ethical dilemma

Journal of Medical Ethics and History of Medicine

Review Article

Medical futility and its challenges: a review study

Maryam Aghabarary 1 , Nahid Dehghan Nayeri

2*

1 PhD Student in Nursing, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Tehran

University of Medical Sciences, Tehran, Iran; 2 Professor, Nursing and Midwifery Care Research Center, Faculty of Nursing and Midwifery, Tehran University of Medical

Sciences, Tehran, Iran.

Corresponding Author:

Nahid Dehghan Nayeri

Address: Nosrat St., Tohid Sq., Faculty of Nursing and Midwifery, Tehran, Iran.

Email: [email protected] Tel: 98 21 66 42 16 85

Fax: 98 21 66 42 16 85

Received: 13 Feb 2016 Accepted: 28 Aug 2016 Published: 20 Oct 2016

J Med Ethics Hist Med, 2016, 9: 11

© 2016 Medical Ethics and History of Medicine Research Center, Tehran University of Medical Sciences. All rights reserved.

Abstract Concerns over limited medical equipment and resources, particularly in intensive care units (ICUs), have raised the issue of

medical futility. Medical futility draws a contrast between physician’s authority and patients’ autonomy and it is one of the

major issues of end-of-life ethical decision-making. The aim of this study was to review medical futility and its challenges.

In this systematized review study, a comprehensive search of the existing literature was performed using an internet search with

broad keywords to access related articles in both Persian and English databases. Finally, 89 articles were selected and surveyed.

Medical futility is a complex, ambiguous, subjective, situation-specific, value-laden, and goal-dependent concept which is

almost always surrounded by some degrees of uncertainty; hence, there is no objective and valid criterion for its determination.

This concept is affected by many different factors such as physicians’ and patients’ value systems, medical goals, and

sociocultural and religious context, and individuals’ emotions and personal characteristics.

It is difficult to achieve a clear consensus over the concept of medical futility; hence, it should be defined and determined at an

individual level and based on the unique condition of each patient.

Keywords: Medical futility, Physiologic futility, Qualitative futility, Decision-making, Withholding of treatments

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Introduction

Concerns over limited medical equipment and

resources, particularly in intensive care units (ICUs),

have raised the issue of medical futility (1-4).

Advances in medical technology, increased

healthcare costs, and the aging of the population

have added to the importance of medical futility in

recent years, so much so that the issue of medical

futility has become an increasing concern (3, 5-9). Technological advances have enabled medical

experts to prolong the lives of terminally-ill patients

even when there is no hope for successful treatment

of their underlying pathology. In addition to

generating debates on heavy healthcare costs, such

practices have increased the demand for intensive

care services and ICU equipment particularly by

elderly people suffering from chronic conditions (5,

8). This increase in demand for intensive care

services may become greater than the supplies in the

near future and cause different problems (1-3). For

instance, the need for ICU beds is estimated to

increase by 80–93% in the subsequent 20 years.

Consequently, the impending shortage of ICU beds

highlights the necessity for paying greater attention

to the debates over futile treatments, particularly in

ICUs (2).

Most people believe that futile treatments should not

be provided; however, there are different viewpoints

about what can be defined as a futile treatment (8).

Differences in people’s perceptions of futile

treatment have created many challenges between

patients’ family members and healthcare

professionals regarding continuing or discontinuing

treatments (3). Contrast between physician’s

authority and patients’ autonomy is another

important issue which has made clinical decision-

making difficult. Some individuals believe that

judgment about futility of treatments is a privilege of

medicine and is more valuable than patients’

autonomy (10). However, there might be instances in

which patients’ family members insist on continuing

treatments, while patients are reluctant to receive

them and healthcare professionals believe that they

are futile (2, 8, 11). Although a physician can

ethically reduce the delivery of treatments which are

inappropriate or futile (3), the questions ‘Is the

treatment really futile?’ and ‘Who has the right to

determine futility (physician, patient, or family

members)? (12) are raised.

Consequently, deciding on the futility of a certain

treatment is among the most sensitive health care

issues which can even result in making decisions that

are unethical. The sensitivity of this issue originates

from the fact that the term ‘futile treatment’ is

widely used in clinical reasoning as a strong reason

for avoiding treatment of a patient. Accordingly, a

cause of concern here is that valuable treatments are

discontinued for patients who are unable to make

decisions because treatments are considered to be

futile (13). Similarly, treatments with small gain may

be eliminated out of their presumed futility. This

may finally result in patients’ premature death.

Another concern in the area of futility is that

essential treatments may be labeled as futile in order

to cut healthcare costs (14). Accordingly, the major

futility-related concerns are: ’What is futility?’ ‘How

can it be defined?’ ‘What are its attributes and

instances?’ ‘What factors affect people’s perceptions

of it?’ ‘Who has the authority to decide upon

continuation or discontinuation of futile treatments?’

‘What factors result in the delivery of futile

treatments?’ and ‘What are the consequences of

futile treatments?’ This review study aims to answer

these questions. The findings of this study can

enhance healthcare professionals’ understanding and

knowledge regarding the nature, definitions,

attributes, reasons, and consequences of the concept

of medical futility.

Method This systematized review was conducted from

December 2013 to April 2014. A comprehensive

search was conducted via PubMed, ProQuest, Ovid,

Wiley Online Library, Science Direct, and Google

Scholar databases. The time interval determined in

the search protocol was 1980–2014. The search

keywords were futility, medical futility, medically

futile care, futile care, futile treatment, ineffective

care, inappropriate care, and non-beneficial care. The

equivalents of these keywords in Farsi were searched

in Persian databases such as Sicentific Information

Database (SID), IranMedex, Magiran, and Medlib.

By using these broad terms, initially, more than

10000 documents (including articles, books, and

theses) were found. After excluding books, theses,

duplicate articles, commentaries and letters to the

editor, the titles of the articles were assessed and the

irrelevant articles were excluded. The abstracts of

the remaining articles were studied. Thereafter, the

full text of 284 articles which met the inclusion

criteria were retrieved and studied. Moreover, the

reference lists of the retrieved articles were assessed.

Finally, 89 articles which met the inclusion criteria

were included in the final analysis. Figure 1 shows

the inclusion criteria, and the process of searching,

retrieving, and selecting the documents.

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Date of searches: 1980-2014

Search terms: futility، medical futility،medically futile care،

futile care، futile treatment،ineffective care ، inappropriate care

Search field tag: the search terms were used in different

combinations in title, abstract, keywords or text.

Search result: 243153 documents were included at this stage.

PubMed

(n = 15467)

ProQuest

(n = 2705)

Google Scholar

(n = 223500)

ScienceDirect

(n = 121)

Wiley

Online

Library

(n = 241)

Ovid

(n = 1108)

Magiran

(n = 3)

SID

(n = 5)

IranMedex

(n = 0)

Medlib

(n = 0)

11253 duplicated documents excluded

The full text of 384 articles were retrieved

(after reading abstracts)

+

15 articles were included by checking the reference lists of key

studies

A total of 89 articles were included in the analysis

(after reading the whole document)

Persian Article English Article

Theoretical Empirical Theoretical Empirical

3 Qualitative Quantitative 45 Qualitative Quantitative 3 1 11 26

Figure 1. The process of searching, retrieving, and selecting the documents

Results

The history and emergence of the concept of

medical futility

Futility in medicine is a concept with a long history.

The Hippocratic Oath includes a part which requires

physicians to avoid over-treating a patient, at any

cost, whose body has been swamped with diseases.

Hippocrates clearly noted that medicine is unable to

treat such patients (3, 15-17). Consequently,

avoidance of futile treatment became an ethical

obligation for physicians since the time of

Hippocrates (12, 18). On the other hand, rapid

advances in medical sciences and technology made it

possible to manage and treat many life-threatening

conditions, increased human longevity, and led to an

increase in the population of elderly people. Medical

technology helped physicians prolong the lives of

many terminally-ill patients without having any hope

for successful treatment of their underlying

pathologies (8, 19). In other words, medical science

reached a state in which it was able neither to

prevent patients’ inevitable death nor to ignore

patients whose death was imminent. Some

professionals have equated such practices with

prolonging the process of patients’ death, pain, and

agony, and reducing their quality of life (QOL).

Moreover, given the scarcity of medical equipment

and the heavy burden of healthcare costs, it was

3670 articles met the inclusion criteria

(after reading title of abstracts)

Inclusion criteria: - Document type: article

- Article type: the and

empirical

- Language: English, and

Persian

- Study design: qualitative,

quantitative, and mixed

methods

- Species: humans

- Subject: health, medicine,

and nursing

- Articles about: history, meaning, definition, attribute, and scope of

medical futility, and

reasons and consequences of providing futile medical

treatments

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considered as an ineffective, worthless, and futile

practice (8, 19, 20). Therefore, the concept of

medical futility was introduced in the late 1980s (19,

21, 22) in order to discontinue life-sustaining

treatments for terminally-ill patients (3, 21, 23). An

important question which was raised then was: ‘Does

one-sided labeling of a treatment procedure as futile

by a physician provide the permission for

discontinuing that procedure or avoiding its

administration (24)?’ The ethical challenge of such a

practice was that human life cannot be decided on

only by physicians, but that patients and their

families also have the right to participate in the

decision-making process. Therefore, the history of

scientific debates about futility in medicine and

medical ethics go back to the 1990s (3).

Other experts considered the contrast between

physicians’ authority and patients’ autonomy as the

reason behind the emergence of this concept (25-27).

The physician-patient paternalistic relationship in the

past sometimes required patients to receive

treatments which they did not like. Patients’

reluctance to and dissatisfaction with receiving such

unwanted treatments caused the medical society to

base clinical decisions and prescriptions on patient’s

right to have autonomy (28). Therefore, the

paternalistic physician-patient relationship was

changed into a participatory relationship. However,

patient’s autonomy was limited only to accepting or

rejecting diagnostic and therapeutic procedures and

it did not include patient’s right to ask to receive

treatments (29). Thereafter, rapid advances in

medical sciences created realistic and unrealistic

expectations from medical technology and enhanced

patient’s autonomy and authority, so much so that

physicians gradually received requests from patients

and their families for treatments which were

considered professionally as futile, ineffective,

worthless, or impossible. Consequently, some

experts believe that the concept of medical futility

was introduced by the medical society in order to

regain its earlier paternalistic authority and position

and to use it as permission for rejecting patient’s

requests (16, 30). However, after some time, it was

found that improper use of this concept can cause

many ethical challenges.

The lexical meaning and the definition of medical

futility

The root of the word ‘futile’ is the Latin word

‘futtilis’ which means worthless. The ordinary

meanings of futile include ineffective, useless,

unsuccessful, and meritless (9). Webster’s dictionary

defines futility as ‘serving no useful purpose;

completely ineffective or producing no valuable

effect’ (31). The definition of this word in the

Oxford English Dictionary is ‘leaky, vain, failing of

the desired end through intrinsic defect’ (32).

Simply, medical futility occurs when:

1. There is a goal 2. There is an action or activity for achieving

that goal

3. There is a virtual certainty that the action or the activity fails to achieve the goal

Consequently, the simplest definition of medical

futility would be: ‘a clinical action which is not

performed for achieving a clear goal, and hence, is

not useful for the intended patient’ (15).

Many scholars considered this simple definition as

inadequate, criticized it, and thus, provided different

definitions for the concept and used different

expressions and terms for explaining it, all of which

added to the ambiguity of the concept (33).

Table 1 shows that there are numerous definitions

and terms for medical futility. Nonetheless, the most

cited definition of medical futility is the definition

which was provided by Schneiderman et al. (34).

Table 1. The definitions of the concept of medical futility in the literature

No Keyword Definition Author(s)

1 Medical futility

Quantitative medical futility: “When physicians conclude (either

through personal experience, experiences shared with colleagues,

or consideration of published empiric data) that in the last 100

cases a medical treatment has been useless, they should regard that

treatment as futile” (p.437).

Qualitative medical futility: “Physicians should distinguish

between an effect which is limited to some part of the patient ' s

body, and benefit which the patient has the capacity to appreciate

and which improves the patient as a whole” (p.950).

“If a treatment merely preserves permanent unconsciousness or

cannot end dependence on intensive medical care, the treatment

should be considered futile” (p.437).

Schneiderman et al.

(17, 34, 35)

2 Medical futility Medical futility “is when treatment cannot, within a reasonable

probability, cure, ameliorate, improve or restore a quality of life

that would be satisfactory to the patient” (p.36).

Quinn

(41)

3 Medical futility

Quantitative medical futility is related to the success of a treatment

in achieving its intended goals.

Qualitative medical futility is related to the value of a treatment to

a patient’s QOL.

Schneiderman et al.

(27)

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4

Medical futility

Futile treatment

“An action, intervention or procedure that might be

physiologically effective in a given case but cannot benefit the

patient, no matter how often it is repeated. A futile treatment is not

necessarily ineffective, but it is worthless either because the

medical action itself is futile, (no matter what the patient s

condition) or the condition of the patient makes it futile” (p.69).

Clark

(38)

5 Medical futility

The concept needs to be defined individually and based on the

unique condition of each patient and the desires of the patient and

family members:

1. Continuing treatments while death is certain and survival is impossible

2. Continuing treatments while post-survival QOL is low (because of permanent physical or cognitive damage)

3. Continuing treatments for a patient with brain death

Heland

(40)

6 Medical futility

The concept needs to be defined individually and based on the

unique condition of each patient:

Medical futility is a state in which an intervention (either

diagnostic, therapeutic, preventive, or rehabilitative) provides no

benefit to the intended patient.

Aramesh

(37)

7 Medical futility

Medical futility at the end of life includes the following instances:

1. Failure to achieve goals such as saving life, prolonging life, and improving QOL

2. Disproportionate harm-benefit ratio: imposing heavy costs or inflicting harm

3. The concept needs to be defined individually and based on the unique condition of each patient

Jox et al.

(30)

8 Medical futility

The concept needs to be defined individually and based on the

unique condition of each patient:

A state in which a certain intervention produces no benefit to a

certain patient. The intervention may include a surgery,

intravenous or oral medications, or laboratory or imaging studies.

Saettele and Kras

(8)

9 Futile treatment

In the context of medicine, futile treatment is a type of care which

does not fulfill the intended goals and includes:

1. A treatment which does not provide a reasonable chance of survival

2. A treatment which is useless or ineffective 3. A treatment which is unsuccessful at enhancing QOL or

medical utility

4. A treatment which can never fulfill the patient’s goals The definitions 1 and 2 are the definitions of quantitative or

physiologic futility and relate to alterations in the functions of

organs. Perceiving and using these two definitions are associated

with few problems and debates for physicians. Definitions 3 and 4

pertain to qualitative futility, are mostly holistic, and seek patient’s

benefits.

Jecker et al.

(36)

10

Futility/Futile

care

Treatment is medically futile or non-beneficial because it offers no

reasonable hope of recovery or improvement, or because the

patient is permanently unable to experience any benefit.

Jones and Hunter

(39)

11 Futile treatment “Treatments that offer no physiological benefits to the patient are

futile” (p.888).

Danis et al.

(24)

12 Futility/Futile

care

Futility is a complex concept which relates to achieving and

fulfilling the intended goals. An action is considered futile once it

cannot achieve its intended goals or its success is empirically

improbable.

Futile care is a state in which providing life-sustaining treatments

produces no medical benefit for the intended patient, cannot

terminate patient’s dependence on intensive medical treatments,

and results in an unacceptable level of QOL.

Meltzer and

Huckabay

(11)

13 Futile care “Medically futile care to mean the use of considerable resources

without a reasonable hope that the patient would recover to a state

Sibbald et al.

(2)

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of relative independence or be interactive with his or her

environment” (p.1201).

14 Futile care

Futile care “consists giving clinical cares irrelevant to a nurse’s job

and giving cares through which the return of patient would be

impossible both physiologically and qualitatively” (p.301).

Bahramnezhad et al.

(54)

15 Futile care Futile care “is useless, ineffective care giving with wastage of

resources and torment of both patients and nurses having nursing

and medical aspects” (p. 235).

Yekefallah et al.

(55)

In their definition, they highlighted the difference

between effect and utility in that effect is limited to a

certain part of a patient’s body while utility or

benefit encompasses all the aspects of a patient as a

whole. According to them, a treatment which has an

effect, but has no utility for a patient is considered as

futile (17, 34, 35). Based on the difference between

effect and utility, futility can be classified as

physiologic, quantitative and normative, or

qualitative futility (Table 2).

Table 2. The types and the examples of medical futility Medical futility Definition Examples

Strict physiologic

futility

(Focuses on

achieving the

physiological effects

of treatments.)

Treatments do not produce the

intended physiological effect

Treatments do not help achieve

the intended physiological goals

 Ineffectiveness of an antibiotic against viral infection

 Ineffectiveness of aspirin in managing cancer

 The treatment is not effective in reversing a physiologic deterioration which will finally

cause death. The medical diagnosis shows

an inevitable death and the treatment will

have no useful physiologic effect. For

instance, ineffectiveness of defibrillation on

asystole or conventional cardiopulmonary

resuscitation for a patient with myocardial

rupture. Quantitative futility

(Focuses on the

success rate of a

treatment.)

The chance of producing the

desired effects is low or poor (less

than 1%).

 The low success rate of saving the life of an elderly patient who suffers from end-stage

hepatic cirrhosis and severe organ failure

Qualitative futility

(Focuses on the value

of treatments in terms

of QOL.)

Treatments which have the

desired physiological effects, but

the effects are useless or

worthless to the intended patient

The effect is producible, but there

are value-laden controversies on

its justifiability

Given the disproportionate harm-

benefit ratio, the treatment has no

value to patient’s QOL.

 A successful resuscitation which finally results in a vegetative state for the patient

 Poor QOL after a successful resuscitation on a patient with end-stage cancer whose

survival had been estimated to be 0%–10%

 Prolonging survival for only two months by using costly and potentially harmful

chemotherapy agents

 Sustaining the life of a terminally-ill patient using life-sustaining treatments (such as

ventilator and vasopressors)

A brief review of the existing definitions of the

concept of medical futility (Tables 1, 2, and 3)

reveals that these definitions have been based on the

following six foundations:

1. The probability of achieving the physiological effects which have been

supposed for a medical treatment (only

physicians can determine it) (12, 17, 24, 34)

2. The probability of achieving the defined goals of a treatment (physicians, patients,

and family members can have roles in

determining it) (11, 23, 30, 36)

3. The amount of benefit and utility which the intended treatment has for the intended

patient (this is completely individual and is

affected by values) (8, 11, 36-39)

4. The survival rate of the intended treatment (30, 36, 40)

5. Post-treatment quality of life (QOL) (8, 11, 17, 30, 34, 36, 40, 41)

6. The cost-effectiveness of the treatment (2, 8, 30)

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The abovementioned data reveals that the probability

of the success of a treatment and the value of the

treatment in terms of QOL are two main themes

which can be extracted from the existing definitions.

However, the diversity of perceptions of acceptable

probability of success and acceptable QOL has made

it difficult to provide a clear and comprehensive

definition of the concept (42). The main problem

occurs when we decide to determine an objective

border beyond which medical treatments can be

considered as futile. In other words, how much

should the probability of success for a treatment or

QOL be in order to consider the treatment futile

(12)? Most importantly, who has the authority or the

competence to define and establish such borders?

We could not find any clear answer to these

questions in the literature; however, in the majority,

it was indicated that judgment on futility is an

individual concept and based on the unique

conditions of each patient (8, 30, 37, 40).

The main components in the definitions of the

concept of medical futility

The data presented in tables 1, 2, and 3 reveal that

the main components of medical futility debates are

goal, effect, utility, and value.

Goals of medicine: The most fundamental

component of medical futility is the goal of

medicine. Determining whether a treatment is

ineffective, useless, or worthless necessitates

weighing it against the intended goals (11, 12, 15,

23, 30). In other words, we can talk about the effect,

utility, or value of a certain treatment only when we

know the goals of that treatment. In the next step, the

probability of achieving the goals and the effect,

utility, and value of achieving the goals are assessed

(23, 42). Consequently, improbability or low

probability of achieving the intended goals is among

the most essential characteristics of the concept of

medical futility (17, 34). The goals may include

 Successful treatment, complete recovery, returning to normal life, and gaining

autonomy and the ability to interact with the

surrounding environment;

 Achieving the physiological outcomes of the treatments irrespective of the quality of their

effects (for instance, successful removal of

excess fluids and waste products by a dialysis

machine irrespective of the effect of dialysis

on the survival of a dying patient);

 Saving life and preventing death;  Improving survival and prolonging life

(without inflicting pain or agony and not at

any cost);

 Alleviating pain and other physical symptoms and providing comfort;

 Psychological palliation (giving hope, sympathizing, and bringing satisfaction to

patients);

 Improving QOL through alleviating physical and psychological symptoms;

 Preparing the patient for a peaceful death. The goals may change during the course of the

disease and in line with the patient’s condition,

medical treatments, access to equipment and

facilities, and etcetera. Any change in the goals may

be associated with changes in individuals’

perceptions of the utility and their judgment about

the futility of a certain treatment (23).

Effect: Effect is the result of achieving the

physiological goals which have been set for a

treatment while utility or outcome implies the quality

of the effect. A futile treatment may exert significant

effects on patients’ physiology or anatomy; however,

the important point here is that the effects are not

useful to the patient. Therefore, ‘utility’ is a key term

in medical futility debates (37).

Utility: Utility can be objective or subjective and

physical or psychological (13). Although the

meaning of utility in the area of medical futility is

the direct and indirect benefits of treatments for

patients, decision upon the futility or non-futility of a

certain treatment is sometimes made based on the

benefits of that treatment for other people (such as

family members or other patients). The most

prominent example in this area is hospitalizing and

caring for a patient with brain death in the ICU.

Given the current inabilities of medical sciences,

providing life-sustaining medical treatments to such

a patient is among the clearest instances of medical

futility (10, 18, 40). The reason is that none of the

abovementioned goals for the patient are achievable,

and thus, continuing life-sustaining treatments is

completely useless to the patient. On the other hand,

such treatments are not futile if they are provided for

the purpose of organ donation to other patients or in

order to help the patient’s family members cope with

and accept their patient’s death. The reason is that

such practices can be beneficial to other people

(including family members and other patients).

Value: For assessing the value of a treatment, not

only the probability of achieving the goals, but also

the amount of benefit should be taken into account.

The benefit can be measured using the benefit-harm

ratio (23, 30). In other words, if achieving the

intended goals inflicts heavy costs, undue pain,

agony, or damage, the value of the benefit resulted

from treatments is dubious. Of course, judgments

about value should also be made individually and

based on patients’ and their family members’ values

and preferences (2, 22, 23, 40). For instance,

prolonging the survival of a patient with end-stage

ovarian cancer for only two months by

administrating costly and potentially harmful

chemotherapy agents may be considered futile and

worthless by many physicians, nurses, hospital

managers, and insurance companies. They may not

consider a two-month increase in survival as an

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optimum goal and may also not consider the benefits

of achieving the goal proportional to the harms of the

treatment. On the other hand, the patient, who is

waiting for the birth of her first grandchild in the

next two months, may consider such short-term

increase in survival as a desirable goal which is

worth achieving.

Factors affecting perceptions of medical futility

Factors which can affect individuals’ perceptions of

the concept of medical futility are the conditions of

patient/disease, medical goals (therapeutic or

palliative), and the value system of patients, family

members, and healthcare professionals. These factors

are discussed in what follows.

The conditions of patient/disease: Patient-related and

disease-related factors can contribute to the

perceptions of futility or non-futility of medical

treatments (Table 4).

Table 3. Comparing quantitative and qualitative futility

Qualitative futility Quantitative futility

 Normative futility  Value futility  Value dependent

 Physiologic futility  Goal futility  Value free

Points to the value of achieving a certain goal

Points to the probability of producing

physiological effects

Points to the success rate of a treatment

Requires knowing patients’ and their family

members’ values and beliefs to decide upon

continuation or discontinuation of treatments

Requires medical knowledge to decide upon

continuation or discontinuation of treatments

Table 4. Patient-related/disease-related conditions which affect perceptions of medical futility

Impossibility of survival Low quality survival Brain death Imminent death Lethal condition Low quality of life

 Total brain death (cortex, medulla,

and cerebellum).

 Partial brain death (cortex, medulla,

or cerebellum).

 The patient will die in the near future (within several hours or

days) irrespective of

treatments.

 A terminally-ill patient

 A dying patient

 Premature babies with fatal congenital defects (will die

within several hours after

birth).

 The patient is suffering from an underlying condition which

will cause a premature death

despite receiving treatments

 A patient with poor prognosis

 A patient with end-stage disease

 A patient with metastatic cancer

 Patients with stable vegetative state

 Very old patients suffering from multiple conditions and organ

failure

 Very old patients suffering from advanced dementia

 Permanent unconsciousness

 Patient’s dependence on life- sustaining equipment, devices,

and medications

Given the ever-changing conditions of patients due

to known or unknown causes (43) as well as

patients’ unique personal values and preferences,

there is no consensus over these factors. According

to some authors, prediction of a patient’s death based

on disease severity, poor prognosis, and low QOL is

not a good criterion for determining futility of

treatment procedures (3, 20, 24, 43). Uncertainties of

human sciences, unpredictability of the future, the

possibility of committing errors while establishing

medical diagnoses and determining prognoses (44,

45), and differences in people’s perceptions of

optimum QOL can affect judgments about futility of

treatments (42).

Medical goals (therapeutic or palliative): Medical

futility is inherently correlated with the goals of

medical treatments. In fact, goals play a central role

in defining medical futility, particularly qualitative

futility (12). The main problems here are: ‘What is

the goal?’ and ‘Who determines the goal and the

time for and ways to achieve the goal?’ In other

words, the goal and the right to decision-making are

the two important criteria for defining and

determining medical futility. Therefore, there are

many debates between healthcare teams and family

members in terms of determining futile treatments

and deciding upon continuation or discontinuation of

treatments (3, 12, 21).

Goals can widely range from completely objective

(i.e., physiologic) to completely subjective

(qualitative and value-dependent). Moreover, they

can be either short-term or long-term. Physiological

goals can be determined and established solely by

physicians. In other words, determining the instances

of physiologic and quantitative futility and deciding

upon continuation or discontinuation of treatments

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Page 9 of 13

are among the responsibilities of physicians. For

instance, only physicians can decide not to

resuscitate a patient with a myocardial rupture.

However, qualitative goals need to be established

based on patients’ and their family members’ desires

and values. In other words, goals may be completely

subjective and even in contrast with physicians’ and

other healthcare professionals’ values. In this view,

determining the instances of futility and deciding

upon continuation or discontinuation of treatments

are not done solely by physicians, rather patients’

personal values and preferences need to be also

taken into account for decision-making (23). For

instance, continuing treatments for a patient with

end-stage lung cancer may not result in the long-

term goals of recovery or hospital discharge.

However, it can help the patient and his/her family

members achieve their short-term goals such as

having an opportunity for being together in the New

Year celebration which is going to be held in the

next two days (12). Thus, we cannot achieve

desirable outcomes if the goal is not established

accurately or the means for achieving the goal are

not selected carefully. Subsequently, failure to

achieve a certain goal may be erroneously

interpreted as futility or worthlessness (15).

The value system of patients and their family

members, and healthcare professionals: The goals

and the benefits as well as the value of achieving

them are always affected by patients’ and their

family members’, and healthcare professionals’

personal, cultural, socioeconomic, and religious

values (3, 7, 8, 12, 22, 26, 46-49). Moreover,

patients’ conditions, personal preferences, priorities,

and values can affect judgments about the futility of

a treatment. Given the importance of the benefits of

medical treatments to patients, considering patients’

values may result in decisions which are based on

unrealistic or even subjective benefits. For instance,

the family members of a patient with brain death

may ask for the administration of a completely

ineffective traditional medication. Despite the known

ineffectiveness of the medication, its administration

helps the patient’s family members feel that they did

all their best in order to save their patient’s life (37).

Another patient may ask for an in vitro fertilization

despite knowing its ineffectiveness. Similarly, such a

request gives her the lifelong feeling that she has not

disregarded any endeavor to have a baby (13).

Therefore, preferring a benefit over another is an

arbitrary value judgment (22).

The scope of medical futility

Our literature review revealed that medical futility

debates revolve around two main areas including

futility in terminal situations and futility in non-

terminal situations (50). Although, futility is a major

challenge in ICUs and focuses on end-of-life care (6,

22, 30, 40, 44, 46), it is not unique to terminally-ill

patients. Rather, many diagnostic and therapeutic

procedures which are performed in non-terminal

situations may relate in some ways to futility (50).

Two instances of futility in non-terminal situations

may include prescribing a non-indicated computed

tomography scan for a trauma patient whose chest

X-ray shows no pulmonary problem or performing a

thyroidectomy on a patient whose hyperthyroidism

had been successfully managed by medication

therapy and had no manifestation of malignancy. On the other hand, although medical futility can be

related to different preventive, diagnostic,

therapeutic, and rehabilitative factors (8, 37), our

literature review indicated that it mainly deals with

life-sustaining treatments (such as cardiopulmonary

resuscitation/the use of ventilator) in end-of-life

situations (6, 19, 22, 30, 40, 44, 46, 50, 51),

particularly, performing cardiopulmonary

resuscitation on patients suffering from terminal

cancers (10, 12, 18, 52).

Reasons behind providing futile medical treatments

The most important reasons behind providing futile

medical treatments which had been referred to either

implicitly or explicitly in the literature were as

follows:

 Patients’/family members’ request and persistence (2, 6-8, 30, 40, 44, 53)

 Healthcare professionals’ personal emotions, beliefs, and attitudes (6-8, 30, 40,

53)

 Organizational factors and fear over getting involved in medical litigation (2, 6-8, 30,

40, 44, 53)

 Social, cultural, and religious factors (2, 6- 8, 30, 40, 44, 53, 54)

The consequences of providing futile medical

treatments

The most important consequences of providing futile

medical treatments which had been mentioned in the

literature either implicitly or explicitly were

 Suffering for the patient (2, 54-56);  Suffering, moral distress, job burnout, job

dissatisfaction, and increased turnover

among nurses and physicians, and hence,

decreased quality of care (2, 9, 11, 40, 49,

54-58);

 Heavy financial burdens on families, healthcare systems, and societies (2, 8, 11,

22, 55, 56, 59);

 Putting other patients at risk (5, 8, 54, 55). Challenges related to medical futility The overlap of medical futility and rationing: When

expensive diagnostic or therapeutic procedures are

prescribed for patients, particularly in ICUs, the two

concepts of futility and rationing are usually

mistaken for each other. Accordingly, differentiating

these two concepts seems essential. In medical

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futility, prescribing a certain procedure for a certain

patient is useless irrespective of the costs of that

procedure or the necessity for fair distribution of

resources. On the other hand, in rationing, the

procedure would be useful to that certain patient;

however, it is neither appropriate nor reasonable to

implement the procedure for that patient once its

costs or other patients’ need for that procedure are

taken into account (17, 60). The important point here

is that futile treatments should be avoided not

because they are expensive, but because they are not

useful to the intended patient and are not effective in

achieving the intended goals. Moreover, treatments

which are useful, but are expensive should also be

avoided occasionally because their benefits are not

proportionate to their costs (21). Another difference

between futility and rationing is that decisions about

futility are made at the bedside of a specific patient

while rationing-related decisions are made at a

community level, based on the needs of different

patient populations, and in order to ensure fair

distribution of resources in the community. It is

noteworthy that futility-related policies should not be

considered as a means for managing costs (17, 21,

60), because one of the most important concerns in

the area of futility is that some treatments may be

labeled as futile in order to cut healthcare costs (14).

Lack of objective and valid criteria for determining

futility: There is no laboratory test or clinical criteria

for accurately identifying patients receiving futile

treatments (44). In addition, due to the subjectivity

(19, 49, 61), complexity (8, 40, 61, 62), and

ambiguity of the concept of medical futility, it is

perceived and defined differently by individuals (2,

44, 49, 61, 63). Consequently, assessing the concept

solely from the perspectives of healthcare

professionals would not be valuable, because their

perspectives toward utility and outcome may be

different from that of patients and their family

members. The type, the amount of the benefit, and

the outcomes of medical treatments should be

assessed based on the values, preferences, priorities,

and desires of patients and family members (2, 26,

40). A major ethical dilemma is: ‘Who has the

competence to determine the usefulness and the

fruitfulness of treatments and care services?’ This

dilemma has remained unresolved because personal,

cultural, and religious values and beliefs as well as

socioeconomic factors severely affect its perception

and interpretation (3, 7, 8, 22, 26, 46-48).

The failure of the ICU scoring system to determine

the instances of futility: Some researchers introduced

poor prognosis, minimal survival chance, and high

probability of death as the predictors for futility and

recommended the ICU scoring system for

determining instances of futility (64). In other words,

they attempted to correlate the scores of the ICU

scoring system with the instances of futility in order

to have permission for withholding and withdrawing

of treatments in ICUs. Instruments such as the ICU

scoring system are usually used for assessing

patients during the first 24 hours after ICU

admission, determining the severity of their

conditions, determining the type of treatments

needed, determining prognosis for patients, and

estimating the probability of death based on a series

of physiological parameters. However, some other

researchers believe that, as these instruments are

based solely on physiological parameters, they

cannot be used for determining the futility of

diagnostic and therapeutic procedures (24).

Therefore, using these instruments for determining

futility was criticized severely, because the studies

showed that

 First, models and systems which determine the severity of illnesses are instruments for

estimating hospital death among critically-ill

patients. Moreover, their validity has been

evaluated in large samples and in certain

confidence intervals. Consequently, on an

individual level, they should be used

cautiously. Once the concepts of probability

and confidence interval are accurately

explained by physicians and understood by

patients and family members, the data obtained

from such scoring systems can provide only

useful, but not authoritative, information for

deciding upon continuation or discontinuation

of treatments. The reason is that survival rate

(which is determined by these instruments) is

only one of the factors in the determination of

the appropriateness of treatments for a patient

in the ICU. Moreover, these instruments cannot

provide information about other factors which

are important to clinical decision-making (such

as patients’ post-ICU conditions as well as

their and their family members’ preferences

and goals) (24, 44). Studies showed that

patients’ and their family members’ evaluation

of treatment options vary with progressive

deterioration of patient’s health. In other

words, compared with healthy people (such as

physicians and nurses), a patient with a critical

illness is more likely to choose sophisticated

treatments which have low potential benefits.

For patients and their family members, a

chance of one percent is much better than no

chance, and hence, their viewpoints need to be

taken into account by healthcare professional

while deciding upon the futility or non-futility

of treatments (3, 23).

 Second, disease severity, poor prognosis, and probability of death cannot be strong and valid

predictors of futility (3, 20, 24, 43). Continuous

alterations in patients’ conditions due to either

known or unknown causes (43) as well as the

inability of illness severity scoring models and

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systems to provide information about post-ICU

morbidity are among the limitations of such

instruments in determining the instances of

futility. Therefore, decisions upon

discontinuing treatments based on the findings

of these instruments would be unwise and

questionable. On the other hand, the concept of

futility is based on value judgments made by

different parties, such as patients, family

members, and healthcare professionals (2, 22,

23). Hence, it cannot be determined and

directly measured based solely on

physiological parameters. To conclude,

although these systems are helpful for deciding

upon the most effective treatments, they cannot

be used independently for determining futility

and making decisions about continuation or

discontinuation (or withholding and

withdrawing) of treatments in ICUs (24).

 Third, any attempt to determine futile treatments is associated with the possibility of

self-fulfilling prophecy. This problem can

affect any situation in which there is a high

probability of death and can result in decisions

about restricting life-sustaining medical

treatments. The risk of self-fulfilling prophecy

is that restricting life-sustaining treatments due

to a high probability of death abnormally

increases mortality rate (3). In other words, the

information obtained from ICU scoring

systems which show a high severity of illness

and a high probability of death can enhance the

possibility of healthcare professionals’ self-

fulfilling prophecy. Once the death of a patient

is highly probable, she/he would receive

limited intensive care services, and hence,

would have greater probability of death (43,

49). According to Wilkinson and Savulescu

(2011), self-fulfilling prophecy is associated

with higher mortality rate among patients

suffering from hemorrhagic stroke and hypoxic

brain injuries, critically-ill patients, and even

patients with brain death (3).

Conclusion

Medical futility is an extremely complex,

ambiguous, subjective, situation-specific, value-

laden, and goal-dependent concept which is almost

always surrounded by some degrees of uncertainty.

Thus, there is no objective and valid criteria for

determination of medical futility. Determining the

futility of a certain treatment for a certain patient and

deciding upon its continuation or discontinuation

have always been difficult and challenging. This

concept is affected by many different factors such as

physicians’ and patients’ value systems, medical

goals, sociocultural and religious context, and

individuals’ emotions and personal characteristics.

Such characteristics have made it difficult to achieve

a clear consensus over the concept of medical

futility. Accordingly, medical futility should be

defined and determined at individual level and based

on each unique case. The most important reasons

behind providing futile medical treatments are

patients’/family members’ request and persistence,

healthcare professionals’ personal motives, and

social, cultural, religious, and organizational factors

predominating the immediate community. On the

other hand, the most important deleterious

consequences of providing futile treatments are

suffering for patients, and heavy financial burdens

on families, healthcare systems, and societies, and

moral distress, job burnout, job dissatisfaction, and

increased turnover among healthcare professionals,

and hence, decreased care quality. It is essential to

study the nature and the mechanism of futile medical

treatments in the sociocultural context of each

community. The findings of this study can enhance

healthcare professionals’ understanding and

knowledge of the nature, definitions, attributes,

reasons, and consequences of the concept of medical

futility.

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