Correspondence
The Rise and Fall of the Futility Movement
N Engl J Med 2000; 343:1575-1577November 23, 2000
- Article
To the Editor:
For evidence of a rise and fall of the futility movement, Helft et al. (July 27 issue)1 use a parochial if not dubious source of empirical data — the number of citations found in a Medline search of scholarly articles. I suggest they look at health care organizations around the country that are actively developing futility policies. Although I am not aware of any systematic survey, I am in frequent contact with institutions engaged in this activity. A recent statewide conference in California critiqued the policies of 26 hospitals. In the majority of these, medical futility was specifically defined, and the definitions were remarkably similar.2 As far as I can tell, the only fall in the futility movement has been from the scholarly towers to the street level, where these decisions are being made every day.
Helft et al. use the term “futile care” rather than the more precise “futile treatment.” Language matters when one is trying to reassure families of one's commitment to ongoing and compassionate attention even if such attention does not involve aggressive interventions.3 Many institutions specify in their policies that, although a particular treatment may be futile, care is never futile.
Helft et al. place their hopes in a process-based approach that arrives at a compromise through conflict resolution. However, the use of such an approach in the absence of underlying principles and definitions may lead to ethically problematic decision making, not by reference to the most appropriate medical standards, but more capriciously, through the demands of the most powerful, uncompromising, and threatening parties.2
3 ReferencesLawrence J. Schneiderman, M.D.
University of California, San Diego, La Jolla, CA 92093-06331
Helft PR ,Siegler M ,Lantos J . The rise and fall of the futility movement. N Engl J Med 2000;343:293-296
Full Text | Web of Science | Medline2
Schneiderman LJ ,Capron AM . How can hospital futility policies contribute to establishing standards of practice? Camb Q Healthc Ethics 2000;9:524-531
CrossRef | Web of Science | Medline3
Schneiderman LJ ,Faber-Langendoen K ,Jecker NS . Beyond futility to an ethic of care. Am J Med 1994;96:110-114
CrossRef | Web of Science | Medline
To the Editor:
Contrary to assertions that there has been a decline in the futility movement and that futile treatment cannot be defined, many hospitals and other health care organizations have developed policies and procedures covering this area, and more will probably do so.1 Such policies can include a careful and inclusive review of any putative case of nonbeneficial treatment, which would include talking to patients and their families about the treatment, as Helft et al. suggest, and the use of second opinions, consultation with specialists, and review by an institutional ethics committee. In other words, the process is about as inclusive as is practicable.
During the lengthy process of developing such broad-based guidelines in northern California, there was a strong consensus that such policies were needed but that fears about liability precluded their implementation.2 Yet, cases involving determinations of futility have more often been marked by careful conflict resolution than by legal action.
2 ReferencesSteve Heilig, M.P.H.
San Francisco Medical Society, San Francisco, CA 941091
Schneiderman LJ ,Capron AM . How can hospital futility policies contribute to establishing standards of practice? Camb Q Healthc Ethics 2000;9:524-531
CrossRef | Web of Science | Medline2
Bay Area Network of Ethics Committees (BANEC) Nonbeneficial Treatment Working Group
Medline
To the Editor:
We agree with Helft et al. that “futile care in hospitals is still very much an issue.” However, it is no longer true that “doctors today are no more empowered to declare a treatment futile unilaterally than they were 15 years ago.”
The Texas Advance Directives Act of 19991 established an extrajudicial mechanism of due process that allows physicians to stop futile treatments without fear of civil or criminal liability if the process is followed. If a physician in Texas concludes that continuing life-sustaining treatment for a terminally or irreversibly ill patient is futile, but the patient's family demands that such treatment be continued, a five-step process can be invoked.
The family is given 48 hours' notice of and an opportunity to participate in an ethics-review process with the facility's ethics committee. More often than not, this review process resolves any disagreement. However, if at the end of the review process, the committee agrees with the treatment team that continuing life-sustaining treatment is futile and the family still insists on continuing aggressive treatment, then additional steps may be taken. Life-sustaining treatments are continued for 10 days while attempts are made to transfer the patient to a facility willing to provide the treatment that has been found to be futile. If no alternative provider is found, then treatment other than comfort care may be stopped without civil or criminal liability unless the family chooses to seek an extension from the state courts to continue the search for an alternative provider. The courts are instructed by the law to grant an extension of the 10-day period only if there is reasonable evidence that an alternative provider can be found during this extension.
Our initial experience as ethics consultants to large tertiary care hospitals has been quite favorable. The process places both temporal and conceptual boundaries on the concept of futility. When both the treatment team and the ethics committee come to the conclusion that further treatment is futile, it is extraordinarily unlikely that another facility will accept the patient. This point helps to persuade the family of the appropriateness of switching to comfort care alone. Placing a process familiar to many ethics committees within the context of the law has changed the tenor of the conversation between providers and patients' families for the better.
1 ReferencesRobert L. Fine, M.D.
Baylor Health Care System, Dallas, TX 75204Thomas W. Mayo, J.D.
Southern Methodist University School of Law, Dallas, TX 752051
Texas Advance Directives Act of 1999. Texas Health and Safety Code ch. 166 (Vernon Supp. 1999). (See http://www.capitol.state.tx.us/statutes/he/he016600.html#he001.166.001.)
To the Editor:
It is certainly true, as stated by Helft et al., that the medical profession has not agreed on a clear set of standards to define futile care. However, even if this were done it is doubtful that courts and the public would feel comfortable allowing physicians to deny care — no matter how futile — unilaterally.
Since the end of the period reviewed by Helft et al., far broader changes in the public's perception of physicians' authority have taken place. With medical information much more readily available through the Internet and other media sources, physicians' authority and, similarly, the respect with which we are viewed by the public may have less and less to do with our clinical judgment and epidemiologic skills and more to do with our ability to participate in medical decision making as one voice among many. Although some may mourn the day when physicians were held in such esteem that they could consider unilaterally denying care, such regret misses the point of larger social changes that go to the very heart of the way in which physicians' authority is constructed. The better question is not, “What do doctors think is appropriate,” but simply, “How can doctors share their wisdom?”
Eric R. Wold, M.D.
Weill Cornell College of Medicine, New York, NY 10021To the Editor:
Medical futility has a very long tradition, tracing back to Sumerian and Egyptian healers, who were capable of deciding and empowered to decide whether to treat or to avoid treating. Moreover, in classical times it was generally considered prudent and moral for physicians to avoid treating those who were hopelessly ill; to do otherwise might have been criticized as fraudulent. The writers of the Hippocratic Corpus persistently advised physicians to refuse to undertake cases “in which the disease has already won the mastery, knowing that everything is not possible to medicine.”1 The same attitude was supported by philosophers such as Plato, who had a particular interest in defining the limits of medicine. Plato referred to the fate of Aesculapius, who, having successfully dared to exceed these limits, was killed with a thunderbolt by Zeus.2 Physicians could declare a treatment futile unilaterally, regardless of their patients' objections. Quite interestingly, this attitude continued even after Christianity became predominant. Thus, when the physicians of the 12th-century Eastern Roman Emperor Alexius I Comnenus concluded that his disease was incurable, it was completely acceptable to let him die alone.3
3 ReferencesEmmanouil Galanakis, M.D., Ph.D.
University of Crete, 71409 Heraklion, Greece1
Hippocrates. Hippocratic writings: edited with an introduction by G.E.R. Lloyd. Lloyd GER, ed. Chadwick J, Mann WN, trans. London: Penguin Books, 1983.
2
Plato. The republic. New ed. Lindsay AD, trans. London: Dent, 1976.
3
Lascaratos J ,Poulakou-Rebelakou E ,Marketos S . Abandonment of terminally ill patients in the Byzantine era: an ancient tradition? J Med Ethics 1999;25:254-258
CrossRef | Web of Science | Medline
Author/Editor Response
The authors reply:
To the Editor: In a sense, the debate about futility comes down to a question of whether process is preferable to principles. Schneiderman prefers principles, since in his view, process is simply a way of veiling domination by the powerful. Schneiderman also appears to believe that principle and definition provide tools for managing “the demands of the most powerful, uncompromising, and threatening parties,” by which we assume he means the “capricious” desires of patients and their families. Such anarchy need not follow from a process that allows patients to participate. Rubin, in her comprehensive review of the futility debate, offers principles for fair process.1 According to Rubin, it must involve “genuine conversation using complete sentences, moral persuasion, and transparent disclosure.” With such safeguards, a process for resolving futility dilemmas may offer a fairer solution than the application of principles not shared by all participants in the dialogue.
To our mind, the elaborate policies described by Fine and Mayo as part of the Texas Advance Directives Act of 1999 fall somewhere between unilateral decision making by physicians and the sort of process we imagine to be fairer and preferable. The family has nearly two weeks of process, impartial outside review by both ethics committees and courts, and the chance to find an alternative provider. Our hospital has a similar, though less cumbersome, policy. It is never invoked.
Physicians today often offer their opinion that further treatment is futile. They may even move to discontinue treatment on that basis before patients or their families would wish to. They may write policies to justify these actions. Those policies may be incorporated into state laws. However, the policies will almost always include ultimate recourse to outside judicial review. To date, courts have been extremely reluctant to override a family's request for continued treatment. Such cases of irresolvable disagreement are both rare and symbolic.
1 ReferencesPaul R. Helft, M.D.
Mark Siegler, M.D.
John Lantos, M.D.
University of Chicago, Chicago, IL 60637-1470- Citing Articles (2)
Citing Articles
1
G ROCKER. (2003) Controversial issues in critical care for the elderly: a perspective from Canada. Critical Care Clinics 19:4, 811-825
CrossRef2
Robert A. Burt. (2002) The Medical Futility Debate: Patient Choice, Physician Obligation, and End-of-Life Care. Journal of Palliative Medicine 5:2, 249-254
CrossRef
