Annals of Long Term Care

Introduction
Physicians often encounter situations in which they believe a particular treatment that they are being asked to provide may not confer any meaningful benefit to their patient. In these cases, a practitioner may decide to withdraw this treatment because he or she has judged it to be futile. However, futility is a morally and ethically freighted term, and physicians need to be knowledgeable about its definition and implications before unilaterally deciding to withdraw treatment.

The impact on the healthcare system of providing medically futile care is also uncertain. Issues of medical futility are particularly relevant to those who take care of elderly patients, who may encounter more problems associated with the end of life. Becoming more familiar with the legal and policy implications of disputes surrounding the withdrawal of care in the terminal setting may help these providers to make better-informed decisions in these settings.

Defining Medical Futility
Care that is medically futile is that which is unlikely to produce significant benefit to the patient. Unfortunately, interpreting the implications of this simple definition is difficult, because deciding what “significant benefit” means has moral and ethical implications.

Medical ethicists have therefore struggled to craft more concrete definitions of futility. Schneiderman et al¹ widely cited definition states that if “in the last 100 cases a medical treatment has been useless, they [physicians] should regard that treatment as futile.”

Schneiderman and colleagues¹ also distinguished between two different types of futility: quantitative and qualitative. In the case of quantitative futility, a particular treatment is capable of producing the desired result but is extremely unlikely to do so in the case at hand. One example of this would be to attempt to perform lifesaving surgery on a patient who is in extremis. On the other hand, under qualitative futility, a treatment is likely to achieve a result, but it may be “lacking in purpose.”² For example, discontinuing HMG CoA reductase inhibitors (eg, simvastatin) for a nursing home patient with end-stage dementia could be justifiable under qualitative futility, because while the medication might improve cholesterol levels, in this particular patient achieving that goal adds little benefit to the overall care of the patient.

Independent of the definitions described above, the most important determinants of how an individual approaches the possible futility of a medical intervention may be the knowledge, values, and experiences of the individuals involved and their perceived goals of care for the patient.

Developing a consistent standard for what constitutes futile care would be valuable because the corollary of a declaration of futility is that the physician has a right to unilaterally refuse to provide a treatment. In this situation, physicians would be invoking their professional autonomy by refusing to provide a treatment that they deem to be, at the very least, useless, if not harmful. The problem with this paradigm is that families of patients may have differing views of what is useless, depending on their ethnic or religious background. For them, longevity may be a priority that has more value than quality of life.

Because quantitative futility is invoked in situations in which a treatment is extremely unlikely to achieve its stated goal, the judgment of futility would be relatively objective in those cases. For example, denying extensive abdominal surgery to a patient who is in extremis could be deemed futile by a physician without having to weigh in on whether quality or quantity of life is more important. However, when qualitative futility is involved, there might be more room for interpretation.