaser of the clinical services has the necessary funds and as long as other patients are not being denied access to clinical resources as a result. In this model, Baby K
Baby K
Baby K was an anencephalic baby who became the center of a major U.S. court case and a debate among bioethicists.-Prenatal assessment:...
would be able to get ICU care (primarily ventilatory care) until funding vanished.
With rising medical care costs and an increase in extremely expensive new anti-cancer medications, the same issues of equity often arise in treatment of end-stage cancer.
External links
- Medical Futility Blog
- Thaddeus Mason Pope, Medical Futility Statutes: No Safe Harbor to Unilaterally Refuse Life-Sustaining Treatment, 75 Tennessee Law Review 1-81 (2007).
- Thaddeus Pope & Ellen Waldman, Mediation at the End-of-Life: Getting Beyond the Limits of the Talking Cure, 22 Ohio State Journal on Dispute Resolution 143-194 (2007).
- Thaddeus Mason Pope, Reassessing the Judicial Treatment of Medical Futility Cases, 9 Marquette Elder's Advisor 229-268 (2008).
- Thaddeus Mason Pope, Legal Briefing: Medical Futility and Assisted Suicide, 20(3) Journal of Clinical Ethics 274-286 (2009).
- Thaddeus Mason Pope, Surrogate Selection: An Increasingly Viable, But Limited, Solution to Intractable Futility Disputes, 3 St. Louis University Journal of Health Law and Policy 183-252 (2010).