'Doctor, Don't Give Up on Me!'

Leigh Page

Disclosures

March 16, 2016

In This Article

When Is Care "Futile"?

For centuries, physicians have advocated letting patients go when they appear to be dying. In fact, the ancient Greek doctor Hippocrates, author of the Hippocratic Oath, advised[16] against treating patients who are "overmastered by their disease."

Today, several specialty societies have tried to define the situations in which physicians are not obligated to provide care, which is called "futile" care. A policy statement[17] approved in 2015 by the American Thoracic Society, in conjunction with a few other clinical groups, provides three reasons why physicians shouldn't have to provide futile care in an ICU. First, "administering ineffective interventions goes against the most basic ethical obligations of clinicians to benefit individual patients and to avoid harm." Second, the profession has "the obligation to steward medical resources responsibly." And third, other patients' trust in these physicians could be undermined if it came to light that they administered "interventions that they knew could not benefit the patient."

The statement also provides some fairly straightforward examples of futile care, such as "ICU admission for a person with end-stage dementia and multiorgan failure" and "dialysis in a patient in a persistent vegetative state." But it stays away from more nuanced situations and does not provide a broad definition of futile care. Such definitions, it says, "are problematic because they often hinge on controversial value judgments about quality of life or require a degree of prognostic certainty that is often not attainable."

Thus, each doctor is expected to come up with his or her own working definition of futility. In doing so, part of what doctors look at is the odds of survival for the patient, based on studies on overall patient outcomes, and the quality of life if the patient were to survive.

Perceptions of the quality of life, however, can be quite different for doctors as opposed to patients, according to Stephen Drake, a research analyst from Not Dead Yet, a group that defends patients who are at risk of not getting care. Physicians, he says, tend to prefer outcomes that preserve the patient's intellect. "The intellect is central to physicians' identity, and the idea of losing your intellect is abhorrent," he says. "That means that physicians might place a lower value on a person with a brain injury than the family would."

Moreover, Drake thinks that doctors often overestimate the amount of disability the patient would have. Indeed, he's witnessed this first hand, with his own care. When Drake was born in 1955, he developed a severe hematoma as a result of a breech birth. The doctor bluntly told his parents that the baby would probably be "a vegetable," adding: "If I were you, I wouldn't even pray that he lives." But his parents insisted that everything should be done. Drake says that he's had to deal with neuromotor issues and learning disabilities, but he is very thankful that his parents didn't follow the doctor's advice. "I would have been the victim of a form of passive euthanasia," he says.

The concept of medical futility that doctors use is really "a value-laden notion," according to 2007 review[18] of the issue by a multidisciplinary team, headed by a philosopher, at McMaster University in Canada. "A small physiological improvement might seem sufficiently beneficial to a patient but not to a doctor (or vice versa)," they wrote. When the values of doctors and patients clash, they concluded, the patient's values should come first. "It is the patient's life to lead and death to die," they argued. "A concern with professional integrity cannot trump that, when there is some possibility, however small, of survival, and the patient wants to take it."

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