When is medical treatment "futile"?

• Author: Bennett, Allen J.
• Position: New York

Two recent events highlight the problem of medical futility--what it means, who should decide when it exists, and whether there are exceptions to the view most doctors take that what is futile should not be done. One event is the re-emphasis by the New York State Department of Health that the "do not resuscitate" (DNR) law in New York state limits the definition of medical futility in a patient experiencing a cardiac or respiratory arrest to whether life can be sustained immediately and seems to take the decision about whether or not a procedure is futile out of the hands of physicians.(1) The other event was the desire of the family of Mrs. Helga Wanglie of Minnesota that she be kept indefinitely on a mechanical ventilator even though she was in a permanent vegetative state for some time.(2)

In classical Greek medicine there was a differentiation between curable diseases, attributed to chance, where there was a physician obligation to heal, and incurable diseases, attributed to absolute necessity, where the physician's intervention could not influence the outcome and there was no obligation to treat.(3) If it was futile to treat, it was improper to do so. Instead, the patient was to be made comfortable.

In the Jewish medical tradition, when a patient is deemed terminal and in the final seventy-two hours of life, treatment is considered an obstacle to death, is termed futile, and is withheld.(4) Christian ethic also recognizes the legitimacy of the withholding of futile medical therapy, whether in the Roman Catholic or in the Protestant tradition.(5)

In this century, even in the era since cardiopulmonary resuscitation (CPR) became available, the great teachers of medicine have emphasized the need to provide comfort to the dying instead of using modern technology when it would be hopeless. Many physicians avoid doing what they know is futile, even if requested by the patient, the family, or society. New York state considers it unprofessional conduct to impose a treatment that is unnecessary.(6) This concept of the avoidance of medical futility has been eloquently expressed by Falk:

A distinguished senior physician has described these terminal life-

prolonging measures as 'mechanical last rights' and argued that patients

with irreversible terminal disease should be allowed to die in peace

without being subjected to unnecessary life-prolonging measures. (In

England, where such a policy is the norm, the American approach of

prolonging life at all costs is viewed with incomprehension and horror.)

In order to allow a patient to die with dignity, we must stress the dignity

of life. We must ... teach our medical students and junior doctors about

the caring aspect of medicine. We must be prepared to explain to

relatives and patients that prolongation of treatment often means

prolongation of misery without effecting a cure. Physicians are justified in

advising that further therapy is of no avail if the prognosis is clearly

hopeless and a distressing death will inevitably ensue. Pursuing every

means to maintain life without regard for the quality of life is a denial of

medical responsibility. To consult with a family regarding termination of

therapy should not mean placing this decision solely in their hands, as so

often happens. This induces guilt that they have somehow brought about

the premature death of their loved one. Families should be made aware

of the hopelessness of a situation and the best ways to make the

impending death as comfortable and dignified as possible.(7)

Examples of Futility Issues

Futility issues arise in many ways. The following are two examples of how futility issues arise in the clinical setting. First, a seventy-six year old white female with widespread recurrent metastatic carcinoma was admitted to the hospital for palliative radiation therapy. Her son, her only child, had expressed a wish at the time of the diagnosis of the recurrence that his mother not be told of the diagnosis, as she would become severely depressed. Still in pain and near the completion of her course of therapy, she developed congestive heart failure, responding poorly to diuretics. The attending physician, this author, discussed the futility of resuscitation with the son, who concurred, stating that he wanted no heroic measures undertaken in his mother's care. A DNR order was written in the patient's medical record order sheets with an appropriate notation as to the discussions held entered in the medical progress notes. Two days later, the evening shift nurse questioned the validity of the order, inquiring as to the whereabouts of a signed consent-to-DNR form.

Second, Helga Wanglie, an eighty-six year old woman, sustained a fractured hip at home, which was successfully treated. She was transferred to a nursing home. She was readmitted to the hospital in respiratory failure and placed on a respirator. Over the next five months, weaning attempts were unsuccessful. She was transferred to another facility, where she sustained a cardiopulmonary arrest during attempts at weaning. She was successfully resuscitated but suffered extremely severe and irreversible brain damage. Her physicians met with her family and discussed limiting further life-sustaining treatment. The family refused. She was transferred back to her original hospital, where she was aggressively treated. Due to her persistent vegetative state, the hospital tried to convince Mr. Wanglie that further treatment was futile and that the respirator should be discontinued. Mr. Wanglie refused, noting that his wife had, on several occasions, expressed a desire that she be aggressively treated at all costs. The hospital filed papers with the Fourth Judicial District Court, Hennipin County, Minnesota, to appoint a guardian to break the medical decision-making deadlock. By the time the case was first heard in court, Mrs. Wanglie's hospital costs exceeded eight hundred thousand dollars.(8) The court denied the hospital's request.(9) Two months later Mrs. Wanglie died, still connected to her respirator.

Definitions of Futility

When is a treatment medically necessary, and when is it medically futile?

Lo and Steinbrook declare the classically held definition of medical...