Futility and the Care of Surgical Patients: Ethical Dilemmas

Abstract

Futility has been a contentious topic in medicine for several decades. Surgery in critical or end-of-life situations often raises difficult questions about futility. In this article, we discuss the definition of futility, methods for resolving futility disputes, and some ways to reframe the futility debate to a more fruitful discussion about the goals of care, better communication between surgeon and patient/surrogate, and palliative surgical care. Many definitions of futile therapy have been discussed. The most controversial of these is “qualitative futility” which describes a situation in which the treatment provided is likely to result in an unacceptable quality of life. This is an area of continued controversy because it has been impossible to identify universally held beliefs about acceptable quality of life. Many authors have described methods for resolving futility disputes, including community standards and legalistic multi-step due process protocols. Others, however, have abandoned the concept of futility altogether as an unhelpful term. Reframing the issue of futility as one of inadequate physician–patient communication, these authors have advocated for methods of improving communication and strengthening the patient–physician relationship. Finally, we discuss the utilization of consultants who may be of use in resolving futility disputes: ethics committees, palliative care specialists, pastoral care teams, and dedicated patient advocates. Involving these specialists in a futility conflict can help improve communication and provide invaluable assistance in arriving at the appropriate treatment decision.

An evolutionary concept analysis of futility in health care

“…is considered qualitative futility (Brody & Halevy, ; Schneiderman, ; Schneiderman & de Ridder, ; Schneiderman et al., ). Medical technology can sustain a patient's life without ever achieving the overarching goals of care—palliation of pain, improved quality of life or the ability to return to prior functional status (Grant, Modi, & Singer, ; Schneiderman & de Ridder, ). Such prolonging of life leads to qualitatively futile care where the patient is either bound by a vegetative state or confined to an institutional setting (Grant et al., ; Schneiderman & de Ridder, ).…”

“…Medical technology can sustain a patient's life without ever achieving the overarching goals of care—palliation of pain, improved quality of life or the ability to return to prior functional status (Grant, Modi, & Singer, ; Schneiderman & de Ridder, ). Such prolonging of life leads to qualitatively futile care where the patient is either bound by a vegetative state or confined to an institutional setting (Grant et al., ; Schneiderman & de Ridder, ). The attribute where life has quantity but not quality is often characterized by the existence of life‐prolonging measures.…”

“…Families/surrogates have the same choices as the individual, when advocating for their incapacitated or incompetent loved ones. Dependent on the geographical location; however, physicians and court authorities may have the right to overrule the decisions of the family (Grant et al., ). Problems arise when definitions do not align, and the goals of the stakeholders differ.…”

Hepatectomy for hepatocellular carcinoma larger than 10 cm: preoperative risk stratification to prevent futile surgery

“…As clinicians await a consensus definition of futility, physiologic futility remains the most strictly defined type of futility and refers to treatment that should not be offered because it cannot be expected to provide any survival benefit to the patient. On this basis, the present group has defined the outcome of surgery for huge HCC as futile if death occurs within 1 year of resection.…”

Prediction of in-hospital mortality after ruptured abdominal aortic aneurysm repair using an artificial neural network

“…33 A fully informed patient and family, however, may still elect to proceed with an unwarranted operation; our risk score is best suited for use as an evidence-based adjunct to the surgeon, as support that an operation may be futile. 34 This study has limitations including the lack of external validation, use of a single-center cohort and the drawbacks inherent in the accuracy and bias of data collected retrospectively rather than prospectively. Introduction of prospectively acquired data into an ANN would yield an improved predictive model.…”