SummaryFutility is an ancient concept arising from Greek mythology that was resurrected for its medical application in the 1980s with the proliferation of many lifesaving technologies, including dialysis and renal transplantation. By that time, the domineering medical paternalism that characterized the pre-1960s physician-patient relationship morphed into assertive patient autonomy, and some patients began to claim the right to demand aggressive, high-technology interventions, despite physician disapproval. To counter this power struggle, the establishment of a precise definition of futility offered hope for a futility policy that would allow physicians to justify withholding or withdrawing treatment, despite patient and family objections. This article reviews the various attempts made to define medical futility and describes their limited applicability to dialysis. When futility concerns arise, physicians should recognize the opportunity to address conflict, using best practice communication skills. Physicians would also benefit from understanding the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, justice, and professional integrity that underlie medical decision-making. Also reviewed is the use of a fair process approach or time-limited trial when conflict resolution cannot be achieved.
Case PresentationMrs. A, a divorced 57-year-old former nurse, was hospitalized 3 months for treatment of calciphylaxis-induced leg wounds. In the prior 3 months, she had resided in a transitional care unit or smaller community hospital for wound care. Her past medical history included diabetic retinopathy, neuropathy, and nephropathy; hemodialysis initiation 4 months into her illness for acute or chronic kidney failure; obesity despite vertical band gastroplasty; hypertension, hypercholesterolemia, previous myocardial infarction, and stenting; and remote breast cancer. She had never received warfarin, had normal parathyroid hormone and low 25-hydroxy vitamin D levels, and underwent a thorough negative serologic evaluation for an alternative diagnose to calciphylaxis. Extensive calciphylaxis treatments included two surgical debridement procedures, with one complicated by septic shock; daily wound treatments; sodium thiosulfate intravenously postdialysis; hyperbaric treatments complicated by tympanic membrane perforation; and intravenous antibiotics for multiple positive wound cultures, fever, and hypotension. The palliative care service addressed pain management and comfort care, although the patient wished for continuing dialysis, wound care, and cardiopulmonary resuscitation. Her stated goal was to live with and support her granddaughter and daughter, whom she believed to be in an abusive relationship with her son-in-law. Mrs. A's hospital team sought transfer to a hospital with burn specialists with wound expertise. One hospital refused, stating that additional aggressive care would not benefit her. A second hospital's burn surgeon accepted her care, unaware of her serum albumin being ,1.5 g...
