NOTE: The UW Dept. of Bioethics & Humanities is in the process of updating all Ethics in Medicine articles for attentiveness to the issues of equity, diversity, and inclusion. Please check back soon for updates!
Author:
Nancy S. Jecker, PhD
Topics addressed:
An elderly man who lives in a nursing home is admitted to the medical ward with pneumonia. He is awake but severely demented. He can only mumble, but interacts and acknowledges family members. The admitting resident says that treating his pneumonia with antibiotics would be "futile" and suggests approaching the family with this stance.
Do you agree?
An elderly patient with irreversible respiratory disease is in the intensive care unit where repeated efforts to wean him from ventilator support have been unsuccessful. There is general agreement among the health care team 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.
Should a distinction be made between the interventions requested by the patient? Should the patient’s age be a factor?
A young accident victim has been in a persistent vegetative state for several months and family members have insisted that "everything possible" be done to keep the patient alive.
What are your professional obligations?
A young accident victim has been in a persistent vegetative state for several months and family members have insisted that "everything possible" be done to keep the patient alive.
What are your professional obligations?
Case 1 illustrates the possible conflicts that can arise with patients or family members about withholding or withdrawing futile interventions. If you and other members of the health care team agree that the interventions in question would be futile, the goals of treatment should be clarified. It can be helpful to ask patients and family members to also articulate their goals, which may reveal some agreement among parties. Once goals are clear, physicians can discuss how various interventions help or frustrate these goals. This requires a process of working with the patient and/or family, and possibly drawing on other resources, such as social workers, palliative care services, hospital chaplains, and ethics consultants. If there is no professional consensus about the futility of a particular intervention, then there is no ethical basis for overriding the requests of patients and/or family members for that intervention.
An elderly patient with irreversible respiratory disease is in the intensive care unit where repeated efforts to wean him from ventilator support have been unsuccessful. There is general agreement among the health care team 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.
Should a distinction be made between the interventions requested by the patient? Should the patient’s age be a factor?
Like Case 1, Case 2 illustrates possible conflicts that can arise with patients or family members about withholding or withdrawing futile interventions. Ventilator support clearly produces a physiologic effect by contracting and expanding the patient’s lungs with oxygen. Yet this does not suffice to show that the treatment helps the patient, which is medicine’s goal. If the patient will never leave the intensive care unit, does ventilator support constitute a benefit to the patient? A central issue this case raises concerns qualitative futility, namely: does the patient’s quality of life fall well below a threshold considered minimal? If you and other members of the health care team agree that the interventions in question would be qualitatively futile, the goal should be to withdraw or withhold these interventions. Achieving this goal requires working in tandem with the patient and/or family, as well as drawing upon resources, such as social workers, hospital chaplains, and ethics committees. If there is no professional consensus about the futility of a particular intervention, then there is no ethical basis for overriding the requests of patients and/or family members for that intervention.
An elderly man who lives in a nursing home is admitted to the medical ward with pneumonia. He is awake but severely demented. He can only mumble, but interacts and acknowledges family members. The admitting resident says that treating his pneumonia with antibiotics would be "futile" and suggests approaching the family with this stance.
Do you agree?
In many cases, "futility" is used inaccurately to describe situations that appear undesirable. For this patient, treating pneumonia with antibiotics stands a reasonable chance of success. The patient's quality of life, though low, is not unacceptably so. Unless the patient (or if found incapacitated, his surrogate) were to say that he would find this quality of life unacceptably low, there is neither quantitative nor qualitative grounds for calling antibiotics futile in this case. Unlike Cases 1 and 2, in Case 3 there is a treatment available that benefits the patient.