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Futility and the Care of the Perioperative Patient

Abstract

Futility in healthcare is an area of significant debate. Generally, a futile treatment is one that is incapable of producing a beneficial result. The degree of benefit required has been contentious in the ethics literature. Different definitions of futility have been proposed to arrive at a consensus regarding which treatments would be provided and to agree on futile interventions that could be withheld. However, each of these definitions has flaws. Some hospitals, healthcare organizations, and states have implemented policies to create a procedural approach to futility disputes. Several authors have advocated discarding the language of futility as it often is an expression of physician frustration and impedes communication between care providers, patients and their surrogates. Many resources are available to assist in difficult cases involving futility including preoperative risk calculators and institutional ethics committees, but, ultimately, the best tool in approaching these challenging situations is open and honest communication between the patient, or surrogate, and the physician.

Keywords

  • Futility
  • End-of-Life Care
  • Inappropriate Treatment
  • Surgery
  • Anesthesiology
  • Perioperative

Scott B. Grant and Parth K. Modi have contributed equally to this chapter.

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References

  1. Powledge TM, Steinfels P. Following the news on Karen Quinlan. Hastings Cent Rep. 1975;5(6):5–6. 28.

    CrossRef  Google Scholar 

  2. Branson R, Casebeer K. Obscuring the role of the physician. Hastings Cent Rep. 1976;6(1):8–11.

    CAS  CrossRef  PubMed  Google Scholar 

  3. Annas GJ. In re Quinlan: legal comfort for doctors. Hastings Cent Rep. 1976;6(3):29–31.

    CAS  CrossRef  PubMed  Google Scholar 

  4. Annas GJ. When procedures limit rights: from Quinlan to Conroy. Hastings Cent Rep. 1985;15(2):24–6.

    CAS  CrossRef  PubMed  Google Scholar 

  5. Annas GJ. Nonfeeding: lawful killing in CA, homicide in NJ. Hastings Cent Rep. 1983;13(6):19–20.

    CrossRef  PubMed  Google Scholar 

  6. Capron AM. Ironies and tensions in feeding the dying. Hastings Cent Rep. 1984;14(5):32–5.

    CAS  CrossRef  PubMed  Google Scholar 

  7. Wolf SM. Nancy Beth Cruzan: in no voice at all. Hastings Cent Rep. 1990;20(1):38–41.

    CAS  CrossRef  PubMed  Google Scholar 

  8. Orentlicher D. From the office of the general counsel. The right to die after Cruzan. JAMA. 1990;264(18):2444–6.

    CAS  CrossRef  PubMed  Google Scholar 

  9. Gostin LO. From Quinlan to Cruzan, Glucksberg, and Vacco- a brief history and analysis of constitutional protection of the ‘right to die’. JAMA. 1997;278(18):1523–8.

    CAS  CrossRef  PubMed  Google Scholar 

  10. Angell M. The case of Helga Wanglie. A new kind of “right to die” case. N Engl J Med. 1991;325(7):511–2.

    CAS  CrossRef  PubMed  Google Scholar 

  11. Miles SH. Informed demand for “non-beneficial” medical treatment. N Engl J Med. 1991;325(7):512–5.

    CAS  CrossRef  PubMed  Google Scholar 

  12. Annas GJ. Asking the courts to set the standard of emergency care – the case of Baby K. N Engl J Med. 1994;330(21):1542–5.

    CAS  CrossRef  PubMed  Google Scholar 

  13. Rutter TL. US doctors win life support lawsuit. BMJ. 1995;310(6989):1223–4.

    CAS  CrossRef  PubMed  Google Scholar 

  14. Capron AM. Abandoning a waning life. Hastings Cent Rep. 1995;25(4):24–6.

    CAS  CrossRef  PubMed  Google Scholar 

  15. Paris JJ, Cassem EH, Dec GW, Reardon FE. Use of a DNR order over family objections: the case of Gilgunn v. MGH. J Intensive Care Med. 1999;14(1):41–5.

    CrossRef  PubMed  Google Scholar 

  16. Orr RD. The Gilgunn case: courage and questions. J Intensive Care Med. 1999;14(1):54–6.

    CrossRef  PubMed  Google Scholar 

  17. Paris JJ. What standards apply to resuscitation at the borderline of gestational age? J Perinatol. 2005;25:683–4.

    CrossRef  PubMed  Google Scholar 

  18. Hippocratic corpus. The art. In: Reiser S, Dyck A, Curran W, editors. Ethics in medicine: historical perspectives and contemporary concerns. Cambridge, MA: MIT Press; 1977.

    Google Scholar 

  19. Dictionary OE. “futile, adj.”: Oxford University Press.

    Google Scholar 

  20. Clark PA, Mikus CM. Time for a formalized medical futility policy. Mercy Health System’s procedures will help free its physicians from legal concerns. Health Prog. 2000;81(4):24–32.

    CAS  PubMed  Google Scholar 

  21. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112(12):949–54.

    CAS  CrossRef  PubMed  Google Scholar 

  22. Veatch RM, Spicer CM. Medically futile care: the role of the physician in setting limits. Am J Law Med. 1992;18(1–2):15–36.

    CAS  PubMed  Google Scholar 

  23. Grant SB, Modi PK, Singer EA. Futility and the care of surgical patients: ethical dilemmas. World J Surg. 2014;38(7):1631–7.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  24. Singer E. Medical futility: hippocratic fact or contemporary fiction? Washington, DC: Georgetown University; 2001.

    Google Scholar 

  25. Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA. 1996;276(7):571–4.

    CAS  CrossRef  PubMed  Google Scholar 

  26. Clarke MG, Ewings P, Hanna T, Dunn L, Girling T, Widdison AL. How accurate are doctors, nurses and medical students at predicting life expectancy? Eur J Intern Med. 2009;20(6):640–4.

    CrossRef  PubMed  Google Scholar 

  27. Yourman LC, Lee SJ, Schonberg MA, Widera EW, Smith AK. Prognostic indices for older adults: a systematic review. JAMA. 2012;307(2):182–92.

    CAS  CrossRef  PubMed  PubMed Central  Google Scholar 

  28. Pellegrino E. Decision at the end of life: use and abuse of the concept of futility. Sgreccia JDDVCaE, editor. Citta del Vatticano: Libreria Editrice Vaticano; 2000.

    Google Scholar 

  29. Rowe CJ, Broadie S, editors. Nicomachean ethics. New York: Oxford University Press; 2002.

    Google Scholar 

  30. Svenaeus F. Empathy as a necessary condition of phronesis: a line of thought for medical ethics. Med Health Care Philos. 2014;17(2):293–9.

    CrossRef  PubMed  Google Scholar 

  31. Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med. 1997;25(5):887–91.

    Google Scholar 

  32. Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Engl J Med. 2000;343(4):293–6.

    CAS  CrossRef  PubMed  Google Scholar 

  33. Brett AS, McCullough LB. When patients request specific interventions: defining the limits of the physician’s obligation. N Engl J Med. 1986;315(21):1347–51.

    CAS  CrossRef  PubMed  Google Scholar 

  34. Veatch RM. Why physicians cannot determine if care is futile. J Am Geriatr Soc. 1994;42(8):871–4.

    CAS  CrossRef  PubMed  Google Scholar 

  35. Youngner SJ. Who defines futility? JAMA. 1988;260(14):2094–5.

    CAS  CrossRef  PubMed  Google Scholar 

  36. Paris JJ, Reardon FE. Physician refusal of requests for futile or ineffective interventions. Camb Q Healthc Ethics. 1992;1(2):127–34.

    CAS  CrossRef  PubMed  Google Scholar 

  37. Fine RL. Medical futility and the Texas Advance Directives Act of 1999. Proc (Bayl Univ Med Cent). 2000;13(2):144–7.

    CAS  Google Scholar 

  38. Smith ML, Gremillion G, Slomka J, Warneke CL. Texas hospitals’ experience with the Texas advance directives Act. Crit Care Med. 2007;35(5):1271–6.

    CrossRef  PubMed  Google Scholar 

  39. California Health Care Decisions Law. 2005.

    Google Scholar 

  40. Maine Uniform Health-Care Decisions Act. 2005.

    Google Scholar 

  41. Maryland Health Care Decisions Act. 2006.

    Google Scholar 

  42. Massachusetts Health Care Proxies – Physicians; refusal to honor proxy. 2006.

    Google Scholar 

  43. New York Health Care Agents and Proxies. 2006.

    Google Scholar 

  44. Tennessee Health Care Decisions Act, Determination of capacity – Compliance by health care provider or institution. 2006.

    Google Scholar 

  45. Virginia Health Care Decisions Act. 2006.

    Google Scholar 

  46. Washington Natural Death Act. 2006.

    Google Scholar 

  47. American Medical Association Council on Ethical and Judicial Affairs. Medical futility in end-of-life care. JAMA. 1999;281(10):937–41.

    CrossRef  Google Scholar 

  48. Bosslet GT, Pope TM, Rubenfeld GD, Lo B, Truog RD, Rushton CH, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):1318–30.

    CrossRef  PubMed  Google Scholar 

  49. Rowland KJ, Kodner IJ, Cashen M, Schwarze ML. Surgical futility: “Aggressive” surgery on the severely demented. Surgery. 2009;145(4):351–4.

    CrossRef  PubMed  Google Scholar 

  50. Jones JW, McCullough LB. I know about Jack and you’re no Jack Kevorkian. J Vasc Surg. 2010;52(2):489–90.

    CrossRef  PubMed  Google Scholar 

  51. Zier LS, Burack JH, Micco G, Chipman AK, Frank JA, Luce JM, et al. Doubt and belief in physicians’ ability to prognosticate during critical illness: the perspective of surrogate decision makers. Crit Care Med. 2008;36(8):2341–7.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  52. Grossman E, Angelos P. Futility: what Cool Hand Luke can teach the surgical community. World J Surg. 2009;33(7):1338–40.

    CrossRef  PubMed  Google Scholar 

  53. Nurok M, Sadovnikoff N. Why are we doing this case? can perioperative futile care be defined? Curr Opin Anaesthesiol. 2013;26(2):176–81.

    CrossRef  PubMed  Google Scholar 

  54. Barnato AE, McClellan MB, Kagay CR, Garber AM. Trends in inpatient treatment intensity among Medicare beneficiaries at the end of life. Health Serv Res. 2004;39(2):363–75.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  55. Emanuel EJ, Ash A, Yu W, Gazelle G, Levinsky NG, Saynina O, et al. Managed care, hospice use, site of death, and medical expenditures in the last year of life. Arch Intern Med. 2002;162(15):1722–8.

    CrossRef  PubMed  Google Scholar 

  56. Zhang B, Wright AA, Huskamp HA, Nilsson ME, Maciejewski ML, Earle CC, et al. Health care costs in the last week of life: associations with end-of-life conversations. Arch Intern Med. 2009;169(5):480–8.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  57. Schwarze ML, Barnato AE, Rathouz PJ, Zhao Q, Neuman HB, Winslow ER, et al. Development of a list of high-risk operations for patients 65 years and older. JAMA Surg. 2015;150(4):325–31.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  58. Lee TH, Marcantonio ER, Mangione CM, Thomas EJ, Polanczyk CA, Cook EF, et al. Derivation and prospective validation of a simple index for prediction of cardiac risk of major noncardiac surgery. Circulation. 1999;100(10):1043–9.

    CAS  CrossRef  PubMed  Google Scholar 

  59. Goldman L, Caldera DL, Nussbaum SR, Southwick FS, Krogstad D, Murray B, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med. 1977;297(16):845–50.

    CAS  CrossRef  PubMed  Google Scholar 

  60. L’Italien GJ, Paul SD, Hendel RC, Leppo JA, Cohen MC, Fleisher LA, et al. Development and validation of a Bayesian model for perioperative cardiac risk assessment in a cohort of 1,081 vascular surgical candidates. J Am Coll Cardiol. 1996;27(4):779–86.

    CrossRef  PubMed  Google Scholar 

  61. Menke H, Klein A, John KD, Junginger T. Predictive value of ASA classification for the assessment of the perioperative risk. Int Surg. 1993;78(3):266–70.

    CAS  PubMed  Google Scholar 

  62. Wolters U, Wolf T, Stützer H, Schröder T. ASA classification and perioperative variables as predictors of postoperative outcome. Br J Anaesth. 1996;77(2):217–22.

    CAS  CrossRef  PubMed  Google Scholar 

  63. Robinson TN, Wu DS, Sauaia A, Dunn CL, Stevens-Lapsley JE, Moss M, et al. Slower walking speed forecasts increased postoperative morbidity and 1-year mortality across surgical specialties. Ann Surg. 2013;258(4):582–8; discussion 8–90.

    PubMed  PubMed Central  Google Scholar 

  64. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, et al. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010;210(6):901–8.

    CrossRef  PubMed  Google Scholar 

  65. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23(10):1638–52.

    CAS  CrossRef  PubMed  Google Scholar 

  66. American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) surgical risk calculator. Available from: http://riskcalculator.facs.org/.

  67. Bilimoria KY, Liu Y, Paruch JL, Zhou L, Kmiecik TE, Ko CY, et al. Development and evaluation of the universal ACS NSQIP surgical risk calculator: a decision aid and informed consent tool for patients and surgeons. J Am Coll Surg. 2013;217(5):833–42.e1–3.

    CrossRef  PubMed  PubMed Central  Google Scholar 

  68. Schuster DP. Everything that should be done – not everything that can be done. Am Rev Respir Dis. 1992;145:508–9.

    CAS  CrossRef  PubMed  Google Scholar 

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Correspondence to Eric A. Singer MD, MA, FACS .

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Grant, S.B., Modi, P.K., Singer, E.A. (2015). Futility and the Care of the Perioperative Patient. In: Jericho, B. (eds) Ethical Issues in Anesthesiology and Surgery. Springer, Cham. https://doi.org/10.1007/978-3-319-15949-2_13

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  • DOI: https://doi.org/10.1007/978-3-319-15949-2_13

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