Keeping Patients Alive a Few Weeks More: Is It Futile Care?

Arthur L. Caplan, PhD

Disclosures

November 15, 2012

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Hi. I am Art Caplan at the New York University (NYU) Langone Medical Center in the Division of Medical Ethics.

Futility. When should doctors even think about doing something that they believe to be futile? What I mean by "futility" is a belief that the treatment or intervention is not going to produce a benefit.

Medscape just conducted a survey of 24,000 doctors, and only 25% said they would not provide futile interventions. A very significant percentage, more than 30%, said that they would. The rest of those surveyed said they might, depending on the circumstances. That is a startling finding because the way we understand futility in ethics and in medical practice is "no benefit." So why would you do things that don't benefit the patient?

Part of the reason for the range of responses is that some doctors said, "Well, there might be a little benefit. Maybe you could keep someone going for a few weeks or a few months." I understand that. I don't think that is futile. That is a decision to provide a marginal benefit.

What counts as a significant or marginal benefit is partly up to the patient. We hear patients say in the intensive care unit, "I want to live so I can see my son's wedding," or "I want to live so I can get to my anniversary." I have heard patients say, "I want to live so I can watch the Super Bowl." Everybody has their own value system about what they think a few more weeks -- a few more days, even -- of life might mean to them. But I don't consider that pure futility. So, if you are in that camp that says, "Well, I might do marginally beneficial things. I have to negotiate that with the patient, let the patient know that it will only be minimally helpful to them -- another day, another week, or another month," I understand that.

However, if you are going to follow that strategy, the patient needs to understand that the situation is still dire, that even if he or she receives the intervention (a little surgery, some medication for cancer, etc.) that this isn't being provided in the hope that somehow he or she will get better or recover. By the time you are having a futility discussion, you need to make it clear to the patient that we are really talking about managing their dying and extending that dying for some period of time, but that this is not a reversal of prognosis.

Some people said in the survey that they would provide futile treatments because there is always the possibility of a miracle. There is always a chance that something could happen. That is a troubling way to approach the subject of futility. It is true that miracles can happen, but for people who we know have end-stage lung cancer, liver disease, or pancreatic cancer, miracles don't come. The evidence says that we know what the prognosis is going to be.

So, although I certainly understand wanting to offer hope to people and give them emotional comfort, we are not doing them favors by saying, "You know, miracles happen; things happen out of the blue." Maybe that is something that the chaplain wants to say, but it isn't something that the doctor should be saying.

A better approach, or a substitute, is to offer people small hope such as, "Would you be comfortable if we said you might be able to see your family tomorrow? Does that give you hope and a reason to go on? Does it make you hopeful if we say there are small goals that we could reach together? You would have a chance to meet with friends and relatives and tell each other how you feel about one another."

Big hopes -- miracles, miracle cures -- are called miracles because it would be miraculous if they happened. Offering small hope instead of providing futile treatments is a more humane way to deal with the reality of death -- small steps, small hopes. Patients understand. They usually know when they are in dire straits, and so do their families. They have the right to hope, but we ought to give them more short-term, reasonable things to hope for and not continue to give them hope that we absolutely know is futile at this point in their care.

The fact that a lot of doctors are still willing to give futile care is probably tied in with another reality, and that is fear about the law. People worry that "if somebody sues me, and I didn't do x, y, or z, then I'm going to be on the wrong end of a malpractice suit."

I have never seen it. I have acted as an expert witness. You don't lose those cases. If you say in good conscience, as a physician, as an expert, that I believed that doing something was futile and I didn't do it, and I talked about that with the patient -- anybody can sue you at any time for anything -- you are not going to lose that case because you are following the standard of care and what you believe to be true as the expert.

Using futile care as a way to stave off or avoid malpractice suits or litigation is not good for the patient, and in these kinds of situations, you want to do what is best for the patient. Prolonging suffering, causing the patient more harm -- if that is part of what futility means, to have a false sense of security about a lawsuit -- is not the way to go.

Futility is certainly complex, but let us not confuse it with marginally beneficial treatments or interventions. That is a different issue, and I fully understand why people would be inclined to negotiate that with the patient, to see what they want to do. Different people will answer differently. Let's not fool ourselves. We want to give hope. But let us not produce hope that isn't grounded in reality, and let us not use futility as a way to stave off fears about litigation. It doesn't work. You are going to be better off not providing the care, and explaining, if anybody challenges you, that continuing to provide that care is pointless, drives up the patient's bill, and probably causes more misery and suffering to the patient.

I'm Art Caplan at the Division of Medical Ethics at NYU Langone Medical Center. Thanks for watching.

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