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Lawrence.Ulrich@notes.udayton.edu |
One difficult, challenging, and perplexing problem facing contemporary healthcare in a climate of self-determination has come to be known as futile treatment. The difficulty arises from the specific technological and social milieu of contemporary medical practice. The issue arises from the fact that today death does not "automatically" or immediately follow from a critical illness or injury. Many interventions can be interposed between the illness or injury and death. In some cases, the course of the malady can be significantly altered or entirely turned around. But this is not the issue which futility raises.
The significant concern with futility arises when the inevitability of death cannot be faced and the desire to postpone death in vain attempts to "cure" takes over the direction of treatment.(1) The attitude in society of keeping death at arm's length rather than embracing it as an essential component of the human reality fuels the pursuit of futile treatment. Since so many life-extending interventions are currently available, with many more being developed for the future, the boundaries of futile treatment are becoming more and more indeterminate. A clear conceptual map around the issue of futile treatment is badly needed because of the difficulty of defining "futility" but it seems to become more elusive as time goes on.(2) At best it may be possible to identify the values involved in making such decisions and the points which must be addressed as decisions about futile treatment are made.
Addressing this issue is essential for implementing the Patient Self-Determination Act. Before examining the issues involved in making determinations of futility, its relation to the Patient Self-Determination Act requires some explanation. The law requires that patients be informed that they have the right to refuse treatment. As we have seen, this means that they have to right to refuse any and all treatments regardless of the reason for their refusal. We have also seen that patients may wonder about the clinical reasons for refusing treatments. In response to this very important level of curiosity, patients should be informed that refusals of futile treatment would be very appropriate.(3) In order to give this information to patients there would have to be some explanation about the parameters of futility and what they should look for in their care related to these parameters. A case can be made that only the patient's physician can identify the notion of futility in the case of any given patient.(4) To begin thinking about the matter of futility somewhere early in the treatment process may make it easier to address the issue if it ultimately emerges in the course of treatment.
As we have seen in the previous section, demanding treatments as an expression of self-determination has some significant limits. One of those limits could be identified as futile treatments. It has never been a part of the Hippocratic tradition to administer futile treatments.(5) On the contrary, to do so would violate the principle of beneficence. Physicians are required to benefit patients and, by definition, futile treatments do not accomplish this end. As a matter of fact, futile treatment may not only not benefit patients, it may actually do harm to them,(6) e.g., by creating illusions about the possibilities of the treatment or even inflicting additional pain. It may also result in treating patients in ways which are contrary to their conditions, a violation of the principle of justice, itself a form of harm.(7) Thus, in discussing the refusal of treatment, it would be most appropriate to include futility in that discussion as a suitable situation for refusing treatment.(8)
Since the Patient Self-Determination Act requires that patients be informed of the policies of a healthcare facility or organization regarding the withholding or withdrawing of life-sustaining treatments, the issue of futility may be relevant here as well. Some healthcare institutions and communities are boldly addressing the issue of futile care by developing policies outlining the stance of the institution regarding futile care.(9) These policies are an attempt to address issues of patient welfare which futile treatments do not promote, caregiver morale which futile treatments often compromise, and resource allocation which futile treatments squander.(10) When such policies are developed patients must know upon admission the general character of the policies and the general manner in which they may be applied in the clinical setting. Patients, or potential patients, must be clear that, just as self-determination does not extend to demanding treatments which are contrary to acceptable medical practice,(11) so also it does not extend to demanding treatments which are prohibited by institutional policy.
At this point it would be helpful to examine directly the issue of futility to gain a better perspective of the issues involved in making such determinations and to explore any flexibility which might be present in setting its parameters within the context of the Patient Self-Determination Act. In the most general terms any kind of action is considered to be futile if it cannot achieve the goal toward which it is directed.(12) Thus, any discussion of futility must begin with a clear definition of the goal to be accomplished. To overcome death as the outcome of treatments directed toward certain types of aggressive cancer is futile. However introducing remission into the disease process may not be futile. As the goals of interventions change, the determination of the futility of interventions will also change.
If the identification of goals is essential to defining futility then several significant questions arise. One must first be clear about what kind of goals are being formulated and about who determines the goals whose achievement should be attempted.(13) The clinician would be the likely person to determine appropriate medical goals, e.g., cure, restoration of heartbeat, return of kidney function, etc., because she possesses medical expertise. The patient, as the primary decision-maker, would be the candidate for identifying the appropriate goals insofar as they are consonant with the patient's values. Finally, the patient's authorized surrogate, as the secondary decision-maker, when the patient is unable to participate in the decisional process, may be considered the appropriate individual to identify the proper goal of an intervention in conjunction with the patient's known values.
The final, and perhaps the most troublesome question of all may be whether the desired goal itself is suitable. With the issue of identifying the decision-maker we have some procedures and criteria to which we have generally agreed as a society. But the propriety of therapeutic goals is often subject to the same variety and lack of agreement as the goals for human life in general in a pluralistic society. This does not mean that it is impossible for clinicians, patients, and institutions to negotiate differences with each other about the goals which are appropriate in the clinical setting. Nor does it mean that parameters for the negotiation cannot be established.(14) It merely means that negotiation and its parameters are essential to addressing the issue of determining futility.
Having seen the general problem of determining futility attention can now be turned to three different forms of futility which can be identified. The first form is the one which has received the greatest attention in the current debates. This can be identified as medical futility. There is no standard definition for this form of futility. However, a very useful definition might be "any effort to achieve a result [medical] that is possible but that reasoning or experience suggests is highly improbable and that cannot be systematically produced."(15) Another dimension has often been added to the definition by designating that a futile intervention is one which does not produce its physiologic effect or has a statistically very low probability of doing so.(16) Thus, treatments that offer no physiologic benefit to the patient can be defined as "futile."(17)
Several issues need to be noted in this dimension of futility. In the first place, since it is a definition of medical futility the determination is made by the physician. Patients do not contribute to this decision. The decision is based purely upon the disposition of the organism and its reaction to therapeutic interventions. The discoveries of scientific investigators provide significant information for the clinician's determination of medical futility. For the determination is not made on the basis of an individual's experience alone or anecdotal evidence from a few colleagues. Rather it is based upon the statistical probability of an intervention's producing a medical outcome. However, any statistical probability which is determined by research efforts must be applied to the particular circumstances of a patient's condition as the patient's physician exercises her clinical judgment.(18)
One of the more difficult issues to address in determining medical futility is certainly the matter of statistical probability. Determining the exact boundaries of futility is impossible. Few medical matters admit of 0% probability, although some could be identified if the diagnosis is accurate.(19) There remains, then, the need to determine whether a 10% probability of an outcome's being produced by an intervention should determine that the intervention is futile. If not 10%, then perhaps 5%, or 3%, or 1%, or 0.5%. Relating statistical probability to futility, therefore is a matter of judgment. If it is a matter of judgment, then the issue becomes one of identifying whose judgment is most accurate, whose should be the overriding judgment, and what counts as a reasonable judgment. At this point there is little agreement on these questions. If a treatment has a low probability of benefit it may be inappropriate but not necessarily futile.(20)
Another dimension of the determination of futility can be identified as personally-determined futility.(21) Personally-determined futility would designate an effort to achieve a result which may be possible but which does not fall within the personally defined goals of the patient (or surrogates who can legitimately speak for patients). As we have seen, each patient approaches the clinical setting with a value history which has helped to define her as a person and some particular goals about her life and what she hopes to accomplish through the therapeutic interventions being considered. In some cases medical interventions may be able to achieve some particular goals which the patient does not consider to be worthy of attainment. For example, CPR may restore heartbeat to a patient only to leave the patient to languish for an indefinite period of time in an intensive care unit or an extended care facility with on-going deteriorating function from some disease process. To live in such a way may not fit within the goals of such a patient. Therefore, while the CPR may not be futile in the medical sense, because restoring heartbeat is the goal of CPR, and this can be accomplished, nonetheless CPR may be futile in a personally-determined sense since it cannot achieve the goals of the patient. In much the same way, looking at the statistical probability issue, a physician may think that any result greater than 5% is not futile while a patient may think that a 10% chance of a favorable outcome is necessary to cross over the line of futility. In many cases, then, the boundaries of personally-determined futility may be more limited than the actual possibilities of medicine. In such cases, the Patient Self-Determination Act, with its right to refuse treatment, accommodates the personally-determined sense of futility quite nicely.
From the opposite perspective it may be the case that an individual might consider her personally-determined sense of futility to be broader than the judgment of medical futility. In such a case, using the CPR example, a physician may judge that a patient may survive a CPR attempt but would be severely compromised and would never survive to leave the hospital. But for some particular reason the patient may be willing to continue living in spite of the seriously compromised condition. Or the physician may consider a 1% chance of a favorable outcome to designate futility but the patient might be willing to pursue treatment on the basis of a less than 1% chance no matter how minuscule. In these situations, where there are differences in values rather than facts, the treatment may be inappropriate or inadvisable in the physician's judgment, but not futile.(22)
One might well wonder why patients or surrogates would be willing to entertain such a broad sense of personal determinations of futility. The answer may lie in the fact that many patients and their surrogates cling to even the slimmest of hopes. In fact, they are often encouraged by caregivers to do so instead of being shown that acceptance and detachment are virtues of equal stature to hope. It is often easier to authorize the use of technological interventions than it is to talk to patients about the difficult subject of futility or inadvisable treatments. With its emphasis on treatment refusals and knowledge of hospital (or extended care facility) policies on withholding or withdrawing treatments, the Patient Self-Determination Act may teach patients something of the limitations of life and medicine and they may become less eager to pursue aggressive therapies which are inappropriate.
However, there are other matters which are involved in making decisions about futile treatments which must be considered. Often futile treatments are selected and not refused because patients and their families are in a state of denial or grief about the nature of the illness or injury which they are facing. Futile treatment is often selected by families for incompetent members as a result of guilt. Guilt is a powerful motive for human actions especially when it is coupled with years of neglect. Finally, fear on the part of caregivers can be a motive for engaging in futile treatment or limiting discussions about futile treatment with patients and their families in spite of medical indications of futility. Fear of liability is often a reason given for overtreatment. Case law is developing which demonstrates that the fear of liability in situations where treatments are futile is greatly overstated.(23)
Because of the wide disparity which can occur in the two senses of futility outlined above, a third sense might be considered which may more correctly reflect the nature of the clinical setting and lead to a reconciliation of any differences which might occur. This third sense could be called a judgment of clinical futility.
Chapter 3 defined the clinical setting as the situation in which the physician and patient encounter each other as both being interested parties in the therapeutic outcomes and as collaborators in the process of making decisions. The clinical relationship is not a one-sided interaction with the pathways of the decisions always going in one direction. Instead it is a relationship of mutuality where trust on both sides confers credibility on each partner and where differences are negotiated in such a way that the integrity of both parties is preserved while retaining the well being of the patient as the primary goal of the clinical encounter.
Because of these dynamics, clinical futility can be described as a judgment which integrates considerations of medical futility and personally-determined futility into a unified whole and which reflects the interests of the total patient and the other individuals who are legitimate participants in the decisional process. Thus, clinical futility considers both the objective research findings coupled with the clinical judgment of the physician and the values and goals of the patient which have been expressed by the patient herself or her authorized surrogate. This approach to futility opens the path to negotiation when differences occur between patients and caregivers. It allows caregivers to set the parameters for honoring the patient's wishes ------ not all wishes can be honored. It also allows patients to push the boundaries of medical futility to allow them to pursue some reasonable values and goals like witnessing a particular event of extraordinary significance to the patient which will occur in the very near future.
There is no easy formula for resolving the negotiations which occur around the issue of clinical futility. Ideally, a compromise will be reached, e.g., by allowing a patient to pursue a course of treatment for a limited time so she might be able to achieve a personal, but reasonable, goal. Or a patient might be given a time limited trial, e.g., an extra week on the ventilator to develop greater certainty in the family about the medical futility of the intervention. However, there may come a time when compromises will not be possible. In such cases, personally-determined futility in the form of refusing treatment always overrides a physician's unwillingness to declare an intervention futile.(24) When patients demand an intervention which is clearly medically futile, then judgments of medical futility override the wishes expressed in judgments of personally-determined futility.(25) When this situation arises, the interests of effective communication between patient/surrogate and physician require the physician to explain to the patient why the intervention is futile.(26)
Reflecting further on two of the reasons for requesting or demanding medically futile treatment the following alternative approach can be used with a patient. Instead of simply responding with the implementation of the treatment, caregivers can address the issues of denial or grief. This should not be done in a way that the patient or family is harmed by the destruction of their defenses. Rather, it can be approached with an attitude of acceptance but with an openness to explore all the relevant issues regarding the patient's condition. This might move the participants in the decision from denial to acceptance and the most appropriate decision which is in the best interests of the patient.
In a similar manner the issue of guilt can be addressed. Guilt is not resolved by recourse to inappropriate technological interventions. Rather guilt is an internal attempt to cope with the inadequacies of one's behavior. Thus, the only way to address it is to meet it in its own arena. Technology does not confront the matter of guilt; at best, it only delays the engagement. Caregivers must always remember that their covenant is with the patient primarily, and only secondarily with the family. Therefore, they cannot, within the context of their traditions and commitments, harm the patient in order to assuage the guilt of family members. It would be ethically inappropriate and contrary to the Patient Self-Determination Act to override a patient's refusal of futile treatment merely to meet the needs of family members.
Thus, when requests or demands for futile treatment are made, an automatic authorization of the technological intervention is often inappropriate.(27) It is more helpful to examine the feelings of the patient or the patient's family or authorized surrogate. With this approach there is a better chance of serving the total good of the patient rather than satisfying some fragment of the patient's clinical presentation such as restoring heartbeat in the presence of multi-system failure. Treating only a fragment of the patient's presentation while all the rest of the patient's presentation is fatally compromised frequently harms the patient rather than providing benefit for her.
Finally, since the issue of legal liability is often identified by caregivers as an additional reason for pursuing medically futile treatment, some perspective is necessary to avoid this pitfall.(28) Liability issues are certainly a major problem in our society and the importance of being cautious about them should not be minimized. However, they can be overemphasized as well. The obligation of caregivers is to provide medical treatment appropriate to a patient's condition and not to harm the patient. Futile treatment can arguably be said to harm the patient. The best protection against liability problems in the matter of futile treatments may not be the implementation of the treatments but rather full disclosure with patients and their families of the nature of the condition which they face and a realistic assessment of the possibilities for a successful outcome.(29) Such an open discussion can have many salutary benefits for patients, families, surrogates, and caregivers alike. Among them will often be the refusal of futile treatments by patients or their authorized surrogates in the context of the Patient Self-Determination Act.
A very practical issue underlies the emerging concern with the utilization of futile treatments. Treatments under these conditions are generally technology intensive with the result that they will be very costly. In a society which is becoming increasingly concerned about its allocation of resources in all economic areas including healthcare, the lack of cost effectiveness of futile care cannot be ignored.(30) While the Patient Self-Determination Act is not intended to address the issue of resource allocation, nonetheless, it can have a favorable impact on it because a wise decision-maker will not select treatments which are not beneficial in some way, thereby saving the cost of futile treatments.(31)
A final consideration is that of stretching the boundaries of medical futility to accommodate the approach to personally-determined futility which represents the values and goals of the patient. Certain interventions may, in the calculated range of probabilities, provide only a very small chance of meeting a medical goal. However, that chance may be sufficient to attempt to meet a very important goal for a particular patient. For example, CPR for an elderly chronically ill patient has a very poor probability of success.(32) However, this patient may wish to witness her grandson's Bar Mitzvah which will occur within a short period of time. This may be sufficient reason to attempt CPR even with the extremely limited probability that the patient will survive the attempt with enough mentation to witness the event which she yearns so much to observe. This example reveals the other side of the Patient Self-Determination Act which requires that patient's be informed of their right to consent to treatment.
Thus, patients who have clearly defined and time-limited goals may best be served by allowing them the latitude to pursue reasonable goals in the face of ultimate medical futility. This approach is certainly in the spirit of the Patient Self-Determination Act and acknowledges the interactive character of the clinical setting. It is true that some negotiation will have to be conducted about what counts as a "reasonable" goal. But negotiation about matters of this kind is common in the clinical setting.
In summary then, there are two major difficulties in addressing the issue of futility. The first is the matter of defining futility with the appropriate categories. The Patient Self-Determination Act provides the opportunity to discuss futility with patients in light of their right to refuse treatments and, in some cases, their right to consent to treatment. But, in order to do so effectively, caregivers must have a clear sense of what they are talking about so that the proper parameters of their discussions can be established.
The second difficulty is equally problematic because its definition is often value-laden.(33) It involves the right of competent patients to demand futile treatment. While the right to refuse treatment has been well established in both ethics and the law, the right to demand treatment has not been so established except in the case of public health care facilities and entitlement programs. Demanding futile treatment is a particular problem because the Hippocratic tradition requires that physicians not harm their patients and, by extension, benefit them when possible. It does not require that they use futile treatment in the care of their patients. Of course, this issue does not emerge with any significant importance until the advent of modern medical technology.
The traditional criteria and principles of bioethics still seem to work. This does not mean that the physician should simply refuse to provide such treatment to her patients. Nor does it mean that she should automatically, and without reflection, authorize futile interventions. Rather, an appropriate strategy might very well be to explore the feelings of patients and their family members which underlie the demand for such treatment. It could be that they mistakenly think they are obligated to accept all possible treatment. In this case, the Patient Self-Determination Act, with its emphasis on the right to refuse treatment, will be very helpful. Or they may not totally understand the issues which they face and then the dynamics of informed consent can be utilized, particularly the third level which allows them to identify and examine their personal values and goals in order to assess the usefulness of a treatment option.(34)
Ultimately, the matter of futility comes down to the objective findings of research, the clinical judgment of the physician, and the clear identification of the reasonable goals of the patient. Negotiating about these factors in the spirit of the Patient Self-Determination Act will provide the greatest chance of maintaining the integrity of medical practice and the well being of patients when they are faced with the challenges of determining the futility of proposed treatments.
1. Of course, the notion of futility does not arise only in end-of-life decisions. Any treatment can be futile if it cannot achieve its goal as we shall see shortly. End-of-life decisions only provide a dramatic example of the issue of futility because the stakes are so high.
2. Brody BA, Halevy A. Is futility a futile concept? J Med Philos 1995;20:123-144. The authors point out four conceptual types of futility definitions: (1) physiologic futility, (2) imminent demise futility, (3) lethal condition futility, and (4) quality of life futility. On their view, the different conceptual approaches serves to complicate the development of a workable definition of futility.
3. On one level, the "refusal" of futile treatment is only possible when the futile treatment is offered. There is much (but certainly not universal) agreement that treatment which is determined to be futile should not even be offered to patients and/or surrogates. (Cf. Jecker NS, Schneiderman LJ. Medical futility: the duty not to treat. Camb Q Healthc Ethics 1993;2:151-159.) On another level, the "refusal" of futile treatment can take the form of agreement with a healthcare professional that a particular intervention is futile and, thus, the treatment will be declined.
4. The patient's physician finds herself in this position because she can integrate the objective research findings regarding a particular syndrome and its natural course with the way in which the patient manifests the disease and the particular patient's health history. This is the clinical judgment of the physician and, while there is an inevitable component of subjectivity in such a judgment, this is a professional clinical standard for making a prognosis. (Cf. Bioethics Advisory Committee. Medical staff guidelines on determining futile and inadvisable treatments. Dayton, OH: Grandview Hospital and Medical Center, 1998. Committee on Ethical Responsibility. Clinical decisions and the determination of futile treatments. Kokomo, IN: Saint Joseph Hospital and Health Center, 1995. Cf. also Ethics Advisory Committee. Clinical futility: position, policy, and guidelines. Anderson, IN: Saint John's Health System, 1995. Cf. also Santa Monica-UCLA Medical Center. Futile care guidelines. Santa Monica, CA: Santa Monica Hospital Medical Center, 1991.)
5. Blackhall LJ. Must we always use CPR? N Engl J Med 1987;317:1281-1285. As foundation to this tradition is the statement in the Hippocratic Corpus, The Science of Medicine: "First of all I would define medicine as the complete removal of the distress of the sick, the alleviation of the more violent diseases and the refusal to undertake to cure cases in which the disease has already won the mastery (italic mine), knowing that everything is not possible to medicine." Lloyd GER (ed). Hippocratic writings. New York: Penguin Books, 1983, page 140.
6. This action would, then, violate the non-maleficence form of beneficence.
7. Engelhardt HT. Ethical issues in aiding the death of young children. In Kohl M (ed). Beneficent euthanasia. New York: Prometheus Books, 1975, pages 180-192. The author here sees harm as sometimes taking the form of "the injury of continued existence" (pages 185-188).
8. Miles SH. Informed demand for 'non-beneficial' treatment. N Engl J Med 1991;325:511-515.
9. Whether developing such policies is a wise move on the part of healthcare institutions is a matter of considerable debate. (Cf. Hudson T. Are futile-care policies the answer? Hospitals and Health Networks 1994;68;26-32. On the negative side of this question cf. Spielman B. Community futility policies: the illusion of consensus? In Zucker MB, Zucker HD. Medical futility and the evaluation of life-sustaining interventions. New York: Cambridge University Press, 1997, pages 168-178.) On the other hand, the lack of a futile care policy can lead to situations such as the Gilgunn case in Massachusetts which is currently under appeal. (Cf. Gilgunn v. Massachusetts General Hospital. No92-4820 (Super. Ct. Mass. April 21, 1995). Wagg D, Reardon F. Treatment decisions in Massachusetts: the legal landscape. Forum 1995;16:5-7.) In this case Joan Gilgunn sued Massachusetts General Hospital and two physicians for the emotional distress which she suffered when her mother's physicians entered a DNR order on her mother contrary to Ms. Gilgunn's wishes and those of her comatose mother whom Ms. Gilgunn represented. The physicians and the hospital contended that CPR would have been futile in this case. The jury was instructed that it would first have to determine if the CPR was, indeed, futile before it could award damages to Ms. Gilgunn. On April 25, 1995 the jury determined that the care was futile and Ms. Gilgunn was unable to recover damages. Ms. Gilgunn, her mother, her mother's physicians, and the hospital might all have benefitted from a clear policy for determining futility. Minimally, a procedural policy for determining futile interventions might have helped. (Cf. Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996;276:571-574.) For additional futility policies and guidelines cf. note 182 above.
10. Murphy DJ. The economics of futile interventions. In Zucker MB, Zucker HD. Medical futility and the evaluation of life-sustaining interventions. New York: Cambridge University Press, 1997, pages 123-135.
11. President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. Making health care decisions: the ethical and legal implications of informed consent in the patient-practitioner relationship. Washington, D.C.: US Government Printing Office, 1982, page 3.
12. Jonsen AR et al. Clinical ethics: a practical approach to ethical decisions in clinical medicine. 4th edition. New York: McGraw-Hill, 1998, pages 22-32.
13. Younger SJ. Who defines futility? JAMA 1988;260:2094-2095.
14. Engelhardt HT. The foundations of bioethics. 2nd edition. New York: Oxford University Press, 1996, page 308.
15. Schneiderman LJ et al. Medical futility: its meaning and ethical implications. Ann Intern Med 1990; 112:949-954, page 950.
16. Younger S. Futility in context. JAMA 1990;264:1295-1296.
17. Ethics Committee of the Society of Critical Care Medicine. Consensus statement of the society of critical care medicine's ethics committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997;25:887-891.
18. Schneiderman LJ et al. Medical futility: response to critiques. Ann Intern Med 1996;125:669-674.
19. PVS patients will not return to consciousness. (Cf. Cranford RE. The persistent vegetative state: the medical reality (getting the facts straight). Hast Cent Rep 1988;18:27-32.) Patients admitted to a hospital with a dissecting aneurysm will not survive CPR to leave the hospital. Patients with a cerebral vascular accident with accompanying hemorrhage have a CPR success rate of only 1.4% (about as close to 0% as one can find). Patients over 90 years of age have a 0% success rate for CPR. (Cf. Schneider AP. In-hospital cardiopulmonary resuscitation: a 30-year review. J Am Board Fam Pract 1993;6:91-101.)
20. Callahan D. Controlling the costs of health care for the elderly --- fair means and foul. N Engl J Med 1996;335:744-746.
21. Wicclair MR. Ethics and the elderly. New York: Oxford University Press, 1993, pages 22-29.
22. Ethics Committee of the Society of Critical Care Medicine. Consensus statement of the society of critical care medicine's ethics committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997;25:887-891. An inadvisable treatment in this situation might be described as a clinical intervention which a physician, relying on the medical literature and her clinical judgment, determines is highly unlikely to produce a beneficial outcome for the patient, will be detrimental to the patient's quality of life, or will not meet a patient's or authorized surrogate's reasonable goals.
23. Kapp MB. Futile medical treatment: a review of ethical arguments and legal holdings. J Gen Intern Med 1994;9:170-177.
24. Wanzer SH et al. The physician's responsibility toward hopelessly ill patients. N Engl J Med 1984;310:955-959.
25. Council on Ethical and Judicial Affairs, AMA. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA 1991;265:1868-1871.
26. Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996;276:571-574.
27. Ruark JE et al. Initiating and withdrawing life support: principles and practices in adult medicine. N Engl J Med 1988;318:25-30
28. Meisel A. Legal myths about terminating life support. Arch Intern Med 1991;151:1497-1502.
29. Kapp MB. Futile medical treatment: a review of ethical arguments and legal holdings. J Gen Intern Med 1994;9:170-177. Cf. also Kapp MB. Treating medical charts near the end of life: how legal anxieties inhibit good patient deaths. The University of Toledo Law Review 1997;28:521-546.
30. Cher DJ, Lenert LA. "Method of medicare reimbursement and the rate of potentially ineffective care of critically ill patients. JAMA 1997;278:1001-1007. The authors here take the position that more careful attention to clinical judgments when the possibility of futility ("potentially ineffective care") arises in the course of caring for the critically ill elderly could save a considerable amount of money. They suggest an annual savings of $48 million in the medicare population of California alone.
31. Lewin-VHI, Inc. An analysis of cost savings of the medicare hospice benefit. Arlington, VA: The National Hospice Organization, 1995. Cf. also Murphy DJ. The economics of futile interventions. In Zucker MB, Zucker HD. Medical futility and the evaluation of life-sustaining interventions. New York: Cambridge University Press, 1997, pages 123-135.
32. Murphy DJ et al. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern Med 1989;111:199-205. Cf. also Taffet GE et al. In-hospital cardiopulmonary resuscitation. JAMA 1988;260:2069-2072.
33. Gewirtz P. On 'I know it when I see it.' Yale Law J 1996;105:1023-1047. Cf. also Ethics Committee of the Society of Critical Care Medicine. Consensus statement of the society of critical care medicine's ethics committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997;25:887-891.