Medical Futility: Where Do We Stand?. National Healthcare Costs. Where Do We Stand?. Meaning. . . What is the status of the futility debate? What is your position on the futility debate? What is the hospital policy regarding medical futility?
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Meaning. . .
Unacceptable likelihood of achieving:
“Those who call for the abandonment of the concept have no substitute to offer. They persist in making decisions with, more or less, covert definitions. The common sense notion that a time does come for all of us when death or disability exceeds our medical powers cannot be denied. This means that some operative way of making a decision when ‘enough is enough’ is necessary. It is a mark of our mortality that we shall die. For each of us some determination of futility by any other name will become a reality.”
Edmund Pellegrino, M.D.
Practical Bioethics, 2005
Definition: “Leaky, vain, failing of the desired end through intrinsic defect” (OED)
futilis = ancient religious vessel that tipped over easily.
Quantitative (or else!)
Rubenfeld & Crawford (1996) Life sustaining mechanical ventilation in bone marrow transplant patients with hepatic failure, renal failure, hemodynamic failure, and lung injury: 0/398.
“It is difficult to specify limits beyond which treatment should be withheld when there is any chance that a life can be saved. However, if we cannot agree that treating 400 patients with prolonged intensive care without producing a single survivor is beyond such a limit, then it is unlikely we can reach a consensus about limiting care in any clinical situation.”
Logical support for proposal:If a physician were morally obligated to offer any treatment that may have worked or that may conceivably work then in the absence of a proven treatment the physician would be obligated to offer a placebo. (Placebo effect can be as high as 30%) But physician is not morally obligated to offer a placebo when no treatment is available.
-Physiologic futility is not value free but a value choice, which departs dramatically from the patient-centered goals of medicine, and has delayed medicine’s appreciation of the importance of good end-of-life care.
-Hospital policies and statutes are developing a majority and “respectable minority” standard of care.
UCSDMC: Futile treatment: Any treatment without a realistic chance of providing an effect that the patient would ever have the capacity to appreciate as a benefit, such as merely preserving the physiologic functions of a permanently unconsciousness patient, or has no realistic chance of achieving the medical goal of returning the patient to a level of health that permits survival outside the acute care setting of UCSD Medical Center. In the event of disagreement among the parties involved in the treatment of a patient, futility will not be invoked before the completion of an appropriate dispute resolution process.
Care whose intent is to relieve suffering and provide for the patient’s comfort and dignity. It may include analgesics, narcotics, tranquilizers, local nursing measures, and other treatments including psychological and spiritual counseling. It should be emphasized that although a particular treatment may be futile, palliative or comfort care is never futile.
Expand decision-making from narrow considerations of life-sustaining treatments (what we will not do) to ethic of care (what we will do).
Michel Evquem de Montaigne. Essays, 1595
Death is inevitable and not necessarily a medical failure. Causing or allowing a bad death is a medical failure.
Physicians must . . . not only set standards for medical practice, but also follow them. Physicians cannot expect parents, trial-court judges, insurance companies, or government regulators to take practice standards more seriously than they already do themselves.
George J. Annas, J.D., M.P.H
AMA Code of Medical Ethics, 1996
All health care institutions, whether large or small, should adopt a policy on medical futility.
AMA Code of Medical Ethics, 1996
d) Involvement of ethics committee if disagreements are irresolvable.
“When further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure.”
E-2.037 Medical Futility in End-of-Life Care.
“Developing Standards of Practice” (1998)
53 ethics committee members
39 hospital ethics committees represented
12 others (nurses, clergy, social workers, community representatives)
All but 2 of 26 hospitals have specific futility policies that define nonobligatory treatment.
All but 2 of 24 hospitals define nonobligatory treatment in terms of benefit to the patient rather than physiology, some with specific examples, e.g., dependence on ICU treatment.
Provides basis for definitional standard that justifies futility decision, and for “respectable minority.”
Whether in the adult ICU or in the NICU, our experience suggests that the process is changing the nature of conversations about medical futility… Although the Texas Advance Directives Act is less than perfect, the process it provides for has been quite effective…We believe it is a process that the medical and bioethics communities should pursue and hopefully improve on in other states.
Fine RL et al. Pediatrics 2005;116:1219-1222
Uniform Health-Care Decisions Act (1994), California Probate Code (2003), Tennessee Health Care Decisions Act (2004), and also Alabama, Alaska, Delaware, Hawaii, Maine, Mississippi, New Mexico…
Uniform Health-Care Decisions Act (1994)
Respectable minority standard:
Ask permission of court to withdraw life-sustaining treatment?
Withdraw life-sustaining treatment according to hospital policy and defend act?
USE IT OR LOSE IT