Another Look at Medical Futility

What is medical futility? What does it mean to stop or not start some procedure or treatment because such action is futile? And what does futile mean in this context? Over the past 7 years on this blog, I have started a few threads which included this issue. Once, I presented the definition of futility as described by physician-ethicst Dr. Steven Miles in his humorous "A Thai Dictionary of Medical Ethics" in which he described an example of the use of the term "futility"as "a siphon for removing puddles of water that form far ahead on highways on hot summer days." Medical futility is a bit more complicated than that. Recently, for me, a concise description of medical futility was made by an ethicist and teacher Laurence B. McCullough, Ph.D. on a bioethics listserv and with his permission, I present his words below. But also what I would like to read from my visitors is how they look at the term "futile" or "futility" in relation to its use by doctors and whether it represents to them as patients or family members of patients a term which has meaning and should be used. ..Maurice.

In its general clinical meaning, 'futile' means that in evidence-based reasoning there is no reasonable expectation that the usually intended outcomes of a clinical intervention will occur. The roots of the concept can be found in the admonition in the Hippocratic text, The Art, against the madness of thinking that clinical intervention has unlimited power to alter the course of disease or injury. (Blackhall in "Must we always use CPR?" suggested 100% failure rate or 97-99% failure rate with high and unacceptable morbidity.)

Providing futile clinical management is not consistent with professional integrity. (See Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician's obligation. N Engl J Med 1986; 315: 1347-1351.) Professional integrity has been a consistent, core consideration of common law on end of life care, starting with Quinlan in 1976.

This general meaning of 'futility' must be specified, to be clinically applicable. (See Jones JW, McCullough LB. Postoperative futility: a clinical algorithm for setting limits. Br J Surg 2001; 88: 1153-1154; Rabeneck L, McCullough LB, Wray NP. Ethically justified, clinically comprehensive guidelines for percutaneous endoscopic gastrostomy tube placement. Lancet 1997; 349: 496-498.)

Physiologic futility: no reasonable expectation that physiologic outcome will be achieved (e.g., antibiotics for viral infection, CPR on totally decapitated human being [from international resuscitation guidelines and my favorite], artificial administration of nutrition to a patient with cancer cachexia). Physiologic futility is not discredited by a transient physiologic effect, such an occasional heartbeat during CPR.

Imminent demise futility: clinical management is expected to be physiologically effective but the patient is expected to die during current admission with no expectation of recovery of interactive capacity. (Medicine is not vitalist in any global tradition of medical ethics. See Baker RB, McCullough LB. The Cambridge World History of Medical Ethics 2009, in which'vitalism' does not appear in the index.)

Clinical or overall futility: clinical management is expected to be physiologically effective and prevent imminent death but the patient is not expected to recover interactive capacity, as in permanent vegetative state diagnosed by American Academy of Neurology guidelines. (Again, medicine is not vitalist.)

Quality of life futility: clinical management is expected to be physiologically effective, prevent imminent death, and preserve interactive capacity but the resulting functional status is not acceptable to the patient from the patient's perspective. (Quality of life is engaging in life tasks and deriving satisfaction from doing so. This concept does not apply to infants or to patients about whom too little is known to reliably identify the life tasks in which they engaged and the values by which they would make judgments about whether engaging in those life tasks with projected functional status will result in sufficient satisfaction.)

The first three specifications fall within clinical expertise; the fourth depends on clinical expertise (prognosis of functional status) but is also a function of the patient's values and beliefs.

These specifications often cannot be invoked a priori. Instead, they become the basis for stopping rules for critical care (initiated by CPR, high-risk surgery) as a trial of intervention. Explaining this concept in advance is a powerful preventive ethics response to requests to "do everything," by focusing on everything that is consistent with excellent medical care.

Race, ethnicity, and money (source of payment) are irrelevant to the conceptualization and clinical application of these specifications, which, when explained, can help address the distrust problem. If someone wants to make discussions of futility toxic, just introduce money, especially with folks of modest economic means or people of color. (Against stupidity, though, even the gods themselves rage in vain. See I Asimov, The Gods Themselves 1972.)

Some surrogate decision makers are not willing or are not able to engage in evidence-based, deliberative discourse. This is a rare but real phenomenon. Education and persuasion end in failure. The remedy becomes the exercise of professional and organizational power, which, in Texas, is sanctioned by our advance directives act. Elsewhere, local healthcare organizations need to agree on a futility policy, so that, when it is enforced by one organization, the others will be in support. (See Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996; 275: 571-574.)

Laurence B. McCullough, Ph.D.

 Dalton Tomlin Chair in Medical Ethics and Health Policy

 Center for Medical Ethics and Health Policy

 Baylor College of Medicine

 Houston, Texas