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Determination of "futility" in emergency medicine
Annals of Emergency Medicine - Volume 35, Issue 6 (June 2000) - Copyright © 2000 American College of
Emergency Physicians
DOI: 10.1067/mem.2000.106991
CONCEPTS
Determination of "futility" in emergency medicine
Catherine A. Marco MD *
Gregory L. Larkin MD, MSPH *
John C. Moskop PhD
Arthur R. Derse MD, JD §
From the Department of Emergency Medicine, St. Vincent Mercy Medical Center, Toledo, OH*; the Department of
Medical Humanities, Brody School of Medicine, East Carolina University, and Bioethics Center, University Health
Systems of Eastern Carolina, Greenville, NC
; and the Center for the Study of Bioethics and the Department of
Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI. §
Received for publication November 23, 1999.
Revision received February 10, 2000.
Accepted for publication February 22, 2000.
The opinions expressed in this article are those of the authors and may not reflect the official
policies and opinions of the American College of Emergency Physicians. Dr. Marco, Dr. Moskop,
and Dr. Derse are members of the ACEP Ethics Committee. Dr. Larkin served as committee chair in
1995-1997.
Address for reprints: Catherine A. Marco, MD, Acute Care Services, St. Vincent Mercy Medical Center, 2213 Cherry
Street, Toledo, OH 43608-2691; 419-843-2452, fax 419-251-4478; E-mail:
[email protected]
.
Copyright © 2000 by the American College of Emergency Physicians.
0196-0644/2000/$12.00 + 0 47/1/106991
The practice of emergency medicine routinely requires rapid decisionmaking regarding
various interventions and therapies. Such decisions should be based on the expected risks and
benefits to the patient, family, and society. At times, certain interventions and therapies may be
considered "futile," or of low expected likelihood of benefit to the patient. Various
interpretations of the term "futility" and its practical application to the practice of emergency
medicine are explored, as well as background information and potential application of various
legal, ethical, and organizational policies regarding the determination of "futility."
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Decisions regarding potential benefit of interventions should be based on scientific evidence,
societal consensus, and professional standards, not on individual bias regarding quality of life
or other subjective matters. Physicians are under no ethical obligation to provide treatments
they judge to have no realistic likelihood of benefit to the patient. Decisions to withhold
treatment should be made with careful consideration of scientific evidence of likelihood of
medical benefit, other benefits (including intangible benefits), potential risks of the proposed
intervention, patient preferences, and family wishes. When certain interventions are withheld,
special efforts should be made to maintain effective communication, comfort, support, and
counseling for the patient, family, and friends. [Marco CA, Larkin GL, Moskop JC, Derse AR.
Determination of "futility" in emergency medicine. Ann Emerg Med. June 2000;35:604-612.]
See editorial, p. 615.
Introduction
Like their colleagues in many other specialties, emergency physicians must routinely consider the
risk/benefit ratio of therapeutic interventions. Risk/benefit analysis may be applied to many
relatively simple cases, for example, the decision whether to prescribe antibiotics for a patient with
an upper respiratory tract infection. In such a case, physicians determine, based on experience and
the medical literature, the probability that the cause is bacterial and that the patient will benefit from
the administration of antibiotics. Physicians also consider the potential risks of prescribing
antibiotics, which may include potential allergic reactions, drug interactions, cost of therapy, and the
impact of overutilization of antibiotics on the development of antimicrobial resistance. Similarly,
consideration of both risk and benefit should be applied to more critical decisions regarding such
interventions as advanced airway management, invasive monitoring, cardiopulmonary resuscitation
(CPR), and other critical care interventions.
In recent years, commentators have argued that the potential for benefit of certain interventions is so
remote that physicians may, or even should, refrain from undertaking these interventions, even if
patients or families request or demand them. [1] [5] These arguments, which appeal to a concept of
medical futility, have evoked a lively ongoing debate with other patient advocates who question
whether an appeal to futility can serve as a legitimate and sufficient reason for unilateral action by
physicians to withhold or withdraw treatment. [6] [11]
Although the term "futility" has met with considerable difficulties and inconsistencies in
interpretation, and debate about its moral force continues to rage, determination of the likelihood of
benefit to the patient remains crucial for decisionmaking in emergency medicine. A background of
conceptual and moral positions regarding futility is briefly reviewed, and the role of futility
judgements in emergency medicine is considered, including the policy statement of the American
College of Emergency Physicians (ACEP) on Nonbeneficial ("Futile") Emergency Medical
Interventions.
The concept of futility
The term "futility," although commonly used, is fraught with difficulties in definition and
interpretation. The word "futile" is derived from the Latin futilis, meaning "leaky." According to
Greek myth, the daughters of King Danaus were condemned by the gods to carry water in sieves, a
futile task. [12] As Caplan [13] has noted, futility judgments are about "odds and ends," that is, a futile
effort must have very low odds of achieving the desired ends. Thus, each futility judgment has a
quantitative aspect (how low are the odds of success?) and a qualitative aspect (what are the desired
ends?).
Scholars have identified a variety of different standards for both the quantitative and qualitative
aspects of futility. [14] [15] For example, Brody and Halevy [14] review 4 different definitions of futility
in the context of resuscitative efforts: (1) physiologic futility (failure to produce any physiologic
response), (2) imminent demise futility (failure to prevent death in the very near future), (3) lethal
condition futility (failure to affect an underlying lethal condition that will result in death in the not
too distant future), and (4) qualitative futility (failure to lead to an acceptable quality of life). Each
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successive definition in this series applies the concept of futility to a broader and more controversial
group of patients.
A widely cited 1990 article on futility by Schneiderman et al [3] proposes a definition of medical
futility, with both quantitative and qualitative aspects. According to this definition, a treatment is
futile if empirical data demonstrates a less than 1% chance of success, or if the treatment "merely
preserves permanent unconsciousness" or "fails to end total dependence on intensive medical care".
[3] [16] [17]
Given this variety of proposed definitions, health care professionals may interpret futile interventions
as those that carry an absolute impossibility of successful outcome, a low likelihood of success, a
low likelihood of survival to discharge from the hospital, or a low likelihood of restoration of
meaningful quality of life. Several authors have demonstrated that there is no consensus among
physicians about the meaning of futility. [7] [15] [18] [19] Because of continuing controversy over the
meaning of futility, it may be wiser to avoid the term and to refer instead to interventions as
"nonbeneficial," "ineffective," "medically inappropriate," or "having a low likelihood of success". [5]
[18] [20]
Moral arguments
Several major moral arguments have emerged in the continuing debate over futile or nonbeneficial
treatment. This section briefly reviews arguments offered by both proponents and opponents of
appeals to futility in medical decisionmaking.
"Pro-futility" arguments
Beginning in the late 1980s, authors began to appeal to the concept of futility as a justification for
limiting medical treatment despite patient or family demands that it be provided. Early work by
Blackhall, [1] Tomlinson and Brody, [2] and Hackler and Hiller [5] focused on the issue of resuscitation
and asserted a right of physicians to withhold resuscitation attempts judged to be futile. Guide-lines
proposed by the Hastings Center [21] and the American Medical Association (AMA) Council on
Ethical and Judicial Affairs [22] recognized decisions to forgo treatments based on physiologic
futility. Other authors proposed criteria for discontinuing prehospital resuscitation efforts. [23] [24] In
their 1990 article, Schneiderman et al [3] argue that physicians may apply futility criteria to withhold
or withdraw care without patient approval. These and other proponents of the concept of futility offer
arguments based on professional integrity, professional expertise, and responsible stewardship of
scarce resources.
The argument from professional integrity asserts that physicians should not be required to violate
their own professional moral standards by providing treatments they believe to be futile or harmful.
Forcing physicians to provide such treatment would violate their integrity as independent moral
agents and reduce them, as Paris and Reardon [4] observe, to "an extension of the patient's (or
family's) whims, fantasy, or unrealizable hopes and desires."
A second pro-futility argument points out that patients and families rely on their physician's expertise
in assessing the patient's condition and recommending reasonable treatment alternatives. If a
physician judges a particular intervention to be futile, it is generally not a reasonable treatment
alternative and thus should not be presented to the patient. However, such judgments should be
based on sound scientific evidence, not on individual opinion or bias. [26] Reliance on physician
expertise is especially vital in emergency situations requiring rapid assessment and initiation of
appropriate treatment.
A third pro-futility argument maintains that physicians have a duty to make good use of the material,
financial, and human resources under their control in the provision of health care. [25] Emergency
physicians may personally provide, order, or supervise a wide variety of treatments in a variety of
settings, within the emergency department, in the out-of-hospital setting, or elsewhere in the
hospital. Providing futile care, however, wastes resources, because it cannot achieve its desired end.
Thus, physicians should not administer or order futile treatments, thereby preserving resources for
situations in which they can confer a benefit, and honoring their professional duty to other patients.
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A number of authors have offered versions of this argument. For example, Murphy and Matchar [27]
suggest that both medical and economic factors be considered when making decisions regarding lifesustaining therapy. Lantos [28] states that "given limited resources, it is ethically justifiable to limit
access to treatments that are expensive and offer minimal benefit...decisions by doctors to curtail use
of those treatments are socially responsible." Several authors suggest that CPR not be considered a
part of the standard of care for certain patients with expected poor outcomes. [5] [29] [31] The time may
come when the United States may need to emulate other countries, where the principles of
stewardship and justice are applied more explicitly, as scarce health care resources must be carefully
used for the maximal societal benefit. [32] [33]
"Anti-futility" arguments
Critics of the limitation of treatment based on physician judgments of futility offer arguments based
on respect for patient autonomy, prognostic uncertainty, and the absence of social consensus
regarding futility standards. [6] [9] [34]
Existing moral and legal precedents, such as the doctrine of informed consent, give patients
substantial control over their own health care. Patients or their families may have very different
opinions from their physicians about what goals of treatment or what odds of a successful outcome
are worth pursuing. When such differences of opinion occur, this argument concludes, respect for
patient autonomy should incline physicians to honor patients' preferences regarding treatment.
Regarding related issues, the AMA Council on Ethical and Judicial Affairs stated that "the social
commitment of the physician is to sustain life and relieve suffering. Where the performance of one
duty conflicts with the other, the choice of the patient should prevail." [35] One more extreme
viewpoint is that "even the irrational choices of a competent patient must be respected if the patient
cannot be persuaded to change them." [36] The concept of autonomy has particular ramifications for
emergency medicine, where time and information are often limited. The realization of the ideal may
not be possible in a timely fashion. Because patient wishes and competence often cannot be
established rapidly or conclusively, decisions must sometimes be made based on physician judgment
regarding potential medical benefit, and a presumed respect for autonomy of the patient.
A second anti-futility argument appeals to the difficulty of making precise and accurate predictions
that medical treatment will have no beneficial effect. Unless physicians can make highly confident
predictions about the outcome of a treatment, they cannot forgo treatment on the grounds that it is
futile. However, studies of critically ill patients conclude that available prognostic measures usually
cannot predict outcomes like death with high levels of probability. [37] [39] The widespread interest in
evidence-based medicine suggests that much of current medical practice remains unproven. Thus,
physicians often lack sufficient evidence to make treatment decisions on the basis of futility.
Particularly in emergency medicine, where an established patient rapport and familiarity with longterm conditions and prognoses are lacking, predicting outcomes may be problematic.
A third anti-futility argument observes that more than 10 years of debate have not yet produced a
societal consensus on the question of futility. Instead, major scholarly and public differences of
opinion persist regarding the legitimacy of most of the proposed criteria for futile treatment. In the
absence of social consensus, this argument concludes that such criteria should not be imposed on
unwilling patients or their representatives.
Decisionmaking in emergency medicine
In view of the persuasive moral arguments both supporting and challenging the physician's authority
to make and act on futility judgments, resolving questions about futile treatment remains a difficult
task. Critical care choices in the ED carry special significance because of the momentous potential
consequences of administering or withholding interventions. Clinical situations in emergency
medicine may present particular challenges in moral decisionmaking, especially in situations where
insufficient information is available, surrogates are unavailable, or there is conflicting information.
Despite the above limitations, emergency physicians should seek to base their treatment decisions on
well-established research results, patient and family wishes, and professional judgment.
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When considering administering or withholding critical care interventions, risks and benefits should
be carefully considered. The primary goals of critical care interventions are to preserve life and
restore health to the patient. Other less tangible benefits to family and friends may accrue, including
reassurance, resolution of guilt, and provision of additional time for acceptance of bad news. Some
defend the societal benefit of teaching resuscitation practices and procedures in resuscitation
settings. [40] Of crucial importance is the principle of continued care for the patient and family, even if
certain medical treatments are withheld. [20] Palliative care, communication, and counseling with the
patient, family, and friends may be of greater benefit near the end of life than technologically
advanced interventions. [16] [41] [43]
One critical care intervention commonly used by emergency physicians is attempted resuscitation in
response to cardiopulmonary arrest. In a recent national survey of 1,252 emergency physicians, most
respondents (55%) reported that they had attempted resuscitation more than 10 times in the past 3
years, despite their professional judgment that the effort would be futile. [44] If the respondents'
judgments about futility were accurate, these resuscitation attempts provided no medical benefit, but
they did consume substantial resources, considering not only supplies, but time, effort, and risk
incurred by health care providers. Why, then, do emergency physicians often attempt resuscitations
that they believe to be futile?
Other responses in this survey suggest several potential reasons. A large majority of respondents
(94%) reported that legal concerns influence their resuscitative practices. Respondents also
commented on the dearth of national guidelines for initiating and withholding resuscitation. Lack of
authoritative guidelines or policies and the fear of liability, together with the existence of certain
institutional policies suggesting resuscitation in the absence of prior do-not-resuscitate (DNR)
orders, may provide strong incentives for emergency physicians (and other health care professionals)
to attempt resuscitation despite expected futility. How, then, can these incentives be overcome to
prevent resorting to futile efforts at resuscitation?
Futile care policies
One antidote to the irrational and profligate use of resuscitative technology is the establishment of
scientifically informed policy or professional consensus guidelines. Various professional
associations and other groups have, in recent years, offered proposals designed to limit the use of
futile treatment. Prominent examples include statements regarding futility from the 1992 National
Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care, [45] from the AMA's
Council on Ethical and Judicial Affairs, [46] [47] and from ACEP. [48] Each of these policies is reviewed
to determine whether they offer useful guidance for ED decision about resuscitation attempts or
other interventions.
1992 National Conference Recommendations
Recommendations regarding futility were included in the report of the most recent National
Conference on Cardiopulmonary Resuscitation and Emergency Cardiac Care in 1992 (Emergency
Cardiac Care Committee and Subcommittees). [45] Although the report recognizes that physicians
should not be obligated to provide futile care, it goes on to say that "unilateral decisions by
physicians to withhold or terminate resuscitation are justified only when it is futile in a strict sense."
The report specifies 3 circumstances in which appeal to futility is sufficient to justify a decision to
withhold or terminate resuscitation:
1. Appropriate basic life support (BLS) and advanced life support (ALS) measures have already
been attempted without restoration of circulation and breathing.
2. No physiologic benefit from BLS and ALS measures can be expected because a patient's vital
functions are deteriorating despite maximum therapy.
3. No survivors after CPR have been reported under the given circumstances in well-designed
studies.
Although terms such as "maximum therapy" are poorly defined, these "strict" criteria appear to be
relatively uncontroversial; however, they are not likely to apply to many decisions about initiating
resuscitation efforts in the ED. Rarely will emergency physicians be aware that a patient has had an
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arrest despite maximum therapy or that CPR has never been successful in a given circumstance.
AMA Council on Ethical and Judicial Affairs
In a 1999 report, the AMA Council on Ethical and Judicial Affairs recommends a "process-based"
approach to futility determinations in end-of-life care. [46] Drawing on an earlier policy proposal by
Halevy and Brody, [47] this AMA report outlines 7 procedural steps for resolving disagreements
between physicians and patients or proxies regarding futile treatment. Some of the proposed steps
include:
1. Deliberation and resolution. Attempts should be made between patient, proxy, and physician
to determine prior understandings regarding appropriate care and futile care.
2. Joint decisionmaking should be made between physician and patient or proxy.
3. Assistance of a consultant or patient representative may be useful in the resolution of defining
appropriate limits of care.
4. An institutional committee (ie, ethics committee) may be involved to aid in the resolution of
defining appropriate limits of care, to the satisfaction of all parties involved.
This procedural approach may hold great promise in nonemergency treatment choices, but it has
little to offer in emergency resuscitation decisions, for obvious reasons. Each of the above steps
requires considerable time, but there is little or no time available for deliberation, consultation, or
transfer when an emergency patient has a cardiopulmonary arrest.
ACEP Policy Statement on Nonbeneficial ("Futile") Emergency Medical Interventions
Acting on a recommendation from its Ethics Committee, the Board of Directors of ACEP approved a
policy statement on futile treatment in 1998. [48] This policy statement asserts ACEP's belief that
"physicians are under no ethical obligation to render treatments that they judge have no realistic
likelihood of medical benefit to the patient." The policy statement goes on to state that emergency
physicians' judgments should be unbiased, based on available scientific evidence and societal and
professional standards, and sensitive to differences of opinion regarding the value of medical
intervention in various situations.
This ACEP policy statement provides support for emergency physicians confronting resuscitation
decisions in one important way, namely, it throws the weight of emergency medicine's most
important professional association behind the claim that there is no moral obligation to provide futile
care. Official endorsement of this position may calm some physicians' fears of liability for
withholding futile resuscitation efforts. The policy statement's support for physicians' futility
judgments is not unconditional, however. Rather, it asserts that these judgments should be based on
available scientific evidence and societal and professional standards. Thus, it raises questions about
what evidence and standards exist regarding the use of resuscitation. This policy statement may be
used by emergency physicians to aid in decisionmaking, and supports the position that the
withholding or termination of nonbeneficial interventions (in appropriate circumstances) may be
justified.
Although the establishment of national guidelines and policies may be helpful in providing general
guidance, and in alleviating certain medicolegal concerns, such general guidelines and policies have
important limitations. General guidelines cannot anticipate and address all of the relevant features of
a particular case, with its unique aspects of history, prognosis, premorbid considerations, quality-oflife issues, advance directives, family concerns, and so on. The individual physician should take each
of these features into account in deciding how to proceed.
Legal issues
Refusing to provide treatment that is considered by physicians to be futile has been a vexing problem
not only for clinicians and ethicists, but also for the courts. Courts have stated that physicians do not
have an obligation to provide care that is futile. However, these statements have been made in cases
where patients or family agreed with the physicians' decision to withdraw a treatment that had been
determined to be futile. [49] In these cases, the courts' support of the patient's right to refuse treatment
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was further buttressed by arguments that physicians also did not have an obligation to continue futile
treatment. Additionally, no precedent law supports a patient's right to demand treatment that
physicians determine is ineffective.
However, no clear legal consensus has emerged, in the few publicized cases where physicians and
the patient or family members have disagreed regarding the medical effectiveness of an intervention
and whether to withhold or withdraw it. These cases have been, for the most part, trial court
judgments, which do not set precedents for other courts. Nonetheless, 3 cases have provided
benchmarks for discussion.
The first case centers on Helga Wanglie, an 87-year-old woman who, after having a respiratory arrest
secondary to emphysema, had respirations assisted by a ventilator and then was in a persistent
vegetative state. After months of ventilator treatment without recovery, her attending physician
believed that further ventilation offered no benefit and recommended withdrawing ventilator support.
Her husband, who was her guardian, wished to continue ventilation. Mrs. Wanglie's physician then
petitioned the trial court to replace the husband as his wife's guardian. The court did not find that the
husband had violated his duty to act in his wife's best interest by insisting on continued treatment. [50]
Although this case has been often discussed in the context of medical futility, in fact, the case merely
demonstrated the reluctance of the courts to replace a spouse who is acting as guardian, without
showing that the spouse/guardian is acting in bad faith or against the best interests of the patient.
In a second case, the patient, Mrs. Gilgunn, was coma-tose after a hip fracture and seizures, and her
physicians determined that she was dying from end-stage chronic obstructive pulmonary disease. Her
daughter insisted on continued ventilation and CPR. However, after an ethics committee
consultation, a DNR order was written, ventilator support was withdrawn, and Mrs. Gilgunn died. A
trial court jury determined that the physicians had not committed malpractice by failing to heed Mrs.
Gilgunn's daughter's wishes. [51] Although this trial court case has been taken by proponents of futility
to indicate that courts and juries are reluctant to second-guess a physician's determination of futility,
physicians should be cautious in using any trial court decision as an indication of what other trial
courts are likely to determine.
In the third case, "Baby K" was an anencephalic infant who had been discharged from the hospital.
Attending physicians did not believe that further treatment, including resuscitation and intubation,
was warranted. However, Baby K's mother wanted maximal treatment for her child. The hospital
sought a declaratory judgment to withhold ventilation despite the mother's objection. A federal
appeals court interpreted the Emergency Medical Treatment and Active Labor Act (EMTALA) to
apply, determining that the plain language of the statute required that a child--even an anencephalic
child--in respiratory arrest presenting to the ED must be treated or stabilized and transferred. [52] [53]
This case, which sets a precedent for those states in the 4th Federal Circuit Court of Appeals
(Virginia, West Virginia, Maryland, North Carolina, and South Carolina) suggests that EMTALA
may have important ramifications for considerations of futility. However, the attending physicians in
this case did not claim that intubation would be ineffective. Instead they claimed that because of the
untreatable nature of the underlying condition, intubation would serve no long-term, worthwhile
purpose. Thus, a more conservative reading of the case suggests that even in the ED, ineffective
treatments need not be offered. It should be noted that this case applies only to the jurisdiction of the
4th Federal Circuit Court of Appeals, and that EMTALA does not necessarily dictate which
interventions and procedures must be performed. The individual physician must make the
determination of which interventions are appropriate in each particular case.
Several conclusions can be drawn from the initial judicial analysis of cases related to the
determination of futility. First, for emergency physicians in most of the country (ie, outside the 4th
Circuit), there is no controlling federal or state law. Second, the plain language of EMTALA requires
treatment or stabilization and transfer of patients who present to the ED for treatment. Third, courts
and juries seem to be reluctant to authorize treatment withdrawal over the objections of family
members, but also seem to be reluctant to hold physicians liable for exercising medical judgment of a
treatment's ineffectiveness. Fourth, physicians should be extremely careful in determining medical
ineffectiveness, since such decisions may be subject to legal scrutiny.
Although medicolegal concerns should be carefully considered, there are significant limitations of
the law in the resolution of ethical issues. Laws and rulings may differ significantly across regions.
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Numerous clinical situations involve unprecedented legal controversy. The law is limited
procedurally as a means of dispute resolution, and often does not address general principles. Thus,
physicians should use a strong ethical framework when making decisions. In addition, acting in the
best interest of patients and society may serve as a reasonable medicolegal argument. Emergency
physicians should have an understanding of both ethical principles and the law, and should carefully
consider both when making ethical judgments.
Resuscitation: Evidence and standards
If judgments about when resuscitation is futile are to be guided by evidence and standards, accurate
knowledge regarding scientific evidence and professional standards is a prerequisite. A large amount
of data regarding the outcomes of resuscitation has been accumulated over the past 30 years. Recent
reviews report widely variable survival rates for victims of cardiac arrest, dependent on a number of
factors, including time elapsed since arrest (down time), [54] [55] presenting rhythm, [56] [57] underlying
medical condition, [58] response to out-of-hospital ALS protocols, [59] [60] age, [61] and long-term care.
[62] Overall, survival for victims of cardiac arrest to hospital discharge has been estimated between
0% and 16%. [63] [68] Certain identifiable groups of patients have survival rates approaching 0%, for
example, residents of long-term care facilities with unwitnessed arrests. [62] Despite this relatively low
success rate, hospital policies (and out-of-hospital policies for emergency medical services
providers) typically suggest or mandate resuscitation for all patients except those with prior do-notattempt-resuscitation orders or clear signs of death, such as rigor mortis or dependent lividity.
Although several commentators recommend a change in policy away from standing orders for
resuscitation, social and institutional policies still suggest resuscitation attempts for most patients. [69]
[70] Current standards thus appear to constrain emergency physicians' ability to forgo resuscitation
attempts they judge to be futile. How should physicians respond to this situation?
Two courses of action suggest themselves. First, unnecessary and unwanted resuscitation attempts
might be prevented by the wider dissemination and use of advance directives, especially living wills
and out-of-hospital or "universal" do-not-attempt-resuscitation orders. In the above-cited study of
resuscitation practice by emergency physicians, more than 95% of respondents cited the presence of
advance directives as having an "important" or "very important" effect on resuscitation decisions,
and 78% of respondents reported that they always honor legal advance directives. [44] It is unclear
why as many as 22% do not honor legal advance directives, although other data suggest this may be
secondary to medicolegal concerns. It may appear that some physicians are willing to commit assault
and battery by attempting resuscitation for a patient with an advance directive, rather than face
potential litigation for withholding resuscitative efforts. Advance directives thus appear to provide
emergency physicians with the knowledge of patient wishes and the legal authorization they require
to withhold unwanted, hence inappropriate, resuscitation attempts. Because only an estimated 15%
to 20% of Americans have completed advance directives, [71] [72] improved compliance with
documentation of patient wishes would have great impact on the actions of health care providers.
However, that reliance on advance directives in forgoing resuscitation does depend on the patient's
prior decision to limit treatment as recorded in the directive. Patients who desire all life-prolonging
treatment presumably will not complete advance directives, and thus physicians caring for these
patients will not be able to rely on advance directives to withhold resuscitation. Additional efforts
toward communication with patients and families before, and during, resuscitation attempts,
regarding advance directives is of paramount importance.
Second, emergency physicians may seek to change existing social and institutional policies
mandating resuscitation efforts. In place of standing orders for resuscitation, policies might be
adopted to give providers more discretion to determine whether resuscitation efforts are futile given
the patient's specific condition. Implementing such a change may be an uphill battle, because it goes
against the grain of decades of public and professional education stressing the value of CPR as a lifesustaining intervention. Additional support for policies limiting use of resuscitation may come from
recognition of its high cost together with increased pressure for cost-containment. [73]
In summary, after more than a decade of intense debate, futility remains a controversial topic in US
medicine and bioethics. Scholars have proposed a variety of definitions of futility and marshaled a
variety of arguments for and against its use in medical decisionmaking. Emergency physicians
frequently encounter decisions regarding the provision of care they believe to be clinically
nonbeneficial. Because of constraints of time, information, and other limitations, judgments in
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emergency medicine are particularly challenging. Procedural approaches common in other medical
contexts, such as family conferences and ethics committee consultations, are impractical in
emergency situations. In all aspects of emergency medicine, decisions should be made regarding
various interventions and therapies, based on the expected risks and benefits to the patient, family,
and society. Determinations of the expected benefit should be based on scientific evidence regarding
the likelihood of benefit, and not on individual bias regarding quality of life, magnitude of benefit, or
other subjective matters.
Emergency physicians are under no ethical obligation to provide treatments they judge to have no
realistic likelihood of benefit to the patient. In fact, there may be an ethical obligation to withhold
such treatment, particularly if it entails significant risk or cost. Evidence suggests, however, that
emergency physicians may be reluctant to forgo treatment efforts without clear support for this
decision in policy, practice standards, or the law. In making decisions regarding withholding or
terminating clinically nonbeneficial treatments, emergency physicians should take into account the
following considerations:
1. Scientific evidence of likelihood of medical benefit (based on similar cases)
2. Likelihood of other benefits (including potential intangible benefits, such as family needs,
communication, and so on)
3. Patient preferences (if available)
4. Family wishes (if available)
5. Potential risks of the intervention (including adverse or suboptimal outcomes)
When an intervention is withheld, special efforts should be made to maintain effective
communication, comfort, support, and counseling for the patient, family, and friends. These
nontechnical, humanistic efforts cost little, and yet retain the promise of a treasured benefit for all
concerned. Caring is one intervention that is never futile.
References
1. Blackhall
LJ. Must we always use CPR? N Engl J Med. 1987;317:1281-1284. Citation
2. Tomlinson
T, Brody H. Ethics and communication in do-not-resuscitate orders. N Engl J Med. 1988;318:43-46.
Citation
3. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med.
1990;112:949-954. Abstract
JJ, Reardon FE. Physician refusal of requests for futile or ineffective interventions. Cambridge Q Healthcare
Ethics. 1992;2:127-134.
4. Paris
JC, Hiller FC. Family consent to orders not to resuscitate: reconsidering hospital policy. JAMA.
1990;264:1281-1283. Abstract
5. Hackler
RD, Brett AS, Frader J. The problem with futility. N Engl J Med. 1992;326:1560-1564. Citation
6. Tmog
7. Lantos
JD, Singer PA, Walker RM, et al. The illusion of futility in clinical practice. Am J Med. 1989;87:81-84.
Abstract
8. Gatter
RA Jr, Moskop JC. From futility to triage. J Med Philos. 1995;20:191-205. Abstract
9. Morreim
EH. Profoundly diminished life: the casualties of coercion. Hastings Cent Rep. 1994;24:33-42. Citation
10. Veatch RM, Spicer CM. Medically futile care: the role of the physician in setting limits. Am J Law Med. 1992;18:1536. Abstract
11. Weijer
12. Stell
C, Elliott C. Pulling the plug on futility. BMJ. 1995;310:683-684. Citation
LK. Real futility: historical beginnings and continuing debate about futile treatment.N C Med J. 1995;56:432-
http://www.mdconsult.com/das/article/body/271083393-3/jorg=journal&source=&sp=1...
8/5/2011
MD Consult - Determination of "futility" in emergency medicine - Annals of Emer...
Page 10 of 12
438.
13. Caplan
AL. Odds and ends: trust and the debate over medical futility. Ann Intern Med. 1996;125:688-689. Citation
BA, Halevy A. Is futility a futile concept? J Med Philos. 1995;20:123-144. Abstract
14. Brody
15. McCrary SV, Swanson JW, Youngner SJ, et al. Physicians' quantitative assessments of medical futility. J Clin Ethics.
1994;5:100-105. Citation
NS. Medical futility and care of dying patients. West J Med. 1995;163:287-291. Abstract
16. Jecker
17. Jecker NS, Schneiderman LJ. An ethical analysis of the use of 'futility' in the 1992 American Heart Association
guidelines for cardiopulmonary resuscitation and emergency cardiac care. Arch Intern Med. 1993;153:2195-2198.
Citation
SM, Graves JR, Larsen MP, et al. Expected death and unwanted resuscitation in the prehospital setting. Ann
Emerg Med. 1994;23:997-1002. Abstract
18. Dull
MZ. How physicians talk about futility: making words mean too many things. J Law Med Ethics.
1993;21:231-237. Citation
19. Solomon
20. Iserson KV. Withholding and withdrawing medical treatment: an emergency medicine perspective. Ann Emerg Med.
1996;28:51-54. Full Text
21. Hastings Center. Guidelines on the Termination of Life-Sustaining Treatment and the Care of the Dying.
Bloomington, IN: Indiana University Press; 1997:1-159.
Council on Ethical and Judicial Affairs. Guidelines for the appropriate use of do-not-resuscitate orders. JAMA.
1991;265:1868-1871. Abstract
22. AMA
AL. Criteria for dead-on-arrivals, prehospital termination of CPR, and do-not-resuscitate orders. Ann
Emerg Med. 1993;22:47-51. Abstract
23. Kellermann
JP, Bodai BI. Guidelines for discontinuing prehospital CPR in the emergency department--a review. Ann Emerg
Med. 1985;14:1093-1098. Abstract
24. Smith
GL, Weber JE, Moskop JC. Resource utilization in the emergency department: the duty of stewardship. J
Emerg Med. 1998;16:499-503. Abstract
25. Larkin
NS, Pearlman RA. Medical futility: who decides? Arch Intern Med. 1992;152:1140-1144. Citation
26. Jecker
27. Murphy
DJ, Matchar DB. Life-sustaining therapy: a model for appropriate use. JAMA. 1990;264:2103-2108.
Abstract
28. Lantos
JD. Futility assessments and the doctor-patient relationship. J Am Geriatr Soc. 1994;42:868-870. Citation
29. Murphy
30. Jecker
DJ. Do-not-resuscitate orders. JAMA. 1988;260:2098-2101. Citation
NS, Schneiderman LJ. Futility and rationing. Am J Med. 1992;92:189-196. Abstract
31. Murphy DJ, Finucane TE. New do-not-resuscitate policies: a first step in cost control. Arch Intern Med.
1993;153:1641-1648. Citation
32. Duthie T, Trueman P, Chancellor J, et al. Research into the use of health economics in decision making in the United
Kingdom--page II. Is health economics 'for good or evil'? Health Policy. 1999;46:143-157. Abstract
33. Rogers IR, Evans L, Jelinek GA, et al. Using clinical indicators in emergency medicine: documenting performance
improvements to justify increased resource allocation. J Accid Emerg Med. 1999;16:319-321. Abstract
34. Rubin
S. When Doctors Say No: The Battleground of Medical Futility. Bloomington, IN: Indiana University Press;
1998.
http://www.mdconsult.com/das/article/body/271083393-3/jorg=journal&source=&sp=1...
8/5/2011
MD Consult - Determination of "futility" in emergency medicine - Annals of Emer...
Page 11 of 12
35. AMA
Council on Ethical and Judicial Affairs. Current Opinions of the CEJA-AMA. Chicago, IL: AMA; 1986:12-13.
36. Brock
DW, Wartman SA. When competent patients make irrational choices. N Engl J Med. 1990;322:1595-1599.
Citation
37. Lynn S, Harrell F, Cohn F, et al. Prognosis of seriously ill hospitalized patients on the days before death: implications
for patient care and public policy. New Horiz. 1997;5:56-61. Abstract
A, Brody BA. The low frequency of futility in an adult intensive care unit. Arch Intern Med. 1996;156:100104. Abstract
38. Halevy
MB, Moskop JC, Kahn CE. Knowing the score: using predictive scoring systems in clinical practice. Am J Crit
Care. 1996;5:147-151. Abstract
39. Zollo
40. Iserson KV. Law versus life: the ethical imperative to practice and teach using the newly dead emergency department
pateints. Ann Emerg Med. 1995;25:91-94. Full Text
41. McCue
SD. The naturalness of dying. JAMA. 1995;273:1039-1043. Abstract
42. Schneiderman
LJ, Faber-Langendoen K, Jecker NS. Beyond futility to an ethic of care. Am J Med. 1994;96:110-114.
Abstract
43. Marco
CA. Coping with unexpected death. Journal of Collegium Aesculapium. 1993;Spring:29-33.
44. Marco CA, Bessman ES, Schoenfeld CN, et al. Ethical issues of cardiopulmonary resuscitation: current practice
among emergency physicians. Acad Emerg Med. 1997;4:898-904. Abstract
45. Emergency Cardiac Committee and Subcommittees, American Heart Association. Guidelines for cardiopulmonary
resuscitation and emergency cardiac care, VIII: ethical considerations in resuscitation. JAMA. 1992;268:2282-2288.
Citation
46. AMA
Council on Ethical and Judicial Affairs. Medical futility in end-of-life care. JAMA. 1999;281:937-941.
Abstract
47. Halevy
A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA. 1996;267:571-574. Citation
48. American College of Emergency Physicians. Nonbeneficial ("futile") emergency medical interventions [policy
statement]. Approved March 1998. Dallas, TX: American College of Emergency Physicians; 1998. Access at
http://www.acep.org/policy/PO400198.HTM
. ACEP on Fax document no. 4198 (dial 800-406-2237; international callers dial 972-550-0911, ext. 3125).
49. Barber
50. In
v Superior Court, 195 Cal Rptr 484 (Ct App 1983).
re Wanglie, No. PX-91-283 (Minn 4th Dist Ct Hennepin County, July 1, 1991).
51. Gilgunn
v Massachussetts General Hospital. No. SUCV92-4820 (Super Ct, Suffolk County, Mass, Apr 21, 1995).
52. Emergency
53. In
Medical Treatment and Active Labor Act (EMTALA). 42 USC 1395 dd. (1986). Publication 99-272.
re Baby "K," 832 F Supp 1022 (ED Va 1993), aff'd, 16 F3d 590 (4th Cir), cert denied, 115 S Ct 91 (1994).
54. Weaver WD, Cobb LA, Hallstrom AP, et al. Considerations for improving survival from out-of-hospital cardiac
arrest. Ann Emerg Med. 1986;15:1181-1186. Abstract
55. Eisenberg MS, Bergner L, Hallstrom A. Cardiac resuscitation in the community: importance of rapid provision and
implications for program planning. JAMA. 1979;241:1905-1907. Abstract
http://www.mdconsult.com/das/article/body/271083393-3/jorg=journal&source=&sp=1...
8/5/2011
MD Consult - Determination of "futility" in emergency medicine - Annals of Emer...
Page 12 of 12
56. Bonnin MJ, Pepe PE, Clark PS. Survival in the elderly after out-ofhospital cardiac arrest. Crit Care Med.
1993;21:1645-1651. Abstract
C, Thompson CM, Gruchow HW, et al. Decision making in prehospital sudden cardiac arrest. Ann Emerg
Med. 1986;15:445-449. Abstract
57. Aprahamian
58. Bedell SE, Delbanco TL, Cook EF, et al. Survival after cardiopulmonary resuscitation in the hospital. N Engl J Med.
1983;309:569-576. Abstract
59. Schoenenberger RA, von Planta M, von Planta I. Survival after failed out-of-hospital resuscitation: are further
therapeutic efforts in the emergency department futile? Arch Intern Med. 1994;154:2433-2438. Abstract
60. Bonnin
MJ, Pepe PE, Kimball KT, et al. Distinct criteria for termination of resuscitation in the out-of-hospital setting.
JAMA. 1993;270:1457-1462. Abstract
DJ, Murray AM, Robinson BE, et al. Outcomes of cardiopulmonary resuscitation in the elderly. Ann Intern
Med. 1989;111:199-205. Abstract
61. Murphy
62. Awoke S, Mouton CP, Parrott M. Outcomes of skilled cardiopulmonary resuscitation in a long-term facility: futile
therapy? J Am Geriatr Soc. 1992;40:593-595. Abstract
63. Becker
LB, Ostrander MP, Barrett J, et al. Outcome of CPR in a large metropolitan area--where are the survivors?
Ann Emerg Med. 1991;20:355-361. Abstract
64. Callaham M, Madsen CD. Relationship of timeliness of paramedic advanced life support interventions to outcome in
out-of-hospital cardiac arrest treated by first responders with defi-brillator. Ann Emerg Med. 1995;27:638-648.
MS, Horwood BT, Cummins RO, et al. Cardiac arrest and resuscitation: a tale of 29 cities. Ann Emerg Med.
1990;19:179-186. Abstract
65. Eisenberg
66. Kellermann
AL, Hackman BB, Somes G. Predicting the outcome of unsuccessful prehospital advanced cardiac life
support. JAMA. 1993;270:1433-1436. Abstract
67. Stratton SJ, Niemann JT. Outcome from out-of-hospital cardiac arrest caused by nonventricular arrhythmias:
contribution of successful resuscitation to overall survivorship supports the current practice of initiating out-of-hospital
ACLS. Ann Emerg Med. 1998;32:448-453. Full Text
J, Fromm RE. In-hospital resuscitation among the elderly: substantial survival to hospital discharge. Am J
Emerg Med. 1996;14:130-132. Full Text
68. Varon
69. Johnson
AL. Towards a modified cardiopulmonary resuscitation policy. Can J Cardiol. 1998;14:203-208. Abstract
70. Bruce-Jones
PN. Resuscitation decisions in the elderly: a discussion of current thinking. J Med Ethics. 1996;22:286-
291. Abstract
71. Broadwell AW, Boisaudin EV, Dunn JK, et al. Advance directives in hospital admissions: a survey of patient
attitudes. South Med J. 1993;86:165-168. Abstract
J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients. J Am Geriatr Soc.
199745:508-512.
72. Teno
KH, Angus DC, Abramson NS. Cardiopulmonary resuscitation: what cost to cheat death? Crit Care Med.
1996;24:2046-2052. Full Text
73. Lee
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