Ethics Grand Rounds: The Futility of Futility

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Ethics Grand Rounds The Futility of Futility

• July 8, 2008
• John Hardt, Ph.D.
• Neiswanger Institute for Bioethics
• Stritch School of Medicine
• Loyola University Chicago

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The Problem of Futility

• Origins of the Concept
• from the Latin, futilis, meaning leaky.
• Greek Mythology
• King Argos, his daughters, their dead husbands
  and a life of futile work.

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The Futility of Futility as a Concept

• Futility as a slippery concept in light of
  medical advance
• TPN, Dialysis, LVADs, long-term mechanical vents,
  ECMO.
• All treatments that replace organ systems and
  sustain life without curing underlying disease.
• ICUs preserve life more than cure disease.
• Okay, but whats the problem?

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Futility Then versus Now

• Drawing upon John Lantos, M.D.s work on
  futility
• Futility used to designate a treatment that
  simply did not work.
• This is only sometimes the case now.
• Futility today is more of an operational
  definition.
• Used to express situations in which docs think a
  treatment should not be provided for a variety of
  reasons.
• From a Treatment to a Situation
• From a Medical Reality to a Legal Concern.

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Varying Definitions of Futility

• Physiological Futility
• intervention cannot lead to intended
  physiological result.
• Lethal Condition Futility
• intervention is futile if patient has underlying
  lethal condition which the intervention does not
  remedy even though it may fix some component of
  the disease state.
• Qualitative Futility
• Intervention may be futile it if fails to lead to
  an acceptable quality of life.
• Notice the difference between the first kind of
  futility and these other two
• Only in physiological futility does the
  intervention not actually work.
• So why do we call them futile? What are we
  actually trying to communicate?

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Improving Our Futility Talk

• Two elements to any futility determination
• Establishing goals of care
• Determined by the family for the most part.
• Establishing the probability of success in
  meeting those goals of care.
• Determined by the physicians.

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Improving Our Futility Talk

• Cannot discuss whether care is futile unless we
  know what the goals of care are.
• If keeping patient alive is the goal the family
  has in mind, then many of our interventions are
  not understood as futile from their
  perspective.

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Closing Points for Consideration

• Trust and Futility Policies
• Futility conflicts often arise because families
  and patients dont trust their physician(s).
• Policies that give override power to
  physicians/health systems generally exacerbate
  feeling of powerlessness in families and promote
  distrust of physicians.
• But physicians are not obligated to offer
  everything that patients/families ask for.
• Compromises your profession and your moral
  integrity.

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The Viability of Communication

• Establish trustand work to recover it when you
  think youve lost it.
• Warn early, express uncertainty about clinical
  outcome if uncertainty exists.
• Establish who is the primary information provider
  for the family.
• Attending physicians, remember the whole picture.
• DNR Orders Dont ask if you dont want the
  answer.
• Do everything, means you better have a long
  conversation with the family.
• Dont miss windows of opportunity
• (a) Chart notes, (b) Surrogates, (c) Advance
  Directives.