Motivating Factors in Futile Clinical Interventions

doi:10.1378/chest.119.6.1944

Chest

Volume 119, Issue 6, June 2001, Pages 1944-1947

https://doi.org/10.1378/chest.119.6.1944 Get rights and content

With modern medical technology, it is now possible to sustain life for prolonged periods in critically ill patients, even when there is no reasonable hope of improvement or achieving the goals of therapy. Such futile and medically inappropriate interventions may violate both the ethical and medical precepts generally accepted by patients, families, and physicians. In this study, we sought to determine who was primarily responsible for such interventions, the nature of their motivation, and the role of a timely bioethical consultation. In a retrospective review, we identified 100 patients of 331 bioethical consultations who had futile or medically inappropriate therapy. The average age of patients was 73.5 ± 32 years (mean ± 2 SD) with 57% being male. Fifty-seven percent of the patients were admitted to the hospital with a degenerative disorder, 21% with an inflammatory disorder, and 16% with a neoplastic disorder. The family was responsible for futile treatment in 62% of cases, the physician in 37% of cases, and a conservator in one case. Unreasonable expectation for improvement was the most common underlying factor. Family dissent was involved in 7 of 62 cases motivated by family, but never when physicians were primarily responsible. Liability issues motivated physicians in 12 of 37 cases where they were responsible but in only 1 of 62 cases when the family was (χ² 5 degrees of freedom = 26.7, p < 0.001). When the bioethics consultation resulted in cessation of the therapy, patients died in a median of 2 days as opposed to 16 days if therapy continued (p < 0.001).

Section snippets

Materials and Methods

In 1995, a formal Bioethics Program was instituted at Cedars-Sinai Medical Center. One of its principal functions has been to encourage, organize, and document bioethical consultations. The patient, the patient's family, or any member of the health-care team may request such consultations. The consultation is performed by a specially trained and specially privileged team consisting of a physician, a nurse, and a social worker. Meetings are held with families and health-care providers in an

Clinical Features

The average age of the patients was 73.5 ± 32 years (mean ± 2 SD). Fifty-seven percent of the patients were female, and the remaining 43% were male. The religious makeup was as follows: Jewish, 43%; Catholic, 15%; no religion, 15%; unknown, 12%; other, 8%; and Protestant, 7%. Fifty-seven percent of the patients were admitted with a degenerative disease process, 21% with an inflammatory process, 16% with a neoplastic disorder, and the remaining 6% were admitted secondary to a traumatic event or

Discussion

Our study is unique in evaluating futile and medically inappropriate care on a practical rather than a theoretical basis. We sought to minimize the ambiguity in the definition of futile or medically inappropriate care by selecting patients who died during the hospital stay without a period of marked improvement. This care is most often given to elderly patients with degenerative disease processes. This is not surprising given that these are the patients most likely to have disorders where the

References (11)

NS Jecker et al.
Futility and rationing
Am J Med
(1992)
American College of Chest Physicians/Society of Critical Care Medicine Consensus Panel
Ethical and moral guidelines for the initiation, continuation, and withdrawal of intensive care
Chest
(1990)
LJ Schneiderman et al.
Medical futility: its meaning and ethical implications
Ann Intern Med
(1990)
DB Waisel et al.
The cardiopulmonary resuscitation-not-indicated order: futility revisited
Ann Intern Med
(1995)
The SUPPORT Principal Investigators
A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)
JAMA
(1995)

There are more references available in the full text version of this article.

Cited by (29)

Perceptions of medical futility in clinical practice – A qualitative systematic review
2018, Journal of Critical Care
Citation Excerpt :
There is still no generally accepted definition in the literature and no widespread guidelines for healthcare staff. Nevertheless, clinical staff uses the concept of medical futility in their decision-making process [19-22]. Many conflicts occur in clinical routine because there is no universal definition of futility: patients and families may demand ‘to do everything’ [23] even if the clinical staff believe that further therapy is futile, or a physician cannot stop a once begun treatment that the nursing staff wishes to forego [23].
To summarize and compare qualitative studies which explored attitudes of patients, families and healthcare providers towards medical futility.
A systematic search of qualitative studies via the PubMed database was conducted. Data were extracted in terms of two aspects: 1) Group of people, which were interviewed about futility; 2) Definitions of medical futility given by these participants. Data were analyzed and synthesized using the method of qualitative content analysis.
The initial search identified 737 articles. 71 studies were reviewed in detail and 10 were finally selected. As a result, three groups of people (physicians, caregiver and patients) and six core categories could be identified: patient treatment, quantitative aspects, resources, professional aspects, reference to balance, definition challenges.
This review describes existing opinions about medical futility and demonstrates the multifaceted understanding of medical futility by physicians, caregivers and patients. The difficulties in defining medical futility demonstrate the need for resources to help healthcare providers and patients to deal with decision-making in such situations.
Inappropriate care in European ICUs: Confronting views from nurses and junior and senior physicians
2014, Chest
ICU care providers often feel that the care given to a patient may be inconsistent with their professional knowledge or beliefs. This study aimed to assess differences in, and reasons for, perceived inappropriate care (PIC) across ICU care providers with varying levels of decision-making power.
We present subsequent analysis from the Appropricus Study, a cross-sectional study conducted on May 11, 2010, which included 1,218 nurses and 180 junior and 227 senior physicians in 82 European adult ICUs. The study was designed to evaluate PIC. The current study focuses on differences across health-care providers regarding the reasons for PIC in real patient situations.
By multivariate analysis, nurses were found to have higher PIC rates compared with senior and junior physicians. However, nurses and senior physicians were more distressed by perceived disproportionate care than were junior physicians (33%, 25%, and 9%, respectively; P = .026). A perceived mismatch between level of care and prognosis (mostly excessive care) was the most common cause of PIC. The main reasons for PIC were prognostic uncertainty among physicians, poor team and family communication, the fact that no one was taking the initiative to challenge the inappropriateness of care, and financial incentives to provide excessive care among nurses. Senior physicians, compared with nurses and junior physicians, more frequently reported pressure from the referring physician as a reason. Family-related factors were reported by similar proportions of participants in the three groups.
ICU care providers agree that excessive care is a true issue in the ICU. However, they differ in the reasons for the PIC, reflecting the roles each caregiver has in the ICU. Nurses charge physicians with a lack of initiative and poor communication, whereas physicians more often ascribe prognostic uncertainty. Teaching ICU physicians to deal with prognostic uncertainty in more adequate ways and to promote ethical discussions in their teams may be pivotal to improving moral distress and the quality of patient care.
Ten common questions (and their answers) on medical futility
2014, Mayo Clinic Proceedings
Citation Excerpt :
Medical research and clinical experience continue to refine best evidence-based practices and how a treatment is viewed as beneficial or not.54 Advances in medications and medical technology have, in many instances, contributed to routine expectations for life prolongation and improvements in the quality and quantity of life among critically ill patients.55 However, not all appealing therapies substantially alter outcomes, and, even among those that eventually prove efficacious, there can be a prolonged learning curve to identify which patients will benefit most from such treatments.
The term medical futility is frequently used when discussing complex clinical scenarios and throughout the medical, legal, and ethics literature. However, we propose that health care professionals and others often use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral, response that the term can evoke. This article introduces and answers 10 common questions regarding medical futility in an effort to define, clarify, and explore the implications of the term. We discuss multiple domains related to futility, including the biological, ethical, legal, societal, and financial considerations that have a bearing on definitions and actions. Finally, we encourage empathetic communication among clinicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points of view is critically important in preventing or attenuating conflict among the involved parties.
Limiting therapeutic effort: Is withholding or withdrawal life-sustaining treatment the same?
2010, Medicina Clinica
Point: The Texas advance directives act effectively and ethically resolves disputes about medical futility
2009, Chest
Futility: A concept in evolution
2007, Chest
Citation Excerpt :
They include provisions for families, as well as clinicians, to object to care they believe to be futile. The “bilateral” nature of the policy is important: one retrospective study of 100 cases of allegedly futile treatment found that families insisted on the treatments in 62% of the cases, whereas clinicians were responsible 37% of the time.10 The policy is invoked only when repeated efforts at consensus have failed, and then is designed to assure that all voices have an opportunity to be heard.
The debate about how to resolve cases in which patients and families demand interventions that clinicians regard as futile has been in evolution over the past 20 years. This debate can be divided into three generations. The first generation was characterized by attempts to define futility in terms of certain clinical criteria. These attempts failed because they proposed limitations to care based on value judgments for which there is no consensus among a significant segment of society. The second generation was a procedural approach that empowered hospitals, through their ethics committees, to decide whether interventions demanded by families were futile. Many hospitals adopted such policies, and some states incorporated this approach into legislation. This approach has also failed because it gives hospitals authority to decide whether or not to accede to demands that the clinicians regard as unreasonable, when any national consensus on what is a “beneficial treatment” remains under intense debate. Absent such a consensus, procedural mechanisms to resolve futility disputes inevitably confront the same insurmountable barriers as attempts to define futility. We therefore predict emergence of a third generation, focused on communication and negotiation at the bedside. We present a paradigm that has proven successful in business and law. In the small number of cases in which even the best efforts at communication and negotiation fail, we suggest that clinicians should find ways to better support each other in providing this care, rather than seeking to override the requests of these patients and families.

View all citing articles on Scopus

View full text

Chest

Ethics in Cardiopulmonary MedicineMotivating Factors in Futile Clinical Interventions

Section snippets

Materials and Methods

Clinical Features

Discussion

Am J Med

Ethical and moral guidelines for the initiation, continuation, and withdrawal of intensive care

Chest

Medical futility: its meaning and ethical implications

Ann Intern Med

The cardiopulmonary resuscitation-not-indicated order: futility revisited

Ann Intern Med

A controlled trial to improve care for seriously ill hospitalized patients: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT)

JAMA

Ethics in Cardiopulmonary Medicine
Motivating Factors in Futile Clinical Interventions