Medical futility

OVERVIEW

  • “Futility” means the absence of benefit
  • a consensus definition of medical futility does not exist
  • ~80% of ICU patients who die do so as a consequence of a decision to withhold or withdraw life support
  • it is more useful to consider the utility of any intervention (the balance of benefits and harms) rather than futility

TYPES OF FUTILITY

Waisel and Truog summarise three different conceptual definitions of futility:

  • Physiologic futility — when a procedure cannot bring about its physiologic objective (e.g. when CPR cannot achieve a BP target) — involves a “value choice” of the measurement of organ function rather than the value of the outcome for the patient as the patient might perceive it.
  • “benefit- centred” futility — involves a quantitative estimate of futility is one in which an intervention is considered futile if it has failed in the last defined number of times attempted (e.g.  100 successful attempts as the threshold) or a qualitative component, where the patient’s resulting quality of life falls well below the threshold considered minimal by general professional judgment (e.g.  treatments which merely preserve unconsciousness or cannot end dependence on intensive medical care)
  • Operationalising futility — treatment that is so unlikely to succeed that many people—professional and lay persons—would consider it not worth the cost (aims to precludes individual caregivers from having to make qualitative or quantitative value judgments)

American Thoracic Society definition

  • “highly unlikely” to result in meaningful survival (a mix of quantitative and qualitative components)

American Heart Association definition

  • “no survivors reported under the circumstances in well designed studies “

Critical Care Society definition

  • treatments are  futile only when they will not achieve their intended goal

LIMITATIONS 

  • a therapy should not be provided if the harms outweigh the benefits — futility does not encompass harms, only the absence of benefit
  • potential  risk of causing offence by using  the term
  • risk of harming patient autonomy by using futility as an overriding force

References and Links

Journal articles

  • Ardagh M. Futility has no utility in resuscitation medicine. J Med Ethics. 2000 Oct;26(5):396-9. PMC1733283.
  • Ardagh M. Utility rather than futility in emergency medicine. Emerg Med Australas. 2011 Oct;23(5):530-1. PMID: 21995466.
  • Danbury C, Newbury C. Futile treatment in intensive care. JICS 2014;15(1):10-11 [Free Full Text]
  • den Hollander D. Medical futility and the burns patient. Burns. 2013 Mar 20. pii: S0305-4179(13)00040-5. PMID: 23523220.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health, a Clinical Adjunct Associate Professor at Monash University, and the Chair of the Australian and New Zealand Intensive Care Society (ANZICS) Education Committee. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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