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Medical Futility

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Chansamone Thepmontry

on 9 April 2015

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Transcript of Medical Futility

Medical Futility

Medical Futility Video
ELMSN: Bahareh Memarzadeh & Javi Fuentes & Chance Thepmontry-Nhep
MSN:Maribel Plasencio & Jorge L. Soler

What is Medical Futility?
What is considered “Futile” ?

Whatever will
produce physiological effect

Whatever is highly unlikely to be efficacious

Whatever probability will produce low grade, or insignificant outcome

More BURDENSOME than beneficial
Speculated or Untried treatment

(Beauchamp, 2009, p. 167).

Problems to consider with medical futility
NO concise definition of medical futility applied to all medical situations
NOT being directly addressed by American Medical Directors Association (AMDA).
The use of the ethics committee was encourage by AMDA to help in end of life care conflicts between physicians and patients.

Physicians, patients and families often have very different views on what is potentially beneficial.
Physician may believe that treatment X in an elderly demented patient is futile, but the family may view X as an important intervention to continue life because their culture views is to preservation of life at all cost.
Medical futility can be easily misunderstood.

(British Journal, 2011; Eskildsen, 2010).

Futility Exceptions and Cautions
Physicians should anticipate and recognize concerns of patient/surrogate within the particular context of medical care: hence may be obligated to discuss even if not to offer treatment (e.g. attempt CPR for patient in ICU)

Physicians should consider making compassionate exception (reasonable accommodation) by offering treatment to achieve short-term goal (e.g., dying patient wishing one last visit by loved one.)

(ACP Ethics Manuel, 2012)

"Interventions that are unlikely to produce any significant benefit for the patient"

“ A treatment evaluated by the health care, the family, or both as being non-beneficial or harmful to a dying patient"

“Any treatment which fails to provide either cure, restoration or palliation of a patient”

(Cuezze & Sinclair, 2009)
Two Types of futility
Quantitative futility:
refers to the intervention that has a very small chance of benefiting the patient; 1% chance of success.This is sometimes called physiological futility, the health care professional judges that the desired treatment will not restore or improve function
For example, CPR in a patient with metastatic cancer. However, there is ongoing debate about how low the probability of benefit should be before calling an intervention quantitatively futile.
Qualitative futility:

refers to interventions that will not improve, and may decrease the patient's quality of life.
For example, hemodialysis for a patient with severe dementia and end-stage renal disease.

(Cuezze & Sinclair, 2009)
Based on
, the treating
determines if treatment is no longer beneficial. Then a
is called to reach a consensus.


communication with patient’s family is
for better outcome and experience.


1. Allow patients/surrogates to decide all about the physiological futility.

2. Allow physician to decide futility

3. Pursue negotiated compromise respecting the autonomy to the physician and the patient equally

(Journal of Nursing Scholarship, 2013)
California Uniform Health Care
Decision Act
Allows physicians to refuse to provide a
treatment when:
It violates their conscience (a “conscience clause)
When they believe treatment would be “medically ineffective.”
The UHCDA Requires:
Physicians to promptly inform the patient
Make all reasonable efforts to assist in transfer of the patient
to a provider willing to comply with the instruction
Provide continuing care until transfer accomplished OR until it appears transfer cannot be accomplished
Continue appropriate pain relief and other palliative care

(English & Morgan, 2000)

Benefit of Treatment vs. Burden on patient
Questions to Consider.
Are we keeping the patient alive when there is no benefit to life of the patient?
Are we giving the patient time to recover to a level of quality of life that the patient will accept?
Or are we merely prolonging or exacerbating the process of death?
Ethical Case Part 3
Ethical Case part 2
ethical Case Part 1
The Texas Advance Directives Act of 1999
Sec, 166.046
Ethical Principal
ACP American College of Physicians - Internal Medicine - Doctors for Adults. (n.d.). Retrieved March 25, 2015, from http://www.acponline.org/running_practice/ethics/manual/manual6th.htm
British Journal of Hospital Medicine. (2011). Medical futility: a commonly used and potentially abused idea in medical ethics, 72(2), 96-99. Mark Allen Publishing Ltd.
Burkle, C., & Benson, J. (n.d.). End-of-Life Care Decisions: Importance of Reviewing Systems and Limitations After 2 Recent North American Cases. Retrieved March 26, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3532693/
California Health Care Association. Appendix 2-D Health Care Decision for Unrepresented Patients: Model Policy for General Acute Care Hospital.
Cuezze, J. E., Sinclair, C.T. (2009). Medical Futility. Retrieved from https://www.capc.org/fast-facts/136-medical-futility/
Eskildsen, M.A. (2010). Medical Futility: Ethical, Legal, and Policy Issues. Annuals of Long-Term Care, 18(3). Retrieved from http://www.annalsoflongtermcare.com/content/medical-futility-ethical-legal-and-policy-issues
Donley, G., & Danis, M. (2011). Making the case for talking to patients about the costs of end-of-life care. Journal of Law, Medicine & Ethics, 39(2), 183-193
Zucker, Marjori B. & Zucker, Howard D. (1997): Medical Futility and the Evaluation of Life-sustaining Interventions. Cambridge: Cambridge University Press.
Beauchamp, T. L., & Childress, J. F. (2009). Principles of biomedical ethics. Oxford university press.
Kompanje, E.J., Piers, R.D., Benoit, D.D. Causes and consequences of disproportionate care in intensive care medicine. Curr Opin Crit Care. 2013;19:630–635.
Truog, R.D., White, D.B. (2013). Futile treatments in intensive care units. JAMA Intern Med.;173:1894–1895
David M. English & Rebecca C. Morgan, Nursing Home Residents and the New California Health Care Decisions Law, 31 McGeorge
L. Rev. 733 (2000)

Policies on Medical Futility
Laws Addressing Medical Futility
Facing Death: How far would you go to sustain the life of someone you love, or your own? Video
Medical Futility Cases
Medical Futility case of Lisa Avila
Current Report on Lisa Avila
Time for A Group Discussion!!!
Class Discussion
What is you input on Lisa Avila's Case?

What do you think about the Hospitals decision to take Lisa off of life support?

What are your thoughts about the family's request to extend Lisa's treatment?

Causes & consequences of disproportionate care in the icu
(1) violation of basal ethical values
(2) patients’ and relatives’ suffering
(3) moral distress, avoidance behavior
(4) compassion fatigue in physicians and nurses.
(5) Cost
(6) Pt. quality outcome
(7) Unhealthy work environment

Payment for futile treatment usually comes from private or public collective resources or from a social insurance program such as Medicare or Medicaid.

The percentage of Medicare payments attributable to patients in their last year of life was 28.3% in 1978 and has remained substantially the same at 25.1% in 2006.

the Congressional Budget Office estimated, prior to 2010 health care reform, that total U.S. spending on health care would reach 25% of the gross domestic product (GDP) in 2025, 37% in 2050, and 49% in 2082

( JAMA Intern Med, 2013).
Who Pays for Futile Treatments
medical futility history
Three major goals of medicine:
Cure, relief of suffering and “refusal to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.

Plato: To attempt futile treatment is to display an ignorance that is allied to madness.”

(Cuezze & Sinclair, 2009)

cost of Futile Treatments
average cost
for a day of
futile treatment
in the ICU was about
Of the 123 patients perceived as receiving futile ICU care, total costs during the three months of the study amounted to
$2.6 million
for the five ICU.
Although sizable, it accounted for only a small portion (3.5 percent) of the hospital costs for the full study cohort of ICU patients during the study period.
Critical care patients accounts for approximately 20 percent of all healthcare costs in the United States; the
annual cost exceeds $90 billion.

( JAMA Intern Med, 2013).
Cost of Futile Care
The joulnal JAMA Internal Medicine, UCLA Health System and RAND researchers published a reporthat stated that intensive care physicians at five academic hospital said they were certain they provided futile care for 11 percent of the critically ill patients they saw over a recent three-month period, and they strongly suspected that they had provided futile treatment for another 8.6 percent of patients.

The goal of medicine is to help the sick. Physicians have no obligation to offer treatments that do not benefit patients. Futile interventions may increase a patient's pain and discomfort in the final days and weeks of life; give patients and family false hope; delay palliative and comfort care; and expend finite medical resources. However, determining which interventions are beneficial to a patient can be difficult, since the patient or surrogate might see an intervention as beneficial while the physician does not. Physicians should follow professional standards, and should consider empirical studies and their own clinical experience when making futility judgments. They should also show sensitivity to patients and families in carrying out decisions to withhold or withdraw futile interventions.

( Beauchamp p. 167,168).

Interventions to Prevent medical Futility
Improving the communication that occurs between healthcare providers and patients or their proxies.

Advanced care planning

Palliative consult

Consult the Ethics Committee

Zucker, Marjori B. & Zucker, Howard, p. 145

rational for futility
I-Death is imminent
II-Best possible outcome for patient (longevity, quality of life such as freedom from excessive physical or emotional pain for patient or family, independence, function,awareness, interaction) is acceptable.

III-Probability of achieving best or even good outcome is very low

(W. D. Doty, 2013, pp. 11-13 )
Jahi McMath
• On December 9, 2013 underwent a tonsillectomy and adeinectomy surgery at Children's Hospital Oakland, California, to relieve the symptoms from sleep apnea

• December 12, She suffered massive bleeding, had a heart attack and was declared brain-dead
• On December 30, 2013, the judge gave the order to the hospital to disconnect the machines after 5 p.m then to 8 p.m.

• On January 5, 2014, On January 5, 2014, Children's Hospital released McMath's body if her mother assumed responsibility for further complications

Court Decision
video Jahi McMath case: Family says brain-dead girl moves on command
(Kompanje, 2013, p. 632).
Texas takes the lead in addressing the issue by establishing legal binding advance directives suggesting the following:

If a physician’s refuses to honor a patient’s treatment decision, it must be reviewed by the facilities ethics committee
The patient or family are both gven written information about hospital’s ethics consultation process and an invitation to participate with at least 48 hours’ notice;
Ethics committee provides a written report of findings to the patient or family;
If the dispute remains unresolved, the staff at the hospital working with the family, must try to arrange a transfer to a provider willing to give the requested treatment;
If after 10 days, no provider can be found, the futile treatment can be withheld or withdrawn
The patient or surrogate may ask a court to grant an extension of time only if the judge determines a willing provider will likely be found;
If no extension is sought or granted, futile treatment may be unilaterally withdrawn by the treatment team with immunity from civil and criminal prosecution.

TEX HS. CODE ANN. § 166.046
Ethical Case Discussion on Medical Futility
(JAMA Intern Med, 2013).
ethical dilemma to Medical Futility
Patients & surrogate argue that, if they have the right to refuse or discontinue certain medical treatments on the basis of their best interest, they have the right to request certain medical treatments on that same basis.

Physicians argue that many of the requested interventions are both burdensome for the patient and medically inappropriate because they fail to achieve the desired physiological effect and result in a misallocation of medical resources.
(Clark, 2007)
Nursing Consideration
Families Statement
Time for A Group Discussion!!!
Currently 10 states addresses Medical Futility:
•All permit healthcare providers to refuse “medically ineffective’ or “medically inappropriate” care.
All require healthcare providers or facilities to notify the patient or surrogate when proposed treatment is determined to be futile.
All require that life-sustaining treatment be continued until the patient can be transferred to another facility willing to comply with the patient’s instructions.

(Burkle & Benson, 2012)

Effective conflict resolution tool.

Permits all parties to compassionately arrives at consensus.

Allows for appeal or patient transfer if consensus cannot be reached.

Creates a fair process and greater consistency in handling medical futility cases.

Opportunity for justice and due process for all the parties.

More defensible than no process at all.

(Kwiecinski, 2006)

Benefits of having a policy
class discussion
(1) which ethical principle are involved in this cases explain ?

(2) Its unethical to give a person who has been declared dead nutrition?

(3) Has anyone who was declared brain dead ever been found later not to be dead?

(3) Are we doing what is best for the patients or what is best for the family?

class discusion
(1) Does the daughter has to respect her
mother's wishes, eventhough her mother is dying?

(2) Is the the Doctor acttitude the right one ?

(3) Discuss the ethical dilema in this case?

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