At times, physicians invoke an arbitrary six-month predicted survival metric used by the U.S. A declaration of futility is not performed through a standardized procedure or algorithm but rather is determined on a case-by-case basis. On the other hand, the physician may find the treatment to be futile or nonbeneficial. If the physician feels that treatment would be beneficial, then he or she would provide all indicated treatments to the patient while simultaneously searching for more guiding information. In the case of this 78-year-old patient, the physician must decide whether treatment is beneficial. While these categories of futility are generally relevant, patients often have their own perception of what they believe to be futile.

Qualitative futility: The intervention is unlikely to restore a patient’s meaningful quality of life.Īny procedure that alleviates discomfort or provides palliation should not be considered futile.

Lethal condition futility: The patient’s underlying disease is likely to impede long-term survival.

Imminent demise futility: The patient will likely die soon regardless of the intervention.

Physiologic futility: The intervention is unlikely to have any clinical effect.

Brody and Halevy categorized 4 conceptual definitions of futility: Although physicians are not obligated to provide futile therapy, there is little consensus for the definition of medical futility. Physicians caring for patients with life-limiting clinical conditions must carefully distinguish between interventions that are beneficial and those that are overly burdensome and potentially medically inappropriate or futile. The discomfort many physicians experience when discussing matters pertaining to end-of-life care and the ambiguity about which clinical service is responsible for holding such discussions (e.g., primary care, geriatrics, palliative medicine) also contribute to the lack of established goals of care. Physicians often care for patients for whom discussions and decisions about goals of care have not been established. The attending physician believes that shifting to comfort care is appropriate. A number of urgent management decisions must be made, including intubation. The patient never completed an advance directive and has no family members or friends. After placing the case in its medical and ethical contexts, a broad legal overview at the federal and state levels will be provided Case: A patient without DMC and without an identified surrogate decision-makerĪ 78-year-old woman with a history of multiple strokes and severe dementia is admitted to the medical ICU from an extended-care facility for treatment of septic shock. We present a hypothetical case to elucidate the medical, ethical and legal considerations in common end-of-life situations encountered in the ICU. These factors can contribute to significant uncertainty among critical care physicians regarding their ethical and legal obligations for terminally ill patients.

Physicians receive minimal training about their jurisprudential obligations in determining end-of-life care, and misconceptions abound regarding their legal responsibilities in this area. Moreover, each state in the United States maintains its own medicolegal system, and many physicians practice medicine in multiple clinical settings and geographic areas, all of which complicate their ability to master the law. Smith, STD, Laurel Hyle, JD, MPH, and Eduardo Mireles-Cabodevila, MDĪmid the various clinical decisions that must be made for critically ill patients in the intensive care unit (ICU), physicians must often confront complex circumstances involving end-of-life care. The article in its entirety, including a complete list of references, can be found here.īy Jonathan Wiesen, MD, Christopher Donatelli, MD, Martin L. We do not endorse non-Cleveland Clinic products or services PolicyĮditor’s note: This is an abridged version of an article originally published in the Cleveland Clinic Journal of Medicine.

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Ethical issues in end of life decisions