Medical Futility

Medical Futility
A Paradigm as Old as Hippocrates
Mary Whitmer, RN, FNP, BC-PC; Susan Hurst, RN, MSN, CCRN, CNRN;
Marilynn Prins, RN, MSN, CNRN; Kelli Shepard, BSW, MDiv;
Doris McVey, RN, BSN, MBA, CPHQ, CPHRM

Medical futility is a concept commonly used to describe medical therapy

that has no known or anticipated immediate or long-term benefit for a
patient. The concept of futility has existed since the time of Hippocrates
and has become the predominant dilemma for many end-of-life
situations. Today, clinicians grapple with ethical conflicts and concepts
in their daily practice. Many healthcare providers use the concept of
medical futility when they are talking with patients and families who are
in a quandary about their loved ones care. This article provides an
overview of medical futility.
Keywords: End of life, Ethical dilemmas, Medical futility, Quality of life
[DIMENS CRIT CARE NURS. 2009;28(2):67/71]

CASE STUDY strated an awareness of his environment with voluntary

A recent case in Arizona demonstrates several ethical,
legal, and conceptual issues regarding medical futility.
The patient and his wife were involved in a car accident,
which resulted in numerous life-threatening injuries to the
male patient. His wife was hospitalized with nonYlife-
threatening injuries. The patients sister functioned as the
decision maker for her brother during the wifes hospitali-
zation. Once his wife was discharged from the hospital,
she became the statutory decision maker for her husband.
According to various physician reports, the patient
had minimal brain activity and optic nerve damage. In
addition, there was a chance that he would remain in a
persistent vegetative state, relying on a ventilator and a
feeding tube for survival. Ten days into his hospitali-
zation, his wife requested to have nutrition, hydration,
and antibiotics discontinued and to have her husband
transferred to hospice.
After the patient was transferred to hospice, his sister
and parents challenged the wifes decision to have the
nutrition, hydration, and antibiotics discontinued. His
family reported that he responded to touch and demon-
movements. The transfer to hospice was also challenged.
His sister petitioned the court to reinstitute potentially
life-saving medical care for her brother and to have a
substitute decision maker appointed. The petition was
based on the allegation that the patients wife was not
acting in good faith or seeking her husbands best in-
terests. Arizona law allows the statutory decision maker
to consent for tube feedings and all other appropriate
medical treatments, but only a guardian or designated
medical power of attorney (MPOA) may discontinue
tube feedings.1
The patients family won the appeal. The court
ordered nutrition, hydration, and antibiotics to be
resumed. A guardian ad litem was appointed, and an
independent neurologist was appointed to evaluate his
neurologic status. Subsequently, he was moved from
hospice to a rehabilitation facility.2,3
INTRODUCTION
In the past, healthcare providers knew death occurred
when heartbeat and respirations ceased. Survivors

March/April 2009 67

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 Medical Futility
understood that their loved one was dead and began the
mourning process. Physicians have been advised by
Hippocrates to refuse to treat those who are over-
mastered by their disease, realizing that in such cases
medicine is powerless.4,5 Most providers understand
medical futility to mean a treatment that will not be
beneficial to the patient and, in fact, may prolong the
dying process. Ethical conflicts often arise when health-
care providers believe that continued treatments are
futile, but the patient or family desires continued
intervention.
The term medical futility is subjective and may be
defined differently by individuals. Definitions have
remained elusive, often leaving families complaining
that futility is the physicians trump card when they do
not want to continue care. Ethical conflicts may arise
between the patient and familys view of autonomy and
the physicians belief in nonmaleficence. Nurses are
often caught in the middle of these ethical conflicts as
they attempt to support families while providing
ordered medical care for their patients. Early communi-
cation between physicians, patients, and families may
clarify healthcare goals. Ethical dilemmas may be
minimized when patient and family goals are under-
stood and communication is open.
Ethical conflicts may arise between
the patient and familys view of
autonomy and the physicians belief
in nonmaleficence.
LITERATURE REVIEW
Some might argue that medical futility as a concept does
not exist and that a different terminology should be used.
A review of the literature includes beliefs of healthcare
providers, patients, families, and religious groups, as
well as Americans with disabilities. All of these differing
opinions can be placed on a continuum where sanctity
of life anchors one end and quality of life anchors the they fearful of being abandoned?
other. Sanctity of life proponents believe that all life is
sacred and all treatments that preserve life are appro-
priate. In the case study, the patients parents and sister
might support the sanctity of life end of the spectrum
since they petitioned the courts to reinstate nutrition,
hydration, and antibiotics. Quality of life proponents
define quality and then accept or reject treatments based
on that standard. It could be argued that the patients
wife was a quality of life proponent because she believed
that his quality of life view would not be consistent with
living with disabilities.
68 Dimensions of Critical Care Nursing Vol. 28 / No. 2
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Futility has been examined both quantitatively and
qualitatively.6,7 Quantitative futility states that the
likelihood of the intervention will benefit the patient is
exceedingly poor.6(p12) Qualitative futility refers to a
condition where the quality of benefit an intervention
will produce is exceedingly poor.6(p12) One might
argue that the wifes decision was based on qualitative
futility because his physicians had assessed him as
having minimal brain activity and optic nerve damage
and there was a chance that he would remain in a
persistent vegetative state relying on a ventilator and
feeding tube for survival.
Some look at medical futility from the ethical
concept of distributive justice and state that society
cannot afford to provide treatments for which there is
no benefit to the patient except to prolong the dying
process. Others argue that physicians are not cost
containment agents.8 These proponents prefer that the
society should set guidelines or pass laws to limit
medical treatment that may be considered futile. Others
agree that the just distribution of scarce resources
belongs in a debate about rationing5(p19) and that
rationing should not factor into the judgment about
whether a treatment course is medically futile.5(p19)
Many healthcare providers ascribe to Trotters9
view that medical futility occurs when (1) a goal has
been decided upon, (2) a treatment plan is recom-
mended that may achieve the goal, and (3) there is
medical certainty that the treatment plan will never
achieve the goal. Therefore, it is critical for the health-
care team to understand the patient and familys
goals of care as compared with the goals of the medical
team. Treatment plans based only on the medical teams
goals may be widely divergent from the patient and
familys goals, which, in turn, may create ethical di-
lemmas. Early, clear, and consistent communication is
essential and may be provided in a conference that in-
cludes the healthcare team, patient, and family. When
patients or families state that they want everything
done, it is important to ascertain the basis for their
decision. Is it because they value sanctity of life, or are
Early, clear, and consistent
communication is essential and
may be provided in a conference.
A team conference including the patient and/or
family and occurring within the first 3 days of an

intensive care unit (ICU) stay may avert misunderstand-
ings and promote a respectful relationship.10 During the
team conference, the patients medical condition and
prognosis are described and the healthcare teams goals
are discussed. The patient and family are considered an
integral part of the team and are given an opportunity
to state their goals.10,11 If the patient and family desire
all life-saving measures to continue and the healthcare
providers disagree, the issue is about differing goals of
treatment rather than futility.
The disability community has spoken out against
the concept of medical futility. The Americans With
Disabilities Act protects people with disabilities who are
conscious as well as those who are unconscious, in a
coma, or in a persistent vegetative state. According to
Batavia in 2002, we must distinguish medical con-
ditions for which treatment is futile from disabilities for
which denial of treatment may constitute illegal dis-
crimination.8(p220) As the number of unconscious ICU
patients increases, societies will grapple with questions
of what defines human life. Is consciousness at the
center of a human life? If so, do unconscious persons
benefit from life-sustaining treatments? Will there be a
time limit imposed on the use of life support for
unconscious patients?
Conversations with patients and families about
residual disability after serious illness or injury help the
healthcare team understand the patients values. It is a
common misconception that patients who survive a
prolonged ICU stay will return to baseline function.
Patients with varying degrees of disability are often
transferred to long-term care facilities. It is not known if
the family in the case study discussed living with a
disability with the medical team. In this case, the
Americans With Disabilities Act might have advised
against removal of any life-sustaining treatments.
Nurses experience moral distress when required to
participate in care that they deem as futile. Intensive care
unit nurses commonly report feeling demoralized, pow-
erless, helpless, hopeless, frustrated, angry, distressed, or
guilty that they had failed the patient. 12(p928) Critical
care nurses report common family misunderstandings.
The most common are beliefs in the miracles of modern
medicine and that advanced technology can help a
loved one avoid death. Intensive care unit nurses also
report that the most common obstacles to good end-of-
life care were disagreements about direction of dying
patients care, actions that prolong patients suffering,
and physicians who were evasive and avoided conversa-
tions with family members.10(p924) Other significant
obstacles were the familys lack of understanding about
patient care, nonacceptance of poor prognosis, and
overriding of the patients advance directive.10
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Medical Futility
SPIRITUAL/CULTURAL CONSIDERATIONS
Many cultural influences impact how one approaches,
views, and communicates in situations deemed medi-
cally futile. The culture of the nonhealthcare commu-
nity contains divergent values and beliefs from the
culture of the healthcare community. Optimally, care-
givers and the patient benefit when the culture of the
patient and family is understood and respected by the
healthcare providers. Skilled members of the interdisci-
plinary team and ethics committee can be valuable re-
sources for these conversations.
One aspect that an ethics committee must take into
consideration is the cultural perspective of those
involved. Ethics committees often include representa-
tives of various cultures and religious traditions. To be
culturally competent, one cannot speak in generalities
but must recognize that all people operate on 3
fundamental levels: universal, cultural, and individual.
The universal level is that which we all share as human
beings, such as eating, sleeping, and communicating.
For this purpose, we will use the broad definition of a
culture as any group of people that share similar ideas,
values, and beliefs.13 The cultural level defines behaviors
and norms for the human experience. The cultural level
is broader than race, ethnicity, and religion and allows
healthcare providers to recognize their own cultural
context. Finally, the individual level is the persons own
preference whether or not to follow cultural norms.
These 3 levels can be demonstrated using the case study.
In this case, the universal level was spirituality. The
cultural level was evidenced by the religious aspect of
the case. According to court documents, the patient was
raised in the Roman Catholic tradition. The patients
individual level was demonstrated as an adult when he
chose to become a member of The Church of Jesus
Christ of Latter Day Saints. It was reported that he later
renounced The Church of Jesus Christ of Latter Day
Saints religion and returned to his Roman Catholic
beliefs.14
Healthcare is a culture in and of itself, sharing its
own language, values, and beliefs. For example, health-
care providers implicitly understand the diagnosis and
prognosis for an individual patient, whereas patients
and families, although given the information, may not
implicitly understand the meaning of the prognosis.
The patients wife seemed to rely on the physicians
assessment of the prognosis. In contrast, his family
seemed to challenge his prognosis as a factor in plan-
ning his care.
Caregivers understand that there are processes and
values within the healthcare environment, which may be
unknown or misunderstood by patients and families.
This often leads to confusion and may limit the familys
March/April 2009 69
 Medical Futility
ability to communicate with physicians and nurses. For
example, many families enter into the healthcare
environment confused about the definitions, terms, and
responsibilities of an MPOA representative. Some
assume that decision making for the care of their loved
one is automatically transferred to the MPOA represen-
tative once the patient enters the hospital. The MPOA
representatives may see themselves as the protector of
the patients desires and may take an adversarial stance
with healthcare providers. Often, patients and families
enter the hospital with a lack of medical understanding
and no designation of an MPOA representative. Many
times, prior conversations with patients about their
healthcare wishes have been brief or nonexistent. In this
case study, the patients sister was the original decision
maker. When his wife was discharged from the hospital,
she became his statutory surrogate decision maker.
Apparently, this family held different opinions regarding
the patients beliefs. This raises the question if the family
had conversations about healthcare decisions or were
decisions being made based on assumptions.
The decision of the MPOA representative or sur-
rogate often becomes whether all treatments are to be
continued or whether a less aggressive approach is
more congruent with the patients wishes. Even if there
were previous conversations with the patient and
MPOA representative regarding end-of-life decisions,
the complexity of critical illness is often the impetus to
have those conversations occur again. The healthcare
providers are asked to explain the meaning and out-
comes of the actions as outlined in the advance
directives.
The patient and familys cultural context influences
decision making. Healthcare providers understand
autonomy to mean that a patient will be told his/her
diagnosis and will make his/her own decisions while he/
she is still able. However, some patients come from
cultures that are communally based, such as the Latino
and Asian cultures, and believe that important health-
care decisions are to be made by the family unit and not
by any one individual. Cultures such as these believe
that it is the familys role to hear medical information
and triage what they may share with the patient. In this
case study, the patients parents and sister seemed to
assume that they would be included in decision making
along with his wife. Communal cultural beliefs often
create a conflict between the healthcare culture that
values patient autonomy and the patients culture that
values family decision making. When these cultural
beliefs are not considered, communication between
families and healthcare providers may end in conflict
because members of each side believe that they are being
asked to violate strongly held values.
70 Dimensions of Critical Care Nursing Vol. 28 / No. 2
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Communal cultural beliefs often
create a conflict between the
healthcare culture that values patient
autonomy and the patients culture
that values family decision making.
Another cultural component is religious belief. Some
healthcare providers either do not discuss this topic with
patients and families or dismiss its relevance to healthcare
decisions. At the same time, many physicians and nurses
feel that a patients or familys religious beliefs may limit
medical decision making. Frustration sometimes occurs
between the healthcare culture and the family culture
when the family believes there may be a miracle. This
may represent a much deeper conversation that is taking
place between family members and their God. Many tra-
ditions have struggled to understand the connection be-
tween faith and illness. Some traditions have prescribed
laws, articles of faith, or social statements that range
from a moral opinion to a prescription of what should or
should not be done during end-of-life situations. In 2005,
the American bishops of the Roman Catholic Church
asked for an opinion regarding the discontinuation of
artificially administered food and fluid from patients in a
persistent vegetative state. On September 14, 2007, the
Vatican responded that it considers the removal of
feeding tubes from people in vegetative states to be an
immoral act.15 In the case study, the patients family of
origin was identified as Roman Catholic so an assump-
tion might be made that the family members decisions
regarding artificial food and fluids were influenced by
their Roman Catholic beliefs.
The emotional crisis of acute or critical illness is
demonstrated within the family unit as a reevaluation of
their spiritual or religious beliefs. Faith and trust are
cornerstones of many religions, and these values may be
tested by the challenging and fearful time of illness. The
family and patient may question whether their religious
beliefs are right or true. In fast-paced and hurried en-
vironments, conversations regarding religious values are
difficult for healthcare providers to incorporate into care.
Many families, regardless of ethnicity or religion, view
the decision to withdraw artificial life support as being
synonymous with being asked to kill their loved one.
RISK MANAGEMENT IMPLICATIONS
As technology advanced, decisions about life and death
changed in complexity. Extraordinary treatment rapidly
became ordinary and the standard of care.16 Sometimes,
families and physicians have the patients living will

or advanced directive to guide care. The physicians role
as sole decision maker may diminish with the family
assuming the voice of the patient in helping to make
decisions for incapacitated individuals. The current
decision-making process not only asks families to con-
sent to treatment but also now asks families to consider
the withdrawal of treatment.
Historically, common law protected individual
rights. The right to self-determination in healthcare can
be traced to state or federal constitutional rights of
privacy or the common law right of informed consent.17
Legislatively, the legal principle of an individuals right
to control his/her own medical care was stated in the
1976 Karen Ann Quinlan case. In this case, the New
Jersey Supreme Court determined that her fathers
wishes on Karen Anns behalf, based on her values,
took precedence over the interests of the State of New
Jersey in preserving her life, given her poor prognosis.18
In 1991, the Patient Self Determination Act, part of
the Omnibus Budget Reconciliation Act of 1990, was
enacted. This act requires that every hospital, hospice,
nursing home, and health maintenance organization
participating in Medicare and Medicaid should provide
patients, at the time of admission, with information
about their right to make their own decisions with
regard to healthcare, including the right to accept or
refuse medical treatment.19
End-of-life issues related to futility usually stem
from several core areas: (1) lack of clear communication
with patients and families, (2) patients and families may
equate do-not-resuscitate orders as no care, (3) patients
and families may not understand or accept the limitations
of medical treatment, and (4) the healthcare provider may
not know who is the legally authorized representative or
may not know the scope of authority of the decision
maker according to state law. Providing opportunities for
nonjudgmental, empathetic, and informative communi-
cations with patients and families through patient care
conferences and bioethics consultation assist in the
resolution of medical futility and end-of-life care.
CONCLUSION
The term medical futility is difficult to define whether
the patient is receiving aggressive care or comfort care.
Medical futility is often thought of as a power struggle
for decisional congruency among the patients, families,
and clinicians. Inherent within this struggle is the
publics belief in the ability of the medical community
to fix most of physical problems. The belief is then
reinforced through the medias announcements of yet
another medical miracle. The thought that death can be
avoided by medical intervention is demonstrated when
families desire to continue treatments even after full
Copyright @ 2009 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Medical Futility
disclosure from the physician and other healthcare
professionals that the prognosis is grim or fatal. The
milieu of unrealistic expectations from the public upon
the medical community, coupled with the ambiguous
line of where and when to stop treatments, creates
situations described as medically futile.
References
1. Arizona Revised Statutes. 36-3231 (D).
2. ProLifeBlogs.com. Euthanasia: the case of Jesse Ramirez. 2007.
http://www.prolifeblogs.com/articles/archives/2007/07/the_
case_of_ jes.php. Accessed July 2, 2007.
3. Childs D. Pulling the plug: ethicists debate Ramirez case. 2008.
http://i.abcnews.com/print?id=3325418. Accessed March 2, 2008.
4. Kasman D. When is medical treatment futile? J Gen Intern
Med. 2004;19:1053-1056.
5. Tan SY, Chun B, Kim E. Creating a medical futility policy.
Health Prog. 2003;July/August:4-20.
6. Angelucci PA. Grasping the concept of medical futility. Nurs
Manag. 2006;37(2):14-15.
7. Bernat J. Medical futility: definition, determination and dis-
putes in critical care. Neurocrit Care. 2005;2:198-205.
8. Batavia A. Disability vs futility in rationing health care services:
defining medical futility based on permanent unconsciousnessV
PVS, coma and anencephaly. Behav Sci Law. 2002;20:219-233.
9. Trotter G. Mediating disputes about medical futility. Camb Q
Healthc Ethics. 1999;8:527-537.
10. Lilly CM, DeMeo DL, Sonna L, et al. An intensive commu-
nication intervention for the critically ill. Am J Med. 2000;
109(6):469-475.
11. Whitmer M, Hughes B, Hurst S, Young T. Family conference
progress note. Dimens Crit Care Nurs. 2005;24(2):83-88.
12. Ferrell B. Understanding the moral distress of nurses witness-
ing medically futile care. Oncol Nurs Forum. 2006;33(5):922-930.
13. Spector R. Cultural Diversity in Health and Illness. Upper
Saddle River, NJ: Pearson Prentice Hall; 1979.
14. Ramirez versus Ramirez, Maricopa County (Arizona) Superior
Court, Case No. CV 2007-051579.
15. Vatican reiterates that it considers removal of feeding tubes
immoral. The Associated Press. September 14, 2007. http://
www.iht.com/articles/ap/2007/09/14/europe/EU-GEN-Vatican-
vegetative-state.php. Accessed June 5, 2008.
16. Lieberson AD. Advanced Medical Directives. Deerfield, IL:
Clark Boardman Callaghan; 1992.
17. Beauchamp TL, Childress JF. Principles of Biomedical Ethics.
New York, NY: Oxford University Press; 1983.
18. In re Quinlan, 70 NJ 10, 355 A2d 647, cert denied, 429 US
922 (1976).
19. Smith JW. Hospital Liability. New York, NY: Law Journal
Press; 2008.
ABOUT THE AUTHORS
Mary Whitmer, RN, FNP, BC-PC, Pallectal Care Nurse Practitioner.
Susan Hurst, RN, MSN, CCRN, CNRN, serves as a reviewer for
the Dimensions of Critical Care Nursing.
Marilynn Prins, RN, MSN, CNRN, Critical Care Department
Data Collector.
Kelli Shepard, BSW, MDiv, Director Pastoral Care Services,
Banner Good Samaritan Medical Center.
Doris McVey, RN, BSN, MBA, CPHQ, CPHRM, Director, Risk
Management Banner Heath System.
Address correspondence and reprint requests to: Susan Hurst, RN,
MSN, CCRN, CNRN, Banner Good Samaritan Medical Center, 2206 N
14th St, Phoenix, AZ 85006 (Sue.hurst@bannerhealth.com).
March/April 2009 71