THE FUTILITY DEBATE

    "In an effort to reduce the inappropriate application of medical interventions to patients who have no potential for benefit, the term medical futility has been increasingly used by physicians and medical ethicists. The rationale has been that informing doctors and the public that physicians have no ethical obligation to offer or provide futile interventions should result in a reduction in the inappropriate use of technology at the end of life. While the existence of medical futility is as unquestionable as the eventuality of death, the impact of the futility concept on decision-making has been hampered by the lack of a clear definition of medical futility. The definition has become increasingly elusive, as technology has pushed back the limits of what can be done to prolong both life and the process of dying.”(1) There remains a more fundamental lack of consensus over what constitutes medical futility, presumably over ethical, philosophical, and definitional issues, despite over 750 recent medical publications on medical futility.(2) The multiple complex forces contributing to futile care at end-of-life described above suggest that resolution of the debate alone will not eliminate futile treatment. Seeking consensus on the meaning of medical futility remains worthwhile, however, and may be necessary before the other forces can be overcome.

The issues raised in the “futility debate” have predominantly centered around (1) an acceptable definition of medical futility if it can be defined; (2) whether physicians have the right or obligation to withhold treatments that they judge to be futile; and (3) whether patients have the right to demand any form of treatment if they feel it will be beneficial to them (i.e., the struggle between the autonomy of patients and the ethical obligations of physicians).

Numerous authors have offered definitions of medical futility, pointing to its recognition since antiquity by Hippocrates and Plato.(3,4) Futile treatments have generally been subdivided into two types:

1. physiologic or quantitative futility (very low statistical probability of achieving the desired physiologic response; and

2. qualitative futility (in which treatment may have a physiological effect, but fails to “benefit” the patient as a whole).(5)

Much of the futility debate has centered on futile CPR.(6,7,8,9) A broader, more comprehensive definition of medical futility was proposed by Drane and Coulehan in 1993(10) as treatment that:

1. does not alter a person’s persistent vegetative state;

2. does not alter diseases or defects that make a baby’s survival beyond infancy impossible;

3. leaves permanently unrestored a patient’s neurocardiorespiratory capacity, capacity for relationship, or moral agency; or

4. will not help free a patient from permanent dependency on total intensive care support.

An operational definition of medical futility has been proposed(11) that requires that the physician combine clinical experience and scientific data with the concepts of both qualitative and quantitative futility through three questions: (1) is death imminent? (2) if treatment leads to full recovery, is the best quality of life that can be hoped for undesirable? (3) is the statistical probability of recovery extremely low? (Figure 3 Medical Futility Algorithm). A negative answer to any of these questions indicates that continued efforts toward curative care are futile. In borderline futile situations, the potential for continued life-prolonging treatment efforts to cause harm or prolong suffering must be carefully weighed against their (often minimal) potential for benefit.  Examples of the practical application of this definition are offered through a published list of common futile medical conditions (Table 1 Medical Futility Diagnoses).

In reality, physicians dismiss treatments as “futile,” or simply unlikely to provide benefit to patients, routinely during medical care. Doctors unilaterally make these decisions based upon their unique medical skills and knowledge. This reality makes the “futility debate” over whether physicians can unilaterally decide to offer specific treatments irrelevant – doctors simply do and must make these decisions all the time.

The critical issue in the physician’s role in dealing with medical futility arises, however, when that physician suspects that all curative or life-prolonging treatment options can no longer benefit the patient. The choice must then be made between concluding that all further curative care attempts are futile or continuing with attempts at curative or life-prolonging treatment. No matter how grave, the physician is typically less than 100% certain of the prognosis and is personally reluctant to “give up” on the patient.  After acknowledging “medical futility,” the physician must choose to deliver extremely bad news to the family, and then launch into the difficult, time-consuming process of helping the family deal with anger, grief, and acceptance. It is no surprise that the physician often continues aggressive, curative care, despite personal recognition of medical futility. Unresolved disagreements among patients, surrogates and physicians are relatively infrequent. The much more common error is that medical futility is simply never acknowledged by anyone. 

The “futility debate,” thus, ultimately centers on the question of whether physicians are willing to embrace their unique responsibility as the professional advocates for patients in recognizing when patients are “there,” that is when all reasonable hope of mastery of disease has vanished. Like all other medical decisions, it is not necessary or possible for all physicians to agree upon exactly what circumstances must exist in all patient conditions in order to define futility. In fact, the decision should and must be unique to each patient. What is needed is for all physicians to recognize the compelling obligation to apply all available data and skill to making the decision that medical futility exists at a specific point in that individual patient’s life that is neither before hope for cure has gone, nor after futile treatment has deprived the patient of the best possible death.

The physician should not feel alone, nor generally attempt to communicate medical futility alone. Communication with and support from physician colleagues, nurses and, when available, a dedicated palliative care team is critical to effective communication and acceptance. Though commonly overlooked, clergy and other spiritual support can serve as an invaluable resource for the patient and family. When possible, the patient’s spiritual leader should be routinely informed and brought into discussions and decisions by the health care team. Physicians should also recognize their own spirituality in making agonizing futility decisions and their own “priesthood” role in the spiritual care of the patient and family.(12)

The physician’s role should always be to delineate the reasonable spectrum of treatment choices ranging from most aggressive to most conservative (including the recognition of medical futility) while the patient or surrogate must choose among medically plausible and reasonable treatment options, based upon personal goals and values and informed consent. In the vast majority of medically futile situations, lack of benefit of curative treatment efforts is clear to the physician. Given a choice, the well-informed patient or surrogate will almost always choose good palliative care over futile, sometimes punishing, “curative” care.

When treatment is not clearly futile, but may offer little benefit with significant risk or morbidity, the informed patient or surrogate must make the decision to accept or reject treatment based upon personal values. The critical ingredient is communication. Communication often breaks down when physicians, patients and families choose to continue to pursue false “hopes” of improbable or impossible cure, rather than going through the painful, sometimes lengthy grieving process of recognizing and dealing with futility. However, it is only through timely recognition and communication that futility exists (by physicians) and acceptance (by patients and families) that curative or life-prolonging treatment is no longer beneficial that patients and physicians can be freed to redefine “hope” as a comfortable death with dignity, through unrestricted palliative care.”(13)

^[1] Doty WD, Walker RM, Medical Futility. Clin Cardiol 2000; 23 (Suppl. II), II-6.

^[2] Helft P, Seigler M, Lantos J. The Rise and Fall of the Futility Movement. N Engl J Med 2000;343:293-295.

^[3] Reiser SJ, Dyck AJ, Curran WJ. Hippocratic Corpus:  The Art. In: Ethics in Medicine.

    Historical Perspectives and Contemporary Concerns, Cambridge, Mass., MIT Press, 1977:6-7.

^[4] Plato; Grube GM (trans): The Republic, Indianapolis, Ind.: Hackett Publishing, 1981:76-77.

^[5] Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: Its meaning and ethical implications. Ann Intern Med 1990;112:949-954.

^[6] Marsh FH, Staver A:  Physician authority over unilateral DNR orders. J Legal Med 1991;12:115-165.

^[7] Blackhall LJ:  Must we always use CPR? N Engl J Med 1987;317:1281-1285.

^[8] Layson RT, McConnell T:  Must consent always be obtained for a do-not-resuscitate order? Arch Intern Med 1996;156:2617-2620.

^[9] Plunkitt K, Matar F, Basta L: Therapeutic CPR or consent DNR-A dilemma looking for an answer. J Am Coll Cardiol 1998;32:2095-2097.

^[10] Drane JF, Coulehan JL:  The concept of futility:  Patients do not have a right to demand medically useless treatment. Health Prog 1993;74:28-32.

^[11] Doty WD, Walker RM.  Medical Futility. Clin Cardiol 2000;23(Suppl.II):II-11-II-12.

^[12] Gregory SR.  Growth at the edges of medical education: Spirituality in American Medical Education. The Pharos  2003:66(2)14-19.

^[13] Basta LL, Doty WD, & Geldart MDD. Medical Treatment of the Cardiac Patient Approaching the End-of-Life. In: Gerstenblith, Gary, ed. Contemporary Cardiology: Cardiovascular Disease in the Elderly. Humana Press Inc., Totowa, NJ. 2005:382-389.

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