The term “medical futility” is commonly used by health professionals to discuss the appropriateness of a medical treatment option. Texas and California have defined statewide futility policy and increasingly hospitals and nursing homes are developing their own futility policies.
The public, policymakers, ethicists and the medical profession have been unable to agree on a clear, concise definition of futility that can be applied to all medical situations. One commonly used definition is that a futile intervention is one that a) is unlikely to be of any benefit to a particular patient in a particular medical situation, and b) will not achieve the patient’s intended goals. The sticking point in all futility definitions is the concept of benefit, as the perception of benefit is highly subjective. Physicians, patients and families often have very different views on what is potentially beneficial. For example, although a physician may believe that renal dialysis in an elderly demented patient is futile, the family that views preservation of life at all costs as part of their cultural ethos, may view dialysis as an important intervention to continue life. Furthermore, medical futility can be easily misunderstood as health care rationing. While economic issues may impact shared decision making, the ultimate question is not "how much does this therapy cost?" rather, "do the advantages of this therapy outweigh the disadvantages in a given patient?"
Two types of futility have been described. Quantitative futility refers to the intervention that has a very small chance of benefiting the patient—the most commonly used number is < 1% chance of success. The term qualitative futility describes a situation in which the quality of benefit an intervention will produce is exceedingly poor. However, neither approach is adequate as there is no consensus on either numeric threshold for quantitative futility nor shared understanding of what constitutes qualitative benefits.
Physicians are not legally, professionally or ethically required to offer medically futile treatments, as defined by the standard of care of the medical community. Ethics committees, hospitals, and local/state medical organizations can provide resources to understand medical futility and professional responsibilities in one’s practice area.
Suggestions: Check with your health care institution re: the presence of an existing futility policy. Avoid using the term “futility” in discussion with patients/families; rather, speak in terms of benefits/burdens of treatment and patient or family-specific goals of care. Involve a palliative care and/or ethics consultant in any situation where “futility” will be invoked as process step in formulating decisions.
References: Doty WD, Walker RM. Medical Futility. Clinical Cardiology. 2000; 23: II6-II16. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: Its Meaning and Ethical Implications. Annals of Internal Medicine. 1990;112:949-954. Cantor MD, et al. Do not resuscitate orders and medical futility. Arch Intern Med 2003; 163:2689-2694.
