1 DETERMINING FUTILE TREATMENTS SEEKING THE BEST INTERESTS OF THE PATIENT

2 DEFINITIONS: FUTILITY FUTILITY. –THE INABILITY TO ACCOMPLISH AN INTENDED GOAL. -SETTING GOALS IN PRACTICE. -PROFESSIONAL PARTICIPANTS. -CONSIDERATIONS. -STRATEGIES.

3 DEFINITIONS: MEDICAL FUTILITY MEDICAL FUTILITY. –A–ANY CLINICAL INTERVENTION WHICH A PHYSICIAN, RELYING ON THE MEDICAL LITERATURE AND HIS/HER CLINICAL JUDGMENT (WEIGHING RELEVANT PROBABILITIES], DETERMINES WILL BE UNABLE TO ACCOMPLISH A PHYSIOLOGICAL GOAL WHICH WILL BENEFIT THE PATIENT. –P–PERMANENT DEPENDENCE ON INTENSIVE CARE INTERVENTIONS. –N–NO REALIZATION OF GOALS IN PREVIOUS 100 CASES.

4 DEFINITIONS: CLINICAL JUDGMENT THE JUDGMENT MADE BY A HEALTHCARE PROFESSIONAL, WHICH TAKES INTO ACCOUNT THE OBJECTIVE FINDINGS, WHICH SUPPORT A DIAGNOSIS AND PROGNOSIS AND WEIGHS THEM IN LIGHT OF THE PROFESSIONAL’S EXPERTISE AND CLINICAL EXPERIENCE TOGETHER WITH THE PECULIAR CIRCUMSTANCE OF AN INDIVIDUAL PATIENT. SUCH JUDGMENTS ARE MADE WITH DUE REGARD FOR A REASONABLE DEGREE OF MEDICAL CERTAINTY AS DETERMINED IN ACCORDANCE WITH REASONABLE MEDICAL STANDARDS.

5 DEFINITIONS : PERSONALLY-DETERMINED FUTILITY PERSONALLY-DETERMINED FUTILITY. –ANY EFFORT TO ACHIEVE A RESULT, WHICH MAY BE POSSIBLE BUT WHICH DOES NOT FALL WITHIN THE PERSONALLY-DETERMINED GOALS OF THE PATIENT (OR SURROGATES WHO CAN LEGITIMATELY SPEAK FOR PATIENTS).

6 DEFINITIONS: CLINICAL FUTILITY CLINICAL FUTILITY. –A–A JUDGEMENT, WHICH INTEGRATES CONSIDERATIONS OF MEDICAL FUTILITY AND PERSONALLY- DETERMINED FUTILITY INTO A UNIFIED WHOLE AND WHICH REFLECTS THE INTERESTS OF THE TOTAL PATIENT AND THE OTHER INDIVIDUALS WHO ARE LEGITIMATE PARTICIPANTS IN THE DECISIONAL PROCESS.

7 DEFINITIONS: INADVISABLE TREATMENTS COMPARE WITH FUTILE TREATMENTS. EXTREMELY UNLIKELY TO BE BENEFICIAL. BENEFICIAL EFFECTS BUT EXTREMELY COSTLY. UNCERTAIN OR CONTROVERSIAL BENEFIT. FUTILE TREATMENTS HAVE NO PHYSIOLOGICAL BENEFIT.

8 BENEFITS THE POSITIVE RESULT FOR A FUNCTIONAL IMPROVEMENT IN THE QUALITY OF LIFE OR THE ACHIEVEMENT OF A PARTICULARLY DESIREABLE GOAL WHICH AN INDIVIDUAL WILL EXPERIENCE AS THE RESULT OF A HEALTHCARE INTERVENTION. COMPLETE RECOVERY. REMISSION OF DISEASE PROCESS. IMPROVED QUALITY OF LIFE. –COMFORT. –RESTORATION OF CONSCIOUSNESS. –IMPROVED PERFORMANCE ACTIVITY. RETURN TO A PREVIOUS LEVEL OF FUNCTIONING. MAINTENANCE OF A MINIMALLY DECENT QUALTIY. OF LIFE FIGHTING A DISEASE. EXPERIENCING A LESS DISTRESSING DYING. COST/RESOURCE SAVINGS. [CONTINUED BIOLOGICAL EXISTENCE].

9 PROCESSING FUTILITY I CLEARLY IDENTIFY THE GOAL OF THE INTERVENTION. –PHYSIOLOGICAL/METABOLIC. –FUNCTIONAL. –VALUE.

10 PROCESSING FUTILITY II CALCULATE AND INTERPRET PROBABILITIES. CLARIFY VALUES.

11 PROCESSING FUTILITY III SET PARAMETERS FOR REASONABLE GOALS. –SPECIFIC TIME-LIMITED GOAL. –WITNESS A PARTICULAR EVENT.

12 PROCESSING FUTILITY IV REALISTIC ASSESSMENT OF BENEFITS. DISTINGUISH BETWEEN BENEFIT AND EFFECT.

13 PROCESSING FUTILITY V LIMITATIONS ON AUTONOMY –THE SCOPE OF THE RIGHT TO REFUSE TREATMENT IS GREATER THAN THE RIGHT TO CHOOSE/DEMAND TREATMENT. –CHOICES ONLY AMONG MEDICALLY INDICATED TREATMENTS. –INFORM PATIENTS BUT DO NOT OFFER TREATMENT --- INFORMATION WITHOUT CONSENT.

14 CLINICAL SITUATIONS BRAIN DEATH. PERSISTENT VEGETATIVE STATE. PERMANENT BRAIN DAMAGE. –S–STROKE. –A–ACCIDENT. MULTIPLE SYSTEM FAILURE. AGE.