INTRODUCTION

    Nothing underscores the wonder of life more than the mystery of death, and death is inevitable for all. The explosion in medical technology over the past half-century has been directed toward attempting to cure or significantly delay the impact of virtually every type of disease, and with significant success. The average life expectancy has risen from 50 to almost 80 years in many industrialized nations.(1)  In many cases, patients are treated well past the point where cure or prolongation of quality life is possible and such treatment may be regarded as futile.

    End-of-life care presents unique clinical and ethical challenges for physicians. In a modern version of the Hippocratic Oath, written by Dr. Louis Lasagna in 1964, medical students pledge to “remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.” Thus, the challenge for physicians has become the recognition of medical futility and the need to avoid the use of expensive, invasive, life-prolonging treatment beyond the point of benefit, when all that is being accomplished is to prolong dying.

    Health care providers commonly feel that dealing with death and dying is the most difficult and unwelcome part of their careers. The goal of this document is not only to provide more skill and comfort in dealing with patients nearing end-of-life, but to provide participants with the knowledge that assisting patients in experiencing a “good death,” through the timely recognition of medical futility and appropriate shift in emphasis to palliative care, can be the most important and rewarding care that can be delivered to another human being.

HISTORICAL PERSPECTIVE

    “For centuries physicians, patients, and families have dealt with end-of-life issues in an appropriate, compassionate, socially responsible manner. When a patient’s illness would become overwhelming, life-prolonging efforts were abandoned and the individual was allowed to experience death, a natural part of life, with dignity and comfort. During the course of struggling with the patient’s illness, physicians would come to the sad realization that further efforts to extend quality life were futile. The recognition of medical futility by the physician, patient, and family would not in any way diminish the need for care and medical attention. Instead, it would mark a shift in the primary goal of care from the prolongation of life to the provision of physical and emotional comfort. This traditional physician-patient-family decision-making process has now become threatened by the erosion of trust that society holds for physicians and by expanding technology, which has made the recognition and acceptance of medical futility increasingly difficult.

    The explosion of medical technology has not in any way altered the cardinal goals of medical care: (1) to relieve physical and emotional pain and suffering; (2) to enhance the quality and functionality of life; and (3) to extend the length of life. Technology has brought an amazing array of beneficial treatment choices, but has also led to immense pressure to offer some form of potentially curative therapy. Since there is almost always something that can justifiably be done to treat one or more of the patient’s medical problems, the norm has become aggressive treatment until death. In many cases, patients are treated well past the point where treatment may be properly regarded as futile. Even though only a small percentage of people are treated aggressively beyond futility, the absolute number remains large. The impact of expensive technology at the end of life is enormous because of technology’s ability to significantly prolong dying. The fact that individuals with medically futile conditions can almost always be found in every hospital critical care unit is obvious evidence of the increasing prevalence of continued life-prolonging treatment beyond the point of futility.”(2)

(1) Last Acts: Means to a Better End: A Report on Dying in America Today.  2002, 2.

(2) Doty WD and Walker RW.  Medical Futility. Clin Cardiol. 2000:Vol. 23 (Suppl. II), II-6.

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