Module 09 PowerPoint Presentation

Futility: Common Pitfalls and Practical Approaches

CHE Ethics Champions 2009

Futility: Common Pitfalls and Practical Approaches

CHE Ethics Champions 2009

Steven J. Squires, MA, MEdDirector, Mission and EthicsTrinity HealthWednesday, December 2, 2009

Steven J. Squires, MA, MEdDirector, Mission and EthicsTrinity HealthWednesday, December 2, 2009

Copyright 2009 Trinity Health – Novi, Michigan UNCLASSIFIED2

Wednesday, December 2, 2009

Futility Case

Consider the following scenario:

“An elderly patient with irreversible respiratory disease is in the intensive care unit where

repeated efforts to wean him from ventilatory support have been unsuccessful. The health care team [generally agrees] that he could not survive outside of an intensive care setting. The patient has requested antibiotics should he develop an infection and CPR if he has a cardiac arrest.”

The physician tells the patient and his family that the situation is futile.

[The University of Washington School of Medicine. (Accessed 2009). “Futility Case 2.” Ethics in Medicine. Available at http://depts.washington.edu/bioethx/topics/futilc2.html.]

http://depts.washington.edu/bioethx/topics/futilc2.html



Case Questions

The following questions result from the physician’s statement to the patient and family that the situation is futile.

A. Does she mean medically futile, meaning the treatment will not achieve its physiological objective or effect with the underlying illness?

B. Does she mean futile, implying consideration other factors such as perceived quality-of-life?

C. Does she know or can she explain differences?

D. Can she separate physiology from opinion?

E. Is it the appropriate time for personal opinion?



Presentation Objectives

1. Define futility. Differentiate futility from other terms and

concepts, such as medical futility and rationing.

2. Discuss pitfalls (challenges).

3. Provide helpful approaches, options, and suggestions for organizations and professionals to prevent or respond better to futility issues.

Note: Any applicable sources are at the bottom of the pertinent reference or quote. Thanks to Lynn Maitland, PhD, for her help with the presentation.



Defining Futility and Differentiating It from Medical Futility and Rationing



Futility Defined and Described

Futility is a specific intervention for a specific patient at a specific time. It “does not refer to a general situation of treatment or to a patient personally.”

[Junkerman, C., Derse, A., and D. Schniedermayer. (2008). Practical Ethics for Students, Interns, and Residents. Hagerstown, Maryland: University Publishing Group, 33.]

Futile care results from inappropriate care, care that is Unnecessary Unsuccessful Unsafe Unkind Unwise

[Jennett, Bryan. (1984). Inappropriate Use of Medical Technology. British Medical Journal, 289(6460), 1709-1711.]



Futility Defined and Described, Cont.

1. Unnecessary – The desired end, or goal, can be achieved by simpler means.

2. Unsuccessful – The patient has a condition too advanced to respond to treatment.

3. Unsafe – The risks of particular complications outweigh any probable benefits.

4. Unkind – The quality of life after the intervention will not be good enough, or long enough in duration, to justify it.

5. Unwise – The intervention diverts resources that would yield greater benefits to other patients.

[Jennett, Bryan. (1984). Inappropriate Use of Medical Technology. British Medical Journal, 289(6460), 1709-1711.]



Futility Defined and Described, Cont.

Futility occurs when one establishes…A. A goal,B. An action directed at achieving the goal, [and has] C. Virtual certainty that the action will fail.[Trotter, G. (1999). Mediating Disputes about Medical Futility. Cambridge Quarterly of

Healthcare Ethics, 8, 527-537.]

Factors weighing in any futility determination are…1. Interventions that are physiologically useless.2. Interventions that are irrelevant.3. Perceived poor quality of life for the patient.4. Low probability of success for the intervention. [Youngner, S. (1988). Who Defines Futility? JAMA, 260(140); 2094-2095.]



Medical Futility Defined and Described

Medical futility includes things that are (have)…1. Physiological uselessness – are treatments that

will fail in strict physiological terms; they will not achieve the physiological objective in the patient.

2. Irrelevance – has no meaning to a dying patient’s underlying deterioration only for temp, short-term physiological goals (shortly postponing death).

Medical futility is “any effort to provide a patient benefit that is highly likely to fail and rare exceptions cannot systematically be reproduced.”

[Schneiderman, L. and N. Jecker. (1996). Is the Treatment Beneficial, Experimental or Futile? Cambridge Quarterly of Healthcare Ethics, 5, 248-256 (bottom quote); Youngner, S. (1988) Who Defines Futility? JAMA, 260(140); 2094-2095 (top criteria).]



Terminology Graph for Rationing & Futility

Reference & (Scope)

Person(s) Deciding

Incl. Those Affected

Licit and Advisable

Bedside Rationing

Patient (Micro)

H.C. Prof. No No

RationingSociety (Macro)

Admin. / Govern.

Partly Maybe

Medical Futility

Patient (Micro)

H.C. Prof. No Yes

FutilityPatient (Micro)

H.C. Prof., Pt., Family

Yes Yes



Categories of Common Pitfalls Related to Futility



Categories of Futility Pitfalls

Situations labeled as futile often have one or more of the following characteristics or components:

A. Differences in the definition of futility (discussed)

B. Involve emotions – mind, body, and spirit angst

C. Fear from professionals and administration

D. Poor or suboptimal communication

E. Misunderstandings about who should determine goals for a patient, besides the patient

F. Insufficient attention to records and patients’ underlying deterioration, condition, or disease



Emotions – The Human Reality

In this section, we will discuss some challenges outlined in the previous slide, beginning with observations about emotions related to futility:

Guilt – Professionals may worry about being connected with treatment withdrawal. “Families may worry about betrayal of patient trust if they agree to withdrawal of treatment. They may also be compensating for past neglect or inattention.”

Mistrust – Patients and families may mistrust physicians due to earlier health care interactions.

Religion – Patient or family waiting for a miracle.[Junkerman, C., Derse, A., and D. Schniedermayer. (2008). Practical Ethics for Students,

Interns, and Residents. Hagerstown, Maryland: University Publishing Group, 34.]



Emotions – The Human Reality, Cont.

Ethnic and socioeconomic differences – “Poor patients may worry that any curtailment of services is rationing. Minority patients may be concerned about undertreatment as a form of discrimination.”

Denial – Patients and families have different coping mechanisms, some of them are more well-adjusted than others. “The patient or family may refuse to come to terms with reliable information of a patient’s impending death.”


Remember that every face has a story, and stress is difficult for everyone.



Emotions – The Human Reality, Cont.

Macro-level(Society, Global)

Intermediate-level(Organizational, Professional)

Micro-level(Individual, Clinical)

Culture Venn diagram depicts complex influences.



Professional Fear – Double Bind

Health care professionals may feel pressure, ‘being squeezed,’ from two sides:

A. Patients as consumers – “Many physicians unreasonably fear liability for not ‘doing everything,’ such as instituting every available technology [upon a patient’s request].”


B. Administration as not supportive – Clinicians also fear not having statements and policy codifications from administration to support their refusal of unreasonable patient and family requests.



Communication – Overt and Literal

Two major kinds of communications difficulties exist.I. Overt and literal difficulties

A. Situations may call for an interpreter.B. An interpreter “should be an objective

observer, preferably with some medical translation training – not a family member.”


C. Persons involved in the situation could use inflammatory or hurtful language.

D. Are professionals using medical jargon or communicating in an understandable way?



Communication – Subtle and Hidden

II. Subtle and hidden difficulties – some sources observe the following about the use of ‘futility’

A. It is pejorative because it has baggage, and is “best regarded as medically obsolete.”

B. Baggage includes negative connotations.C. People associate it with failure, often

stakeholders’ failure to agree on common terminology and goals, including the failure of stakeholders to have necessary discussions.

D. It is arbitrary and lacks uniformity.[Gillion, R. (1997). Futility and Medical Ethics. Journal of Medical Ethics, 23, 339-340 (point I).

Cantor, N. (1996). Can Healthcare Providers Obtain Judicial Intervention Against Surrogates Who Demand ‘Medically Inappropriate’ Life Support for Incompetent Patients? Critical Care Medicine, 24(5), 883-887 (point IV).]



Communication and Control Case

Consider the following scenario:

“Fred, a dying 33-year-old AIDS patient, has been deteriorating in the hospital for months, too

incapacitated to make care decisions for himself. Expanding bed sores and progressive systems failure have left Fred a patient for whom comfort care is the agreed upon medical management. Regardless of medical opinion, his wife…insists everything be done, including DNR, dialysis, and invasive procedures. The staff [agrees] the wife’s

requests will result in ineffective, futile care.”[Catholic Health East. (July 2003). “Futility Policies.” e-Cases in Ethics. Available at

http://www.che.org/members/ethics/docs/227/0703%20futility%20policies.doc.]

http://www.che.org/members/ethics/docs/227/0703%20futility%20policies.doc



Communication and Control Case Questions

The following questions result from previous case.A. Do we know definitively the use of ‘futile’ and

‘ineffective?’ Do you think physicians mean ‘futile’ or ‘medically futile’? Consider meaning.

B. Using the Trotter definition (goal, action, virtual certainty), what are some suggested actions?

C. Do effectiveness determinations depend on goals? Are there relevant differences between short-term goals (family coming in to say goodbye) and long-term goals (restoring functioning)? Why may it help to frame the actions and goals as specifically as possible?



Control – Futility Locus of Control

Many of the debates about futility center around who the stakeholders are in determining futility.

The futility definition (goal, action, virtual certainty) by Griffin Trotter responded to prior commentaries.1. Howard Brody’s comments suggest that patients

are the locus of authority for futility.2. Lawrence Schneiderman infers that authority for

futility resides with professionals. Trotter feels it rests with the greater medical

community (those who promote medical ideals).[Trotter, G. (1999). Mediating Disputes about Medical Futility. Cambridge Quarterly of

Healthcare Ethics (CQ), 8, 527-537. Brody, H. (1998). Bringing Clarity to the Futility Debate: Don’t Use the Wrong Cases. CQ, 7(3), 269-272. Schneiderman, L. (1998). Commentary: Bringing Clarity to the Futility Debate, CQ, 7(3), 273-278.]



Insufficient Attention = Confusion

How many times does it seem like futility situations arise out of nowhere? This could be due to…

Medicine’s structure with many specialties and caregivers.

Human interactions and attention being imperfect.It could result in… Unrealistic goals – Patients and families may

have unrealistic goals because “physicians fail to discuss goals to the patient in terms of the change that would most likely result from the specific intervention being considered.”




Insufficient Attention = Confusion, Cont.

Plan and role confusion – “Can occur in the formulation of the care plan. This situation is most likely to occur in serious illness with multiple consultants (and no one apparently in charge).”


Decisional confusion – Is when there is no clear answer about who is the decision-maker or when a decision itself is unclear.

Documentation errors – Happen when professionals do not record or document critical conversations in the patient’s medical record. These errors add to the amount of confusion.



Approaches, Options, and Suggestions to Prevent or Optimize

Responses to Futility Issues



Categories of Approaches to Futility Issues

The suggestions, options, and approaches to futility correspond to challenges mentioned previously:

A. Differences in the definition of futility

B. Involve emotions – mind, body, and spirit angst

C. Fear from professionals and administration

D. Poor or suboptimal communication

E. Misunderstandings about who should determine goals for a patient, besides the patient

F. Insufficient attention to records and patients’ underlying deterioration, condition, or disease



Definition Approaches – Infinite Complexity

Concept

Interpretation

Application

Denotation Connotation



Definition Approaches – Awareness

No definition is perfect because all have ambiguity. Some helpful suggestions are:

A. Seek your own clarity about definitions, comparing and contrasting the features of each.

B. Actively listen to understand how others use terms. Are there contradictions you may clarify? How about ambiguities for clarification?

C. Engage others in conversations about their interpretations of ‘inappropriate’ and ‘futile.’

D. Clarify misconceptions, contractions, ambiguities.E. If choosing a definition, choose one with least

ambiguity.



Emotional Approaches – Avoiding “Futility”

Because some sources advocate avoiding the use of “futility,” try phrases such as:

1. “This won’t help.”2. “This might even cause more problems.”[Junkerman, C., Derse, A., and D. Schniedermayer. (2008). Practical Ethics for

Students, Interns, and Residents. Hagerstown, Maryland: University Publishing Group, 37.]

3. This is not a medically appropriate treatment for the following reasons…

4. We could withdraw aggressive treatment.Remember, we withhold or withdraw a particular

treatment, but never withhold or withdraw care. We always provide compassionate care.



Professional Fear Approaches – Backdrop

Negative rights of refusal have become positive rights for treatment in the form of demands.

The technological imperative is influential. We live with chronic diseases; we have options. 60% of U.S. deaths occur in hospitals and 85% of

all cancer patients admitted to an ICU die there. <20% of admissions to acute and LTC have

directives; many procrastinate due to difficult topic.[Fleming, D. (2005). Futility: Revisiting a Concept of Shared Moral Judgment. H E C Forum,

17(4), 260-275.]

70% of patients and families with ICU experience were willing to do it again for one month of life.

[Burns, J. and R. Truog. (2007). Futility: A Concept in Evolution. Chest, 132, 1987-1993.]



Professional Fear Approaches – Codifying

On one hand, one source recommends that hospitals develop policies around futile treatment.

[Tan, S., Chun, B., and E. Kim. (2003). Creating a Medical Futility Policy. Health Progress, 84(4).]

1. Policies include process flows for scenarios.2. Some defer to the ethics committee for support.3. Options when providers agree on futility include

seeking a court order for a guardian ad litum, life support withdrawal, or transferring the patient.

[Truog, R. and C. Mitchell. (2006). Futility – From Hospital Policies to State Laws. American Journal of Bioethics, 6(5), 19-21.]

On the other hand, codification may endorse only one approach, which could create adversaries.

[Hamel, R. and M. Panicola. (2003). Are Futility Policies the Answer? Health Progress, 84(4).]



Professional Fear Approaches – Culture

“Culture eats strategy for lunch everyday.” Could policy be an articulation or form of strategy? If so, policy alone will not sufficiently address cultural, organizational, or professional barriers. Some organizations feel that a futility policy will

generate administrative support and legal safety.Do policies assist cultural change?Will policies alleviate meaningful differences

around value conflicts?Why make a policy for what we already know?What about intractable disputes?

Policy could reveal futility/medical futility tension.



Professional Fear Approaches – Policy

What are other reflections regarding futility policy?• If legalism is the problem, it should not be the only

solution. There is no need craft policy that we do not provide medically inappropriate treatment.

• Abandon definitional approaches to futility policies in favor of upstream (proactive) procedural ones.

• Policies should support saying the correct thing at the right time – good communication.

[Burns, J. (2006). Does Anyone Actually Invoke Their Hospital Futility Policy? Advances in Neonatal Care, 6(2), 66-67.]

In certain circumstances, is it ever appropriate to say, “Hospitals are not hotels and cannot provide skilled, long-term care” for you?



Communication Approaches – Processes

Part of the larger context beyond mere policy is communication. What does this entail?

“Keeping families informed throughout illness.” “Families [should] receive adequate information in

easily understandable terms and are relatively clear about the implications of that info.”

“It is critical that all involved in a given case be clear about the goals of treatment throughout the course of the patient’s disease.”

“Take care in how options are presented to families. Too often…it is…a ‘buffet.’”

[Hamel, R. and M. Panicola. (2003). Are Futility Policies the Answer? Health Progress, 84(4).]



Communications Approaches – Discussion

Rather than using the inflammatory term “futility,” try the following conversations starters:

I. “What are the realistic goals of this particular patient in these particular circumstances?”

II. “Is the treatment being considered likely to achieve these goals without undue burden?”

III. “Is the planned intervention consistent with the provision of good patient care?”

Note: Have the relevant information necessary for any discussion. Careful conversations along the way may avoid difficult later confrontations.




Control Approaches – Medical Futility

Physicians and other health care professionals are not obligated to provide treatments…

That do not offer the patient medical benefit. Outside the bounds of good medical practice. Where objective evidence about the effectiveness

of the intervention, applied to the particular situation, does not exist.

Even after specific patient or family requests for inappropriate treatment.

[American Medical Association, Council on Ethical and Judicial Affairs. (1992). Guidelines for CPR: Ethical Considerations in Resuscitation. JAMA, 268, 2282-2288. President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research. (1982). Making Health Care Decisions: The Ethical and Legal Implications of Informed Consent in the Patient-Physician Relationship. Washington, D.C.: U.S. Government Printing Office, 42-44.]



Attention Approaches – Support

1. Educational efforts geared to help professionals reflect and identify futility conflicts prospectively.

2. Role play to help facilitate language and conversations, so professionals say the correct things at the most appropriate manner and time.

3. Instruments such as Goals of Care Assessment Tool (GCAT) may help establish relevant goals.

4. Policies should concentrate less on supporting unilateral determinations (decision-making) and more on “stipulating conditions that trigger a [proactive] mandatory conversation with families.”

[Fins, J. and M. Solomon. (2001). Communication in Intensive Care Settings: The Challenge of Futility Disputes. Critical Care Medicine, 29(2), N10-N15.]



Meta-Messages

1. Professionals identify medical futility issues.

2. Patients and families know wishes best.

3. Futility discussions should involve families, patients, and relevant professionals.

4. Communicate and document often.

5. Avoid use of overuse of the term ‘futility.’

6. Utilize technology and records to proactively identify futility issues.

7. Use proactive ethics.8. Know traditional futility

policies only go so far.9. Culture may be the real

barrier, not policy.10.Educate; clarify goals

and expectations.11.Don’t acquiesce to

inappropriate requests.



End

Case (if there is time).

Questions?

Thank you for your time!

Module 09 PowerPoint Presentation

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