I. Principles.

1. The goals of a treatment being considered should always be clearly identified, as well as the possibility of achieving those goals.

2. From the physician's perspective, futile treatments are those which will not accomplish their intended goal of providing physiologic benefit to the patient; from the patient's perspective, futile treatments are those which will violate the patient's values or will not help the patient achieve his/her goals.

3. Inadvisable treatments are those whose benefits are considered to be extremely unlikely or which may produce uncertain or controversial benefits and are incapable of accomplishing positive medical ends for the quality of life of the patient and/or accomplishing the realistic wishes of the patient/authorized surrogate.

4. The employment of treatments which are considered futile, i.e., unreasonable in the clinical situation, is medically improper.

5. The employment of treatments which are considered futile, i.e., unreasonable in the clinical situation, is not legally necessary.

6. The employment of treatments which are considered futile, i.e., unreasonable in the clinical situation, violates the dignity of the patient and the ethical principles of beneficence and justice.

7. The clinical judgment of the attending physician in deciding whether a treatment is futile, i.e., incapable of providing physiologic benefit to the patient, is determinative.

8. In cases where no medical benefit from the intervention under consideration will result for the patient, the attending physician is not obligated to offer the intervention to the patient/authorized surrogate.

9. In cases where no medical benefit from the intervention will result for the patient, the attending physician should explain to the patient/authorized surrogate why the intervention being considered is improper and/or should describe the appropriate level of care.

10. When inadvisable treatments are being considered, every effort should be made to identify any value conflicts which may underlie the discussion and weigh carefully the probabilities for success or failure which accompany the treatment.

11. In cases where the intervention being considered will not meet the values of the patient or fulfill the patient's wishes, the patient's/authorized surrogate's decision to refuse treatment is final, provided the stipulations of #13 are met.

12. The wishes of the patient always take precedence over the wishes of the surrogate.

13. Patients possessing decisional capacity and who have no minor child totally dependent upon them always have the right to refuse treatments. In some cases patients can refuse treatment even if there is a minor child dependent on them, especially if the patient has made provision for the minor child.

14. Authorized surrogates have the right to refuse treatment on the patient's behalf within the context of substituted judgment (when possible) or in view of the patient's best interest when substituted judgment cannot occur.

15. The right to refuse treatment does not confer on patients a correlative right to demand futile treatment.

16. Valid advance directives will be honored provided they conform to the laws of the State of Ohio and direct treatment approaches within the bounds of appropriate medical practice.

II. Topics for Discussions about the Futility or  Inadvisability of Treatments.

1. A detailed and accurate account of the patient's condition.

2. A realistic assessment of the patient's prognosis.

3. An identification of the goals of the treatment being considered and the reasonable chances for achieving those goals in this particular patient.

4. A realistic assessment (considering relevant probabilities) of the benefits a particular intervention being considered might provide for the patient.

5. A realistic assessment (considering relevant probabilities) of the burdens a particular intervention being considered might impose on the patient.

6. A careful distinction of the effects of an intervention and the benefits of an intervention.

7. A clear identification of the patient's beliefs, values, and wishes regarding medical treatments and lifestyle expectations.

8. The manner in which the patient's beliefs, values, and wishes have been expressed.

9. The meaning of a patient's advance directive.

10. The option to seek treatment elsewhere.

III. Procedures.

1. Identification of the patient's authorized surrogate will occur within 24 hours of admission.

2. Appropriate hospital personnel (e.g., chaplaincy, social services, patient advocacy), in conjunction with the attending physician, will be utilized to determine the beliefs, values, and wishes of the patient.

3. Careful consideration will be given to the beliefs, values, and wishes of the patient and the authorized surrogate.

4. Procedures for informed consent will be followed.

5. Direct communication with the patient will be utilized whenever possible.

6. When the patient lacks decisional capacity all relevant information will be communicated to the authorized surrogate.

7. The authorized surrogate will exercise decisional authority for the patient if the patient is unable to do so.

8. Patients/authorized surrogates should always have the opportunity to refuse treatments.

9. Consensus of the team of healthcare professionals who are involved in the care of the patient (i.e., medical staff, patient care, and medical integration) will be developed regarding the futility of an intervention.

10. When conflicts arise, reasonable flexibility and negotiation should be pursued.

11. There will be clear documentation in the patient's chart of the reasons for determining an intervention to be futile.

IV. Recourses.

1. In cases where the physician and the patient/surrogate do not agree on the direction of interventions, a second medical opinion will be encouraged.

2. Social services, chaplaincy, patient advocacy, etc. will be utilized to help patients/surrogates address their emotional responses to a determination of futility or inadvisability.

3. A consultation with the hospital's Bioethics Committee is recommended if there is a continuing conflict regarding the physician's judgment of futility or inadvisability, the patient's/authorized surrogate's judgment of futility, or continuing concerns of members of the healthcare team.

4. If a patient/surrogate persists in demanding treatment which is determined to be medically futile, an appeal may be made to the Probate Court for emergency guardianship in order to settle the matter.

V. Definitions

Advance Directive:An indication of the treatment wishes of a patient through a documented
conversation with his/her physician, a living will, or a durable power of attorney for healthcare.

Attending Physician:The admitting physician is the physician of record who is responsible for
coordinating the care of the patient in consultation with other specialties unless the admitting physician designates a medical specialist who is closely involved in the patient's care.

Authorized Surrogate:The individual who has authority to make healthcare decisions for a patient
when he/she lacks decisional capacity. The order of decision-makers is guardian, attorney-in-fact appointed in a durable power of attorney for healthcare, spouse, adult children, parents, adult siblings, next in the order of kinship.

Beneficence: The principle which requires that actions minimally do not harm another or ideally
provide a benefit to another.

Benefit: The positive result for a functional improvement in the quality of life of the patient or the
achievement of a particularly desirable goal which an individual will experience as the result of a healthcare intervention.

Best Interests: The test which requires a decision-maker to chose those interventions which a
reasonable person would select in achieving a benefit for a patient.

Burden: The suffering one must endure as the result of an intervention; it may take a physical,
psychological, or moral form.

Clinical Judgment: The judgment made by a healthcare professional which takes into account the
objective findings which support a diagnosis and prognosis and weighs them in light of the professional's expertise and clinical experience together with the peculiar circumstances of an individual patient. Such judgments will be made with due regard for a reasonable degree of medical certainty as determined in accordance with reasonable medical standards.

Decisional Capacity: The ability of individuals to appreciate their situations and the consequences
flowing from them, understand relevant information about their conditions, manipulate that information rationally, and communicate their choices.

Dignity: The intrinsic worth that individuals possess by the very fact that they are persons existing in a
moral community who manifest themselves with a variety of physical, psychological, and moral characteristics.

Futile Treatment: Any clinical intervention which a physician, relying on the medical literature and
his/her clinical judgment, determines will be unable to accomplish a physiological goal which will benefit the patient; also an intervention which does not conform to the patient's or authorized surrogate's wishes, values, and goals.

Futility: The inability to accomplish an intended goal.

Inadvisable Treatment: Any clinical intervention which a physician, relying on the medical
literature and his/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.

Justice: The principle which requires one to give to individuals what they deserve based upon factors
which are warranted in their situations.

Substituted Judgment:The test which requires a decision-maker to chose those interventions which a
patient would make, in light of the patient's own values, in situations where the patient is unable to make the decision for himself/herself.