Futility
The bioethics "F-word"
Welcome to Bioethics Basics. I’m Aimee – a nurse-turned-ethicist and ethics educator. My goal is to make ethics education more accessible by simplifying complex concepts in bioethics for the busy point-of-care clinician.
In clinical practice, appealing to claims of “futility” is relatively commonplace. As an ethics consultant, I have often received consult requests due to perceived “futile care.” Typically, these involve cases where the clinical team has assessed that a critically ill patient is approaching end-of-life, yet the patient’s family has not yet come to terms with this fact – these often manifest as conflicts around code status (i.e. full code versus DNR/DNI).
Despite the intuitive appeal of the term, for many years bioethics scholars have cautioned against using the word except in very particular circumstances. This is, in part, due to challenges with definitional clarity – what do we mean by futile? According to whom? Who gets to decide?
For example, a clinician may claim that continued ICU care is “futile” in the sense that the patient is unlikely to survive to ICU discharge, however the patient’s family may contend that any additional time with a loved one is worthwhile and therefore, not futile. In other words, the term is inherently subjective and value laden.
Some have attempted to draw distinction between qualitative and quantitative futility (see Schneiderman et al., 1990), however even these attempts don’t avoid issues with subjectivity and different value judgments.
This subjectivity is problematic in part because claims of futility may be used to justify unilateral withdrawing or withholding of interventions under the guise of objectivity. It is true that clinicians are not obligated to provide interventions that are assessed to be more harmful than helpful, or those for which the burdens outweigh the benefits. However, in many cases QOL judgments hinge on an assessment of quality-of-life, which is a notoriously subjective one and one in which clinicians and patients often disagree. Ultimately, an assessment of acceptable quality-of-life ought to be up to the patient (or surrogate, by extension) to decide. That said, clinicians should avoid providing treatments where it is clear that the risks outweigh the proportional benefits.
What terms can be used instead?
In a landmark policy paper (widely referred to as the 5-Society Statement), the ATS/AACN/ACCP/ESICM/SCCM recommend only using the term futile in “the rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal.” In other words, appealing to physiologic futility remains ethically appropriate, when clinically indicated.
In addition, the 5-Society Statement recommends using “potentially inappropriate treatment” in situations when “treatments… have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them.” Others have used the phrase “nonbeneficial treatment” in the case that “the burden of treatment outweighs any benefit to the patient.”
In most cases where potentially inappropriate or nonbeneficial treatments are creating conflict, an ethics consult may be appropriate. The 5-Society Statement outlines an escalation process that ought to be followed in order aid in resolving intractable conflict.
Additional Reading:
This post is for educational purposes only and does not constitute medical or legal advice.