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Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians
  1. Ralf J Jox1,
  2. Andreas Schaider2,
  3. Georg Marckmann1,
  4. Gian Domenico Borasio3
  1. 1Institute of Ethics, History and Theory of Medicine, University of Munich, Munich, Germany
  2. 2Department of Internal Medicine, Hospital of Traunstein, Traunstein, Germany
  3. 3Chair in Palliative Medicine, Centre Hospitalier Universitaire Vaudois, University of Lausanne, Lausanne, Switzerland
  1. Correspondence to Dr Ralf J Jox, Institute of Ethics, History and Theory of Medicine, University of Munich, Lessingstrasse 2, 80336 Muenchen, Germany; ralf.jox{at}med.lmu.de

Abstract

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile.

Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis.

Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families.

Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.

  • Medical futility
  • withdrawing treatment
  • end of life
  • intensive care
  • palliative care
  • neuroethics
  • clinical ethics
  • care of the dying patient
  • definition/determination of death
  • anaesthetics/anaesthesiology

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Footnotes

  • Competing interests None.

  • Ethics approval Ethics approval was granted by the Ethics Committee of the University of Munich.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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