Medical Futility in End-Of-Life Care

Medical Futility in End-of-Life Care

Report of the Council on Ethical and Judicial Affairs

aainfoaainfoCouncil on Ethical and Judician Affairs, American Medical Association

Use of life-sustaining or invasive interventions in patients in a persistent vegetative state or who are terminally ill may only prolong the dying process. What constitutes futile intervention remains a point of controversy in the medical literature and in clinical practice. In clinical practice, controversy arises when the patient or proxy and the physician have discrepant values or goals of care. Since definitions of futile care are value laden, universal consensus on futile care is unlikely to be achieved. Rather, the American Medical Association Council on Ethical and Judicial Affairs recommends a process-based approach to futility determinations. The process includes at least 4 steps aimed at deliberation and resolution including all involved parties, 2 steps aimed at securing alternatives in the case of irreconcilable differences, and a final step aimed at closure when all alternatives have been exhausted. The approach is placed in the context of the circumstances in which futility claims are made, the difficulties of defining medical futility, and a discussion of how best to implement a policy on futility.

JAMA. 1999;281:937-941

In the course of caring for a critically ill patient it may become apparent that further intervention will only prolong the final stages of the dying process. At this point, further intervention is often described as futile. There has been controversy in the literature and in clinical practice regarding what constitutes futile intervention.

Clinical paradigms of futile care often involve life-sustaining intervention for patients in a persistent vegetative state, or resuscitation efforts for the terminally ill.1-4 Other paradigms include the use of aggressive therapy such as hemodialysis, chemotherapy, or surgery for advanced fatal illness without a realistic expectation of care or palliation, and also the use of less invasive treatments such as antibiotics or intravenous hydration in near-moribund conditions. Questions of futility can also arise when interventions are useless and the condition is not life-threatening. This report, however, limits itself to the use of interventions in patients with life-threatening illnesses.

The American Medical Association Council on Ethical and Judicial Affairs thus far has not defined an approach to determine what is and what is not medically futile, although it has discussed related issues concerning end-of-life care in other reports. For example, it has affirmed the ethical standing of withdrawing and withholding unwanted interventions, noted the constructive role that advance care planning can play in preempting difficult and conflicted situations, and advised the use of a range of orders not to intervene.5, 6 The Council has also opposed physician-assisted suicide,7 out of concern that recent calls from citizens and professionals for physician-assisted suicide are a response to experiences of excessive and futile intervention at the end of life.

In this report, the Council recommends a process-based approach to futility determinations. This recommendation follows from a discussion regarding various types of circumstances in which futility claims are made, an exploration of the difficulties of defining medical futility, and a deliberation on how to best implement a policy on futility.

CIRCUMSTANCES IN WHICH FUTILITY JUDGMENTS ARE IMPLICATED

One type of circumstance that may prompt claims of futility is discrepancy between the values or goals of the involved parties. In these situations, one party, eg, the patient or proxy, wants to pursue the goal of preserving life even if there is little or no hope of future improvement, while another party, eg, the physician, sees dying as inevitable and wishes to pursue the goal of comfort care. In such circumstances of disagreement it is likely that the physician, in complying with proxy goals, intervenes with the sense that the only reasonable expectation for the intervention is to prolong the dying process. The parties may also hold reverse goals, for example, the proxy may believe that the physician is inappropriately pursuing life-prolongation when death is inevitable.

Some conflicts are intensified by disagreements over who has decision-making authority. The case of Helga Wanglie was one in which a hospital went to court to get permission to withdraw treatment from a patient.8 However, the patient's husband successfully asserted that his substituted judgment about his wife's view of appropriate medical intervention should take precedence over the medical team's view that intervention was nonbeneficial. Indeed, this case, the cases holding that a patient has a right to be free of unwanted intervention, and the entire health care proxy movement indicate legal endorsement for a hierarchy of authority regarding medical decision making. The choice of the patient and the decision of his or her next of kin or designated health care proxy take precedence over the physician's recommendation.9

On the other hand, some cases have upheld the prerogative of the profession to decline medical intervention that it considered futile, such as the ruling in Gilgunn v Massachusetts General Hospital.10 When physicians argue for professional standards, there is often a charge that professionals are parentalistically forcing their standards on patients.11, 12 Unilateral decision making by physicians feeds this reasoning and therefore futility assessments should be implemented in ways that clearly do not warrant such a charge.

Widely publicized court cases, such as those of Wanglie8 and Gilgunn,10 indicate that patients, families, physicians, and others would benefit if the medical system could handle these situations with less need for recourse to the courts. Additionally, in the rare cases that do go to court, it would help their adjudication if a fair professional and institutional policy on futility existed against which to judge compliance or noncompliance. There is already evidence that related institutional policies, such as those regarding do not resuscitate orders, have been helpful in upholding standards and in adjudicating conflicts.11

Another context in which futility questions come up is resource allocation. Some commentators argue that elimination of futile care is good for both patients and allocation of resources.13 But other commentators have countered that there is a danger that judgments about futility mask a covert motive to conserve resources. Rationing refers to