1. EPECEPECEPECEPEC EPECEPECEPECEPEC Medical Futility Module 9 The Education in Palliative and End-of-life Care program at Northwestern University Feinberg School of Medicine, created with the support of the American Medical Association and the Robert Wood Johnson Foundation

2. EPECEPECEPECEPEC EPECEPECEPECEPEC Medical Futility Generally imprecise and value laden term Not generally useful concept to guide appropriate treatment Consider alternate terms “Non-beneficial treatment” “Unseemly care”

3. Objectives List factors that might lead to futility situations Understand how to identify common factors how to communicate and negotiate to resolve conflict directly the steps involved in resolving intractable conflict

4. Clinical case

5. Common definitions of medical futility Won’t achieve the patient’s goal Serves no legitimate goal of medical practice Ineffective more than 99% of the time Does not conform to accepted community standards

6. Strict physiologic futility No evidence or rationale supporting intended purpose of an intervention Examples CPR in rigor mortis CPR in refractory shock, multi organ failure on maximal support

7. Futility based on goals of care No evidence intervention will accomplish goals of care Examples Antibiotics and feeding tubes in advanced progressive dementia in a patient with chronic pain, agitation, and clear goals of care to allow natural death CPR in young person with progressive cancer, widespread skin necrosis who desires comfort

8. Clinicians and futility Patients / families may be invested in interventions Clinicians / other professionals may be invested in interventions Any party may perceive futility

9. Is this really futility? Unequivocal cases of medical futility are rare Miscommunication, value differences are more common Case resolution more important than definitions

10. Conflict over treatment Unresolved conflicts lead to misery most can be resolved Try to resolve differences Support the patient / family Base decisions on informed consent, advance care planning, goals of care

11. Differential diagnosis of futility situations Misunderstanding Personal factors Conflicting values between family / clinicians

12. Misunderstanding of diagnosis / prognosis Underlying causes How to assess How to respond

13. Misunderstanding: underlying causes... Doesn’t know the diagnosis Too much jargon Different or conflicting information Previous overoptimistic prognosis Stressful environment

14. ... Misunderstanding: underlying causes Sleep deprivation Emotional distress Psychologically unprepared Inadequate cognitive ability

15. Misunderstanding: how to respond... Choose a primary communicator Give information in small pieces multiple formats Use understandable language Frequent repetition may be required

16. ... Misunderstanding: how to respond Assess understanding frequently Do not hedge to “provide hope” Encourage writing down questions Provide support Involve other health care professionals

17. Personal factors Mistrust Grief Guilt Intrafamily issues Secondary gain Physician / nurse

18. Difference in values Religious Miracles Value of life

19. Types of futility conflicts Disagreement over goals benefit

20. Proxy selection Patient’s stated preference Legislated hierarchy Who is most likely to know what the patient would have wanted? Who is able to reflect the patient’s best interest? Does the proxy have the cognitive ability to make decisions?

21. A due process approach to futility Earnest attempts in advance Joint decision making Negotiation of disagreements Involvement of an institutional committee Transfer of care to another physician Transfer to another institution

22. EPECEPECEPECEPEC EPECEPECEPECEPEC Medical Futility Summary