1. SOC 573 - Medical Futility James G. Anderson, Ph.D. Purdue University

2. Definition of Medical Futility Quantitative Definition - The expectation of success empirically is so unlikely that its exact probability can’t be calculated. Qualitative Definition - Any treatment that merely preserves permanent unconsciousness or total dependence on intensive medical care.

3. Questions What is the process by which standards are devised and quantitative judgements made? Society for Critical Care Medicine - 1990 Consensus report on the ethics of forgoing life support Medicaid stipulates that recipients are to receive “medically necessary” care but does not stipulate standards

4. Questions What is the process by which standards are devised and quantitative judgements made? The Pepper Commission in 1990 tried to define minimum health benefits. The State of Oregon combined public values, professional judgment, cost- effectiveness data to rank procedures covered under the state Medicaid program

5. Questions Who decides when treatment is futile? Healthcare providers Patients and their surrogates The courts

6. Determining Futility Determination of futility combines technical considerations, clinical judgments, and patient values. Determination requires shared decision making.

7. Making Judgments How do we make judgments that combine factual and normative (moral) ingredients? Values can influence how one recognizes and interprets facts. We must make a sharp distinction between scientific knowledge and moral and political judgments.

8. Making Judgments Scientific data provide probabilities not certainties. Probabilities can not always be kept free of values. The use and interpretation of scientific data for moral or politicalk purposes will be a function of the values we bring to bear on the data.

9. Questions How do we determine medical futility for patients who are in a comma, in a persistent vegetative state or who are suffering from multi-organ failure or severe dementia? When if ever does cost become a consideration?

10. Tension Physicians must have the right to act on their values and sense of integrity just as patients must be allowed to act on theirs. The physician is the expert but may act paternalistically. The patient and family want autonomy and want to follow a democratic process. How do we resolve the inherent tension between doctors and patients?

11. Questions If patients and their surrogates insist on continuing treatment that is considered futile, who should pay for the treatment? If health care providers discontinue treatment against the wishes of patients and their surrogates, will this cause the public to lose trust in the health care system?

12. Questions If the physician accedes to family wishes to continue futile care, is he/she sending the family a mixed message of false hope? Does the physician have an obligation to protect the patient’s interest? How does the physician determine what is in the best interest of the patient?

13. Questions In the absence of laws, are the family members best qualified to decide whether treatment is futile? When if ever are physicians justified in refusing to continue futile treatment? Should the potential costs to the provider (hospital) and to the public of futile care be a consideration?