Futile medical care

Futile medical care is the continued provision of medical care or treatment to a patient when there is no reasonable hope of a cure or benefit. This may be in the form of a surgeon operating on a terminal cancer patient even when the surgery will not alleviate suffering; or doctors keeping a brain-dead person on life-support machines for reasons other than to procure their organs for donation. It is a sensitive area that often causes conflicts between medical practitioners and patients or kin, who expect everything possible to be done for their loved ones, regardless of the cost or implications for other patients.

Proponents of evidence-based medicine may suggest discontinuing the use of any treatment that has not been shown to provide a measurable benefit. Where there is no hope for improvement of an incapacitating condition, no treatment is warranted. Futile care is distinct from 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.[1]

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".[2]

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.[3] No physical or spiritual 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.[3] 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.[3]

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 harvesting 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 statistical 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 1999 study in the Journal of the American Medical Association has validated an algorithm developed for these purposes.[4]

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.[1]

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 commodity 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.[1]

See also

References

  1. ↑ 1.0 1.1 1.2 Khatcheressian, J; Harrington, SB; et (July 2008). "'Futile Care': What to Do When Your Patient Insists on Chemotherapy That Likely Won’t Help". Oncology 22 (8).
  2. ↑ Doctors Struggle With Tougher-Than-Ever Dilemmas: Other Ethical Issues Author: Leslie Kane. 11/11/2010
  3. ↑ 3.0 3.1 3.2 Appel, Jacob M. (November 22, 2009). "What's So Wrong with "Death Panels"?". The Huffington Post.
  4. ↑ Council on Ethical and Judicial Affairs, AMA (1999). "Medical Futility in End of Life Care". JAMA 281 (10): 937–941. doi:10.1001/jama.281.10.937. PMID 10078492.

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