Medical Futility

Vivian Agbobu, Robert Davila, Trixy Ridoloso, Nina Siregar

 Medical Futility Definition
Real Life Medical Futility
Scenarios
Anti-Futility Arguments
Medical Futility in Different

Overview
Medical Settings
How Culture and Religion
Affects Medical Futility Attitudes
Ethical Components
Legal Perspective
Community Policies
Medical Futility Defined
Refers to a situation in which irreversibly dying patients have reached a point where
further treatment provides no physiological benefit or is hopeless and becomes optional.

Two types of Medical Futility

1. Quantitative Futility: The likelihood of an intervention to benefit the patient are

expected to be exceedingly poor.
2. Qualitative Futility: The quality of benefit an intervention will produce is
exceedingly poor.

Both refer to the expectation that a specific treatment will not have a physiological effect
on the individual.

(Beauchamp & Childress, 2013) (Jecker, 2014)

Situations Labeled as Futile
Whatever physicians cannot perform
Treatment that has no physiological effect
Treatment that is highly unlikely to be effective/successful
Whatever will produce a low-grade, insignificant outcome
An intervention that is highly likely to be more burdensome than beneficial to
the patient
An intervention that is speculative because it is an untried treatment
Whatever warrants withdrawing or withholding treatment.
(Beauchamp & Childress, 2013)
Anti-Futility Arguments
Ethical Obligations in Futile Interventions

Physicians are not obligated to offer treatments that do not benefit the patient.
Futile interventions can
Increase pain and discomfort during a patients final days and weeks of life.
Give false hope to patients and their family
Delay palliative and comfort care

Though the ethical requirement to respect patient autonomy allows a patient

to choose acceptable medical treatment options (or to reject all options), it
doesnt entitle patients to receive any treatment they ask for.

(Jecker, 2014)
Death with dignity (Trixy)
Physicians and medical futility: critical care
The ICU has a multitude of high complex patients who need
life sustaining measures such as mechanical ventilation or
artificial hydration. Due to the severity of a patient's illness that
is commonly seen in the critical care unit and the high risk of
death, it is important that the physician communicate at an
early stage and throughout the course of the disease about the
patient's wishes and the physician's prognosis.

Death is imminent and involves the patient, family, and

physician.

Daily evaluation is necessary over a period of days and/or

weeks.

The decision to withdraw or withhold specific therapies should

be based on discussions with the patient, family, or health care
proxy when appropriate.
( Zucker & Zucker, 1997)
Physicians and Medical Futility: General Medical Care
In the clinical setting, the issue of futility can generally be described as:

1. When is the value of treatment or procedure sufficiently small or uncertain

that it can be considered to be futile and, accordingly, the right of patients
to choose it should be limited?
2. Who decides that a medical treatment is futile, and what would be an
equitable mechanism to establish and put into effect such determinations?
A treatment may be considered futile either because the benefit of the
treatment is unlikely to be reached or because, even if successful, there are
serious limitations to the benefit to be achieved, as would be the case when
the effect would be to continue a life in the permanently unconscious state.
Physicians and Medical Futility: General Medical Care
Another aspect of medical futility relates to the burdensome nature of the
procedures under question.
Treatment that would serve only to prolong a dying patients life for a short amount of time at
the cost of undue pain or loss of personal dignity or both
The treatment may be seen as excessive even when the patient isnt suffering because of its
intrusive nature seems inappropriate for a short extension of life in a patient where there is no
longer hope for control of the underlying fatal disease.
The treatment may be seen as excessive because its cost is disproportionate to its benefits, it
deprives other patients of scarce resources or may conflict with broader societal values
The risk of invoking futility to withhold care is that such decisions may be
justified through a futility analysis that appears to focus on the patient but is, in
fact, driven by the interests of others
Physicians and Medical Futility: General Medical Care
Several observers have noted that a workable
approach to the issue of futility will have to
represent a middle ground between the
extremes of unlimited patient autonomy and
absolute empowerment of physicians to
designate certain clinical choices as futile
What is envisioned is a process that strongly
recognizes the right of patients to control
decisions but with safeguards to place
limitations on that right
Physicians and Medical Futility: General Medical Care
Another aspect of this evolving consensus requires that when futility is invoked
to limit patient determination, the decision should not simply reflect the
judgment of an individual physician but should, instead, result from some
institutional or professional consensus
This could lead to generic designations of futility, for example ruling that CPR in all patients with
less than one month to live to be futile
Knowledge of an institutions designations of futility may permit patients to be
better able to select institutions whose policies are most in keeping with their
own values and expectations
Persistent vegetative state (PVS) and futility
Condition characterized by complete unawareness of the self and the
environment
No evidence of sustained, reproducible, purposeful, or voluntary behavioral responses to visual,
auditory, tactile or noxious stimuli
Show no evidence of language comprehension or expression
Have bowel and bladder incontinence
After three months of PVS, recovery in all categories is quite unlikely
After six months it is quite rare
And after twelve months is is so rare that only 6 patients could be identified, all
of whom sustained permanent severe or moderate disability
PVS and futility continued
To many loved ones these lives achieved no purpose but rather was a source
of continuing pain
To those who care for PVS patients, the intense and prolonged effort to
maintain their lives often seems out of proportion to any goal that is achieved
and lacks the emotional reward associated with the care of responsive patients
At an institutional or societal level, expenditure of resources to extend these
lives is hard to justify when compared with other medical needs
PVS and futility continued
Dworkin (1993) puts it this way: Many people have a parallel reason for
wanting to die if an unconscious vegetable life were all that remained. For
some, this is an understable worry about how they will be remembered, but for
most, it is a more abstract and self-directed concern that their death, whatever
else it is like, express their conviction that life had value because of what life
made it possible for them to do and feel. They are horrified that their death
might express, instead, the opposite idea, which they detest as a perversion:
that mere biological life - just hanging on - has independent value.
Futility Issues in Pediatrics
Many think that medical treatment for children is different from that for adults
Unfortunately, pediatrics also has a less optimistic side
Some congenital anomalies, genetic disorders, and malignancies have not yet
yielded to the press of modern medical science
Current technology and medical skill are unable to provide a reliably good
outcome for very small preterm infants, certainly those born at 22 weeks of
gestation or earlier
Futility Issues in Pediatrics
Two features that distinguish the futility
confrontation in pediatrics
1. Our deeply held belief and hope that
childhood should be different and that
children should not die before some
imaginary natural life span
2. Medical uncertainty in pediatrics, in the
difficulty of predicting eventual outcomes,
especially those pertaining to
neurodevelopment
Most futility cases arise in pediatrics arise in
neonatal care
Futility Issues in Pediatrics
An increasing number of neonatologists seem more ready to recommend
discontinuation of treatment
In one case, involving a premature infant of a physician and his wife in
Michigan, had discussed what to do when his wife went into preterm labor
The parents expressed the view that the pregnancy had not progressed sufficiently far to justify
resuscitation or similar intervention
Those attending the delivery did not accept or know of the parents views and the infant was
treated vigorously, taken to the NICU and provided with mechanical ventilation
Angered by these events and convinced that the treatment was futile, the father went to the
NICU and disconnected the infant from life support, ensuring death
The father was later prosecuted for a criminal offense but was acquitted by a jury
Futility Issues in Pediatrics
By contrast, some parents feel entitled to insist on continued mechanical
ventilation and repeated resuscitations, expressing their religious beliefs of
divine intervention on behalf of their child or their hostility and opposition to
the willingness of physicians to forgo treatment
Another preterm infant, born in Washington state, became the object of heated
attention when, after a few weeks of very active treatment, he developed
complications - neurologic injury, gastrointestinal obstruction, and kidney
failure
The hospital physicians declared that further therapy was inappropriate
The parents refused to accept this judgment and obtained legal counsel to support their press
for continued therapy
Learning of the dispute from the media, physicians at another hospital in the region contacted
the family and accepted the child for the interventions that the parents desired
The case of
Charlie Gard
How culture and religion affect attitudes
It create a barrier between patient and healthcare provider in negotiating a
sensitive and dignified process of dying for the patient
Religion and cultural values are the the source of strength and comfort for
patient in time of crisis and when facing ones own mortality
Religion attempts to lift humans above pain, illness, and death, and help the
believer to cope with grief and death
Some religions believes in Gods will or afterlife, and that he/she may accept
adverse events and death with calmness
Family members may have difficulty when making a life-sustaining decisions
from a terminal ill relative or who is in PVS
The Catholic Perspective
- Takes the bioethics doctrine of double effect (the good and bad effect of an
action)
- Allows withholding and withdrawing of futile therapy if it is burdensome or
dangerous to the expected outcome
- Although pain and suffering is important to induce ones spiritual growth, this
does not mean that pain relief should be withheld for patient to understand the
redemptive nature of suffering
- In 2004, Pope II announced that cessation of nutrition and hydration resulting
in death by starvation is strictly forbidden
The Jewish Perspective
- The Halacha (Jewish legal system) allows withholding and withdrawing
life-sustaining treatment if its a recurrent nature and patient has consent to it,
as this is seen as omitting the next treatment rather than committing an act of
withdrawal
- Instead, withdrawal of continuous life-sustaining treatment (respirator or
cardiac pacemaker) is forbidden
- Withdrawal of artificial nutrition and hydration is not allowed as it is seen as an
act of leading to death
The Buddhist Perspective
- Proceeding with futile treatment goes against the
teachings of Buddhism
- The ethical validity is measured based on the motive
of such conduct
- If patient aim for death, it will be an offence to refuse
medical care
- Artificial nutrition and hydration cannot be
discontinued, even if patient is in persistent vegetative
state
The Islamic Perspective
- The saving of a life is considered one of the
highest merits and imperatives in Islam
- Resorting to futile treatment in order to put off
death is not acceptable in Islam
- Life saving equipment cannot be switched off
unless the doctor is certain about the
inevitability of death
- Administering analgesia to lessen suffering in
end-of-life care is permitted even if in the
process, death is hastened
When religious beliefs and medical judgments
conflict
- In the ordinary course of events, there is a joint decision process involves:
Physician diagnose, prognose, and recommend treatment
Patient Accept/reject recommended treatment using personal values
- Conflict occurs when autonomy involves not only the right of patients and their
families to accept or decline a proposed therapy, but also the right to whatever
life-sustaining intervention they desire
- Most religious believers reject brain death as a determination of death, where
one whose heart still beats still lives.
Such conflict between religious beliefs and medical judgments are seen in several
major futility cases:
1. Helga Wanglie Case (1991)
Husband insistence on continuing treatment for his wife. This was based
on his belief that God alone can take life, not human. The removal of life
support would show lack of faith in Gods ability to heal.
2. Gilgunn v. Massachusetts General Hospital (1995)
The daughter of a 72 yo comatose woman sued physician for failing to
attempt cardiopulmonary resuscitation (CPR) on her mother despite the
mothers multisystem failure. The daugher reasoning was because her religion
says that life is everything and is in Gods will.
Ethic committees and end of life decision making
A legal perspective
If one has the right to control ones health care by refusing medical treatment
even if that decision is contrary to medical advice, one also retains the right to
request and receive health care, over a physicians objections
Although this logic is compelling, it is important to realize that the the right to
refuse treatment does not easily transfer to the right to receive treatment
The difference between the two is dramatic
The law has almost uniformly conceded the former but has only hesitantly
recognized the latter, and only in situations related to public health and safety
A legal perspective
As a negative right, the right to refuse medical care is bolstered by a long legal
tradition
Rooted in the constitutional right to privacy and liberty and the common law right to be let alone
In contrast, the positive right to receive treatment is not supported by a similar
historic foundation
The federal judiciary has been reluctant to find a constitutional right that requires the state or
other individuals to provide services or expend resources or both to safeguard an individuals
claim to such right
A legal perspective
Do Not Resuscitate (DNR) legislation
A DNR order is a physicians written order not to attempt CPR on a particular patient
Every DNR law requires consent of either the patient or surrogate before the order can be issue
A few statutes have adopted a futility rationale as a possible basis of withholding CPR in the
absence of consent
Consent need not be secured to withhold a procedure that, in the opinion of the physician,
should not be offered because it cannot benefit the patient
In 1994, Georgia added the following amendment to their DNR law
Such presumption of consent does not presume that every patient shall be administered
cardiopulmonary resuscitation, but rather that every patient agrees to its administration unless it
is medically futile Medically futile was defined within the definition of candidate for
nonresuscitation
A legal perspective continued
The 1988 case of Helga M. Wanglie involved an 86-year-old woman who went
into a PVS after a hip fracture resulting in a series of severe medical
complications. Before her death, she lay unconscious, with her life being
sustained by a respirator and a feeding tube. Physicians recommended
removal of life support because they deemed it to be futile. When her husband
refused to consent to withdrawal of her treatment, a Minnesota district court
judge declined to name another guardian in his place. In this case, the court
decision had more to do with the right of Ms. Wanglies husband to make her
decisions than it did with the care teams ability to withdraw life support.
A legal perspective
In Gilgunn v Massachusetts General Hospital, doctors were sued for
negligence after they decided to withdraw mechanical ventilation and issue a
do-not-resuscitate order for a 71-year-old patient dying of multiple organ
failure, over the objection of her daughter. The suit was brought after the
patients death, as opposed to the previous case. The jury ruled in favor of the
defendants apparently based on the rationale that the treatment was futile.
The Texas Advance Directives Act of 1999
Legislation passed by the Texas Legislature in 1999 provides a legally sanctioned, extrajudicial
process for a healthcare facility to discontinue life-sustaining treatment against the wishes of a
patient or his/her surrogate decision makers.
Established a new standard for living wills and medical powers of attorney
It is the first, and thus far only, state statute to provide a detailed framework for adjudicating
conflicts between patient families and healthcare providers in end-of-life cases
Community projects (Vivian)
Although the issue of medical futility originated in the the professional community, the development
of treatment guidelines should involve the perspective of the public community as well
The Professional and public community should synthesis in work together in order to come to a
decision about medical futility
This is an example of a method of societal level decision making, where the both the
physician and patient make clinical decisions
Shared decision making is the primary goal of the bioethics movement
Adequate attention to diverse perspectives of different moral communities concerned
autonomy, beneficence, and justice, will require special compromise from each community
The following slides are examples of local public and professional communities either working
separately or together when making medical futility
Community policies (Vivian)
Professional Community Project
Dr. Art Arvin from the Santa Monica UCLA medical center reviewed clinical cases with
significant financial losses in their facility
He noticed that of the patients transferred into this facility came from nursing homes and
already had acute illness. The tremendous resources and interventions provided to theses
patients could not restore a satisfactory quality of life.
The hospital committee then developed a medical futility policy, which defined medical futility
as treatment other than comfort care, that will improve and restore the quality of life.
The Santa Monica project leaders concluded that the family, patient, and provider, should be
equally involved when making decisions in regards to medical futility.
Participants of the Santa Monica project concluded they need to include the public through
education meetings, community meetings, and public policy initiatives when making decisions
in regards to futile care.
Community Policies Continued
Public Community Projects
The ECHO project is a community wide project designed by the Sacramento Healthcare
Decisions, which is a nonprofit that promotes appropriate care for dying or irreversibly ill
patients in the Sacramento area, by educating and involving the public in health care policy
making and medical futility decisions.
The ECHO project gave rise to the classic medical futility debate, medical futility or give
treatment demanded by the families?
A six month long public dialoge was created to educate the community on medical futilyu
Imput from the public and health care professionsal created a strict medical futility protocal that
will cut the cost from uneccassry medical treatments
Community Policies Continued
What drives community efforts to develop futility policies?
Community efforts, beliefs, and concerns, are usually consistent with widespread beliefs
Overtime health care works have learned that courts will not always defer to physician
judgments, and may frame the issue different from the health care workers view.
Proposed Goals for community efforts
Define medical futility
Prescribing appropriate procedures and developing a standard of care
Developing more appropriate goals
Conclusion (Vivian)
Medical futility refers to a situation in which irreversibly dying patients have reached
a point where further treatment provides no physiological benefit or is hopeless
and becomes optional. Many have labeled some scenarios of medical futility as
futile due to personal ethical, religious, and cultural beliefs. Therefore, the issue of
medical futility has been seen in major judicial cases around the country in multiple
medical settings. This has caused the public to become integrated in the policy
making process for medical futility. Overtime, the community has had an impact on
medical futility practices. Some have argued that the public has done more harm
than good, but a middle ground between the physicians, patients, public, and the
law needs to be met.
References
Beauchamp, T.L. & Childress, J.F. (2013). Principles of biomedical ethics. New York, NY: Oxford University Press.

Jahn Kassim, P., & Alias, F. (2016). Religious, Ethical and Legal Considerations in End-of-Life Issues: Fundamental Requisites for
Medical Decision Making. Journal Of Religion & Health, 55(1), 119-134. doi:10.1007/s10943-014-9995-z
Baby K
Set up the scene where doctor (Robert) is letting mom know (Nina) that her baby
was born without a brain and to issue a DNR order. Nurse Vivian comes in to
comfort and further discuss options with mom and provide spiritual and emotional
care. Trixy narrates and splits up every one into groups to discuss
Socrative Question