Definitions

medical care

Futile medical care

Futile medical care refers to the belief that in cases where there is no hope for improvement of an incapacitating condition, that no course of treatment is called for. It is dissimilar to the idea of euthanasia because euthanasia involves active intervention to end life, while withholding futile medical care does not encourage, nor speed the natural onset of death. The difference is of utmost importance to physicians who have taken and who adhere to the traditional Hippocratic oath - and have thus taken a professional vow that under no circumstances will they "prescribe a deadly drug nor give advice which may cause [a patient's] death."

Arguments against providing futile medical care

Arguments against futile care generally center on two issues. First, futile care has no possibility of achieving a good outcome and serves only to prolong death. No physical or spiritual benefit comes from such care. Futile care also prolongs the grieving process and frequently raises false hope. Also, futile care can be very difficult on caregivers, who may see themselves as forced to act against the best interests of their patient.

Secondly, in a setting of limited resources, futile care involves the expenditure of resources that could be used by other patients with a good likelihood of achieving a positive outcome. For instance, in the case of Baby K, attempts to transfer the infant to other centers were unsuccessful because there were apparently no unoccupied pediatric ICU beds in the region (though it is believed likely that other centers simply did not want to use their resources for futile care). Many critics of that case insist that the medical expenses used to keep the anencephalic child on life support for 2+ years could have been better spent on awareness and prevention efforts for her condition.

Issues in futile care considerations

The issue of futile care in clinical medicine generally involves two issues. The first issue concerns the identification of those clinical scenarios where the care would be futile. The second issue concerns the range of ethical options when care is determined to be futile.

Assessment of futility

While scenarios like providing ICU care to the brain dead patient or the anencephalic patient when organ harvesting is not possible or practical are easily identifiable as being completely futile, many other situations are less clear. For instance, should surgeons attempt a heroic clinical rescue in a 99-year-old unconscious patient with a ruptured abdominal aortic aneurysm, even though survival with a good outcome would be so very unlikely as to warrant publication of the case as a clinical case report? What is actually true is that various bleak clinical scenarios will vary in their degree of futility. Another example: when elderly patients sustain large third degree burns, mortality can be very high. This is similarly true for elderly patients sustaining massive trauma.

The last four decades has seen the clinical community make impressive efforts at improving the quality of their prognostic efforts. As a result, simple but imprecise rules of thumb like “percent mortality = age + percent burn” have now given way to very sophisticated algorithms based on multiple linear regression and other advanced statistical techniques. These are complex clinical algorithms that have been scientifically validated and have considerable clinical predictive value, particularly in the case of patients suffering severe burns.

While one intent of such algorithms is to provide high-quality prognostic information to aid patients and families in making difficult decisions, it takes little imagination to see how they could be used to guide resource allocation in a setting of limited resources.

Usually such prognostic algorithms produce an estimate of the probability of the patient surviving. While clinicians faced with difficult clinical scenarios where the probability of survival is, say, 30% might be expected to mount a valiant effort, when the chance of survival falls well below 1%, most clinicians would be expected to focus on palliative and comfort measures rather than attempting aggressive clinical measures. In a study of patients so severely burned that survival was clinically unprecedented, during the initial lucid period (before sepsis and other complications set in) patients were told that survival was extremely unlikely (i.e., that death was essentially inevitable) and were asked to choose between palliative care and aggressive clinical measures. Most chose aggressive clinical measures. This suggests that the will to live in patients can be very strong even in hopeless situations.

As another practical clinical example that occurs very frequently in large hospitals, it can sometimes be problematic to decide whether or not to continue resuscitation when the resuscitation efforts following an in-hospital cardiac arrest have been prolonged. Clinicians often want to know when continuing resuscitation in such settings is futile. A recent study in the Journal of the American Medical Association has validated an algorithm developed for these purposes.

Options for futile care

The second issue in futile care theory concerns the range of ethical options when care is determined to be futile. Some people argue that futile clinical care should be a market commodity that should be able to be purchased just like cruise vacations or luxury automobiles, as long as the purchaser of the clinical services has the necessary funds and as long as other patients are not being denied access to clinical resources as a result. In this model, Baby K. would be able to get ICU care (primarily ventilatory care) until funding vanished.

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