Maurice Bernstein, M.D.
Coming to the decision that a treatment is futile—meaning that further medical treatment would have no useful result and should not be started or continued—is a decision made with hesitation or at times not at all, either by the patient or family or, unfortunately, even by the physician. Why is that so? There are probably many reasons including misunderstanding by the patient or family regarding the limits of a treatment or the natural course of the illness or an unwillingness by the physician to raise issues of futility with them either because of the difficulty of communication or because unwillingness to admit professional defeat or even, who knows, perhaps some other self-interest.
What is most important is that each stakeholder, in attempting to make a decision, should understand that the term medical futility is not a single expression regarding outcome but has a multifaceted definition and its particular meaning must be specified in any discussion regarding decisions for therapy.
Ethicist Laurence B. McCullough, PhD and his colleagues writing about futility summarize the four ways ethicists in the past have defined medical futility.
1. Physiologic Futility (Tomlinson and Brody) implies that the there is no reasonable expectation based on scientific evidence that a physiologic outcome from treatment can be achieved. A surgical example given would be surgical intervention in a patient with a Glasgow Coma Score of 3 following an intra-cerebral bleed would be futile since spontaneous brain function could be restored would not be a physiologic expectation.
2. Imminent Demise Futility (Brody and Halevy) implies that the treatment of the patient may provide a physiologic good but that overall the patient’s deteriorating medical condition cannot be reversed to prevent an imminent death.
3. Clinical or Overall Futility (Schneiderman et al) implies that though the treatment may provide a physiologic good and the chance of imminent death may be avoided by the treatment, the results, though leaving the patient alive, will not result in a patient who can recover capacity to interact with the environment or continue as a human being. The example of such a patient is a person who could be kept alive on parenteral nutrition and hydration, but would be left in a permanent vegetative state.
4. Quality of Life Futility (Tomlinson and Brody) represents that, determined by the clinicians, the treatment is physiologic, that there will be no expected imminent demise and the patient will retain an interactive capacity but despite these good results, the final outcome will not meet the values, beliefs and goals set by the patient or surrogates who are aware of the patient’s wishes and desires.
The choice of what to stop or what to not start in terms of therapy must begin with discussion of these four futility components. Other considerations which deal with monetary costs of therapy, triage of scarce resources or simple societal justice are, I think, not really part of a futility decision though in some special situations are necessary for special consideration on their own regarding the starting or continuing therapy.
What is necessary is that all parties to the decision are fully informed about the status of these four parts of futility as they pertain to the patient. But even with the facts available, there still may be resistance by the patient or family to express an acknowledgment of futility. Or physicians, as previously noted, may resist presenting a view contrary to that of the patient and family. Conflicts are more likely to arise in these present days of patient autonomy where, by ethics and established law, patients have the power to make their own therapeutic decisions of the options available. Conflicts between the patient/family and the medical profession with regard to starting or stopping treatment may need the education and mediation of hospital ethics committees. Sometimes, even ethics committees may not bring resolution and the courts and state laws have to intervene.
Since there is a certain unknown in medical or surgical therapy, there are always “miracles” which are brought up to challenge the concept of therapeutic futility. And yet, I think, futility is a reality and its full consideration should be part of decision making regarding the therapy for the patient.