COUNCIL REPORT Medical Futility in End-of-Life Care

I N THE COURSE OF CARING FOR A critically ill patient it may become apparent that further intervention will only prolong the final stages of the dying process. At this point, further intervention is often described as futile. There has been controversy in the literature and in clinical practice regarding what constitutes futile intervention. Clinical paradigms of futile care often involve life-sustaining intervention for patients in a persistent vegetative state, or resuscitation efforts for the terminally ill. Other paradigms include the use of aggressive therapy such as hemodialysis, chemotherapy, or surgery for advanced fatal illness without a realistic expectation of care or palliation, and also the use of less invasive treatments such as antibiotics or intravenous hydration in near-moribund conditions. Questions of futility can also arise when interventions are useless and the condition is not life-threatening. This report, however, limits itself to the use of interventions in patients with life-threatening illnesses. The American Medical Association Council on Ethical and Judicial Affairs thus far has not defined an approach to determine what is and what is not medically futile, although it has discussed related issues concerning end-of-life care in other reports. For example, it has affirmed the ethical standing of withdrawing and withholding unwanted interventions, noted the constructive role that advance care planning can play in preempting difficult and conflicted situations, and advised the use of a range of orders not to intervene. The Council has also opposed physician-assisted suicide, out of concern that recent calls from citizens and professionals for physician-assisted suicide are a response to experiences of excessive and futile intervention at the end of life. In this report, the Council recommends a process-based approach to futility determinations. This recommendation follows from a discussion regarding various types of circumstances in which futility claims are made, an exploration of the difficulties of defining medical futility, and a deliberation on how to best implement a policy on futility.