Defining when medical care is considered “futile” for critically ill patients continues to be a challenging and controversial dilemma for physicians. The Council on Ethical and Judicial Affairs of the American Medical Association recently recommended a process by which determinations about futility may be made for patients with life-threatening illnesses. However, the Council was careful to avoid specifying what does and does not constitute futile medical care.
Claims of futility often increase when the patient, the physician and family members disagree on the goals of treatment. Similarly, friction may develop when decision-making authority is not clearly defined. The law does not appear to favor either side consistently. In some cases, the court has sided with the patient's (or proxy's) right to choose care that has not been recommended by the physician. In other cases, the court has agreed that physicians do not have to provide care that is considered medically futile. The latter situation is problematic in that the physician appears to be imposing his or her will on the situation. Futility questions also arise in the context of resource allocation. The Council strongly urges that discussions of futility avoid arguments that make use of resource-saving criteria or rationing.
The Council concedes that an objective, concrete definition of futility is unattainable; therefore, it recommends adopting a fair process for mediating futility cases. In the past, several proposals have attempted to delineate what constitutes futile medical care. One that attempts to quantify the concept of futility suggests that if an intervention does not work in more than 1 percent of patients, it should be considered futile. However, this approach does not account for factors such as comorbidities and cognitive function. Therefore, an approach that combines quantitative and qualitative factors is recommended. Another proposal suggests that interventions that merely prolong dying are futile. The flaw in this proposal is that in some situations, delaying death may be justifiable, as in cases of organ donation. Other proposals recommend the use of community standards in determining what constitutes futile.
The Council recommends a four-step algorithm for assessing futility (For more information, see the accompanying figure on the fair process for considering futility cases). The process includes four steps to achieve resolution, two steps to allow for alternatives if resolution cannot be achieved and a final closure step. The concept of futility will remain highly subjective, so a perfect solution may never be achieved. In the future, use of outcomes data, knowledge of the patient's wishes and involving a consultant to help in the review of options may help patients and physicians reach agreement on this issue.