Mediative Fluency and Futility Disputes

Abstract

Futility disputes are more likely to be resolved-and relational breaches repaired-by engaging in a process that fosters communication between clinicians, patients, and families. This essay calls for mediative fluency. The preemptive use of a futility definition can stifle conversation when it is needed most, exacerbating the very power imbalances and associated health disparities that often precipitate futility disputes. When clinicians, patients, and families engage in dialogue, clinicians can appreciate what motivates requests for what is thought to be futile care, and patients and families can better understand the limits of available therapies. This sharing of knowledge, values, and attitudes cannot be achieved through the unilateral invocation of a futility definition. Furthermore, futility definitions are prone to interpretative judgment by clinicians and can be informed by the norms and attitudes attendant to a practitioner's medical specialty. They also need to be interpreted in the context of emerging trends in medical therapeutics and in relation to the clinical details of each case. In the aggregate, these challenges make the application of a futility definition futile.

Ethics and the 2018 Practice Guideline on Disorders of Consciousness

“…The concept of futility is important to evidence-based medicine, as it can support withholding medically ineffective treatment and facilitate dialogue with families about end-of-life decisions. 30 But the meaning of futility might differ from the vantage point of clinicians and families. Clinicians are often justified in making futility judgments when the requested intervention departs from standards of care, 31 but this is complicated when standards are evolving.…”

Medical Futility: Choosing the Next Intervention

“…"Without a trusting therapeutic relationship, collaborative decision-making, which is critically important, especially at the end of life, is not possible." 6 Within such relationships, the physician should be empowered to offer wisdom in addition to data. Curlin and Hall lay out this responsibility beautifully in an article in which they describe the need for wisdom in addition to competence, respect instead of cold autonomy, and candor instead of neutrality.…”

“…Rather than depending on legal decisions or hospital authorities to settle medical futility disputes, conflict is better handled within a relationship between decision makers. “Without a trusting therapeutic relationship, collaborative decision-making, which is critically important, especially at the end of life, is not possible.” 6 …”

The concept of futility in health: A scoping review

“…Within the scope of health care provision, it is accepted by most professionals that they should not implement futile interventions, for the fundamental principle that an intervention that is useless causes harm without benefit. 5 Treatments that aim to save life or maintain life cannot be promoted when they are considered futile. 6 However, despite all the negative consequences associated with futility, there is evidence that futile interventions continue to be implemented, especially in terminally ill patients and in intensive care units.…”

“…Although several authors have made efforts to define futility, there is a lack of universal consensus on what constitutes this concept. 5 The concept of futility is related to qualitative and quantitative assumptions 6,8 and is often associated with the promotion of inadequate treatments that do not improve the prognosis of the disease, alleviate physiological symptoms or prolong life. 9 This interpretation of futility, which is based mainly on the objectives and results of procedures and interventions, is problematic 9 and can lead to the invocation of this concept in ethically objectionable ways.…”