Medical Futility: The F Word

Medical Futility is a term that was first coined in 1962. No one likes to talk about it, but in the age of increasing pressures for medical resources and limits on spending, we cannot ignore it any longer.
Medical futility is defined as:

  1. a judgment that further medical treatment of a patient would have no useful result.
  2. a medical treatment whose success is possible although reasoning and experience suggest that it is highly improbable.
    –Mosby Medical Dictionary

The fact is, hospitals and ICUs are financially incentivized to do more for most patients in ICU because of their fixed costs. Medical economists have identified the ”supply sensitive” model of ICU care, suggesting that the more it’s available, the more patients are offered it.

Interestingly, a study at UCLA, a region with a high number of ICU beds, showed that 20% of patients being cared for in an ICU were thought to be receiving “futile care” by the physicians caring for them. Careful follow up of those cases identified as “futile” suggested that the doctors were correct: 85% of those patients died before leaving the hospital, and the other 15% left in a severely compromised state, most dying within 6 months. This study suggests that experienced critical care doctors can identify when patients are not going to get a “useful result” and begs the question: “Why does this happen?”

I believe it has to do with communication. One patient I remember well lay in the ICU essentially brain dead for 2 weeks because no one could convince his family that he was not going to get better. Not only was the family conflicted, but the multiple physicians caring for him couldn’t reach a timely consensus about his prognosis either. Fear of getting blamed for a death is one obstacle for physicians communicating with the families of critically ill patients, and another is uncertainty about what will happen. However, I believe the uncertainty about prognosis or outcome can be lessened if everyone talks in terms of the patient’s own goals for recovery.

This was illustrated to me in an exceptional circumstance a few years ago. My clients were the family of an elderly woman who’d been hit by a car and sustained major brain injuries and bleeding. They were concerned she wasn’t getting better, and knowing she wouldn’t be happy living in a compromised condition, hired me to help them understand the choices ahead. After 3 weeks in the ICU in a deep coma, she began having seizures. A group of physicians caring for her was concerned that this was a bad sign and approached the chief neurologist about the possibility of withdrawing life support.

The neurologist, an experienced neurointensivist, said: “Not so fast. We have to try some different seizure medicines first.” To everyone’s great surprise, her seizures stopped and she soon regained consciousness. Furthermore, she is alive today and very nearly the person she was before the accident. I asked the neurointensivist how he knew that she would do so well. He replied: “I really didn’t, but I knew from talking to her family that she would want to be given every last chance, and I knew from experience that there was still a chance of meaningful recovery”

That experience stuck with me because it demonstrated how difficult it is to declare futility. Newer terms such as “medically unnecessary” or “non-beneficial” do little to clear the waters either. The question becomes: Necessary for what? Beneficial to whom? . We must acknowledge there is always someone or something benefitting from the care, whether it’s the hospital’s bottom line, a grief struck family or sometimes, unexpectedly, the patient.

I contend that the only way we can rid ourselves of the term “futile” and use “medically non-beneficial” appropriately is to know what the patient’s OWN goals and values are beforehand. When this is known, the conversation becomes about the likelihood of the patient in question achieving those goals. For many, that will lead to a transition from non-beneficial ICU care to comfort care or hospice. For others, the decision will be to press on in the hope of a suitable recovery. In either case, when the outcome is uncertain, patients and families are entitled to frank goal-oriented conversations, second opinions when necessary, and frequent updates about likely outcomes.

If every physician on the team were held accountable to the patient’s over-arching goals, such as the goal to recover enough to continue to enjoy their loved ones without pain, and not simply “surviving”, I think consensus about how to proceed would be easier to reach. Getting to the right decision about each patient occupying a critical care bed in the US is an imperative for us all. Apart from the enormous financial burdens ICU care places on our society and on families, we must consider unanticipated events such as Ebola, terrorist attacks, and natural disasters when every patient occupying an ICU bed will be undoubtedly be subjected to another taboo medical term: Rationing

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