Requests for futile or inappropriate interventions near the end of life

Patients and families may, at times, request interventions that clinicians believe to be either futile or potentially inappropriate. Futile interventions are those that simply cannot accomplish the intended physiological goal. Requests for futile interventions are uncommon, and when a patient or surrogate decision maker requests an intervention that is futile, the clinician should decline the request and carefully explain the rationale for the refusal. More commonly, a patient or surrogate decision maker may request an intervention that the clinician believes to be potentially inappropriate. Potentially inappropriate interventions are those that have at least some chance of accomplishing the effect sought by the patient, but clinicians believe that competing ethical considerations justify not providing them. Conflicts can often be avoided through excellent communication; however, when conflicts arise and a mutually agreeable solution cannot be reached, such requests should be managed by a fair dispute resolution process. Five leading international, multidisciplinary, critical care organizations have published guidance for handling such disputes in the intensive care unit setting. Although the multi-organization futility statement was developed for use in intensive care units, the definitions and process can be employed in a multitude of healthcare settings and should form the basis of handling such requests in palliative medicine.