Futility And Nonbeneficial Interventions

The term futility is fraught with difficulties in definition and interpretation. Health care professionals may interpret futile interventions as those that carry an absolute impossibility of successful outcome, a low likelihood of success, a low likelihood of survival to discharge from the hospital, or a low likelihood of restoration of meaningful quality of life. Schneiderman and colleagues defined "futility" as "any effort to achieve a result that is possible but that reasoning or experience suggests is highly improbable and that cannot be systematically produced."6 Several authors have demonstrated that there is no consensus among physicians about the meaning of futility.78 Because of these difficulties, it is probably more accurate to use the appropriate terminology, such as "nonbeneficial," "ineffectual," or "low likelihood of success."

The withholding or limitation of medical interventions that have a predicted low likelihood of producing a successful outcome can be a difficult and far-reaching decision. Many emergency physicians continue to attempt resuscitation on patients in cardiac arrest, in situations considered nonbeneficial, often because of fears of litigation or criticism.9 Medical ethicists have stated widely variable opinions regarding rendering treatments considered futile or of low likelihood of benefit. The AMA Council on Ethical and Judicial Affairs stated that "the social commitment of the physician is to sustain life and relieve suffering. Where the performance of one duty conflicts with the other, the choice of the patient should prevail."10 One extreme viewpoint is that even the irrational choices of a competent patient must be respected if the patient cannot be persuaded to change them.11 However, most ethicists agree that physicians are under no obligation to render treatments that they deem of little or no benefit to the patient. ACEP has a policy which states that "physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of medical benefit to the patient."12

There have been numerous ethical opinions supportive of the position of offering only those treatments judged to be of likely medical benefit. The Hastings Center concluded, "if a treatment is clearly futile ... there is no obligation to provide the treatment."13 The AMA Council on Ethical and Judicial Affairs holds that CPR may be withheld, even if requested by the patient, "when efforts to resuscitate a patient are judged by the treating physician to be futile." 14 Blackhall stated that in cases of low likelihood of successful resuscitation, "the issue of patient autonomy is irrelevant."15 Tomlinson and Brody stated that "physicians have no obligation to provide, and patients and families have no right to demand, medical treatment that is of no demonstrable benefit." 16 Hackler and Hiller believe that "respect for patient autonomy does not require that the physician initiate decisions of medically pointless procedures." 17 Schneiderman and colleagues wrote that "futility is a professional judgement that takes precedence over patient autonomy and permits physicians to withhold or withdraw care deemed to be inappropriate without subjecting such a decision to patient approval."6 Jecker and Schneiderman also stated that physicians have no ordinary ethical obligation to offer futile interventions. 18 Paris and Reardon wrote that "physicians as moral agents should exercise professional judgment in assessing patient requests. If the request goes beyond well-established criteria of reasonableness, the physician ought not feel obliged to provide it." 19

Ultimately, the decision regarding CPR, its likelihood of benefit to the patient, and decisions to provide, limit, or withhold resuscitative efforts are to be made by the emergency physician in the context of well-established research results, patient and family wishes, and professional judgment. Individual bias regarding quality of life or other related issues should be avoided. There are many cases where dying should be accepted as a natural process, even in an emergency setting. Perhaps palliative care, communication, and counseling with the patient, family, and friends may be of greater benefit then technology of unlikely benefit.

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