SOC 573 - Medical Futility

1. SOC 573 - Medical Futility James G. Anderson, Ph.D. Purdue University

2. Definition of Medical Futility • Quantitative Definition - The expectation of success empirically is so unlikely that its exact probability can’t be calculated. • Qualitative Definition - Any treatment that merely preserves permanent unconsciousness or total dependence on intensive medical care.

3. Questions • What is the process by which standards are devised and quantitative judgements made? • Society for Critical Care Medicine - 1990 Consensus report on the ethics of forgoing life support • Medicaid stipulates that recipients are to receive “medically necessary” care but does not stipulate standards

4. Questions • What is the process by which standards are devised and quantitative judgements made? • The Pepper Commission in 1990 tried to define minimum health benefits. • The State of Oregon combined public values, professional judgment, cost-effectiveness data to rank procedures covered under the state Medicaid program

5. Questions • Who decides when treatment is futile? • Healthcare providers • Patients and their surrogates • The courts

6. Determining Futility • Determination of futility combines technical considerations, clinical judgments, and patient values. • Determination requires shared decision making.

7. Making Judgments • How do we make judgments that combine factual and normative (moral) ingredients? • Values can influence how one recognizes and interprets facts. • We must make a sharp distinction between scientific knowledge and moral and political judgments.

8. Making Judgments • Scientific data provide probabilities not certainties. • Probabilities can not always be kept free of values. • The use and interpretation of scientific data for moral or politicalk purposes will be a function of the values we bring to bear on the data.

9. Questions • How do we determine medical futility for patients who are in a comma, in a persistent vegetative state or who are suffering from multi-organ failure or severe dementia? • When if ever does cost become a consideration?

10. Tension • Physicians must have the right to act on their values and sense of integrity just as patients must be allowed to act on theirs. • The physician is the expert but may act paternalistically. • The patient and family want autonomy and want to follow a democratic process. • How do we resolve the inherent tension between doctors and patients?

11. Questions • If patients and their surrogates insist on continuing treatment that is considered futile, who should pay for the treatment? • If health care providers discontinue treatment against the wishes of patients and their surrogates, will this cause the public to lose trust in the health care system?

12. Questions • If the physician accedes to family wishes to continue futile care, is he/she sending the family a mixed message of false hope? • Does the physician have an obligation to protect the patient’s interest? • How does the physician determine what is in the best interest of the patient?

13. Questions • In the absence of laws, are the family members best qualified to decide whether treatment is futile? • When if ever are physicians justified in refusing to continue futile treatment? • Should the potential costs to the provider (hospital) and to the public of futile care be a consideration?