Why the term ‘persistent therapy’ is not worse than the term ‘medical futility’

The discussion around the use of the term ‘medical futility’ began in the late 1980s. The Polish Working Group on End-of-Life Ethics (PWG) joined this discussion in 2008. They offered their own approach to the issues regarding medical futility based on the category of persistent therapy. According to the PWG, ‘persistent therapy is the use of medical procedures to maintain the life function of the terminally ill in a way that prolongs their dying, introducing excessive suffering or violating their dignity’. In this paper I attempt to show that the term ‘persistent therapy’ is neither worse nor better than the term ‘medical futility’, but it captures different aspects and nuances. Additionally, the Polish social and religious background plays a significant role in shaping the category of persistent therapy.

Dealing with Futile Treatments Based on the Humanistic Approach

: Medical futility is one of the most common controversial topics in medicine, medical ethics, and philosophy of medicine. Every day, doctors are dealing with patients who are in a condition that must have a decision about requested futile treatment with their own beliefs, opinions, and different demands. This is an important issue that must be taught during teaching courses. Therefore, it is good to provide general policies for teaching how to make the best decision, establishing better communication between doctors and patients, and maintaining their Autonomy. On the other hand, with the interference and expansion of humanistic and holistic attitudes in the treatment of patients, it must be considered that at all treatment levels, especially decisions related to end-of-life, it is better to involve this point of view in our policies. In the present article, we tried to give a general conclusion of general policy and present standards for a humanistic policy by analyzing various countries’ policies and expressing their bugs.

Born Dying

This chapter examines the existential and ethical questions raised by care for infants born with life-threatening physiological impairments. The parental narratives of infants born dying present unique illustrations of how The Church of Jesus Christ of Latter-day Saints (LDS) convictions of the revealed reality—including the salvific value of embodied life, parental commitment and autonomy, the eternal family relationship, and medical futility—influence medical decisions regarding life endings at the beginnings of life. These convictions support a narrative that can run contrary to the progressive and vitalistic impulse of biomedicine: children who die prior to accountability have already displayed their faithfulness in the pre-mortal life and do not need the trials for mortal life for their eternal progress. These convictions enable parents to re-story their experience of tragedy into a quest for blessing.

Association of medical futility with do-not-resuscitate (DNR) code status in hospitalised patients

Guidelines recommend a ‘do-not-resuscitate’ (DNR) code status for inpatients in which cardiopulmonary resuscitation (CPR) attempts are considered futile because of low probability of survival with good neurological outcome. We retrospectively assessed the prevalence of DNR code status and its association with presumed CPR futility defined by the Good Outcome Following Attempted Resuscitation score and the Clinical Frailty Scale in patients hospitalised in the Divisions of Internal Medicine and Traumatology/Orthopedics at the University Hospital of Basel between September 2018 and June 2019. The definition of presumed CPR futility was met in 467 (16.2%) of 2889 patients. 866 (30.0%) patients had a DNR code status. In a regression model adjusted for age, gender, main diagnosis, nationality, language and religion, presumed CPR futility was associated with a higher likelihood of a DNR code status (37.3% vs 7.1%, adjusted OR 2.99, 95% CI 2.31 to 3.88, p<0.001). In the subgroup of patients with presumed futile CPR, 144 of 467 (30.8%) had a full code status, which was independently associated with younger age, male gender, non-Christian religion and non-Swiss citizenship. We found a significant proportion of hospitalised patients to have a full code status despite the fact that CPR had to be considered futile according to an established definition. Whether these decisions were based on patient preferences or whether there was a lack of patient involvement in decision-making needs further investigation.

Cost of Futile ICU Care in One Ontario Hospital

Critical care is a costly and finite resource that provides the ability to manage patients with life-threatening illnesses in the most advanced forms available. However, not every condition benefits from critical care. There are unrecoverable health states in which it should not be used to perpetuate. Such situations are considered futile. The determination of medical futility remains controversial. In this study we describe the length of stay (LOS), cost, and long-term outcomes of 12 cases considered futile and that have been or were considered for adjudication by Ontario’s Consent and Capacity Board (CBB). A chart review was undertaken to identify patients admitted to the Intensive Care Unit (ICU), whose care was deemed futile and cases were considered for, or brought before the CCB. Costs for each of these admissions were determined using the case-costing system of The Ottawa Hospital Data Warehouse. All 12 patients identified had a LOS of greater than 4 months (range: 122-704 days) and a median age 83.5 years. Seven patients died in hospital, while 5 were transferred to long term or acute care facilities. All patients ultimately died without returning to independent living situations. The total cost of care for these 12 patients was $7 897 557.85 (mean: $658 129.82). There is a significant economic cost of providing resource-intensive critical care to patients in which these treatments are considered futile. Clinicians should carefully consider the allocation of finite critical care resources in order to utilize them in a way that most benefits patients.

New perspectives on brain death

Brain death, or death by neurological criteria (BD/DNC), has been accepted conceptually, medically and legally for decades. Nevertheless, some areas remain controversial or understudied, pointing to a need for focused research to advance the field. Multiple recent contributions have increased our understanding of BD/DNC, solidified our practice and provided guidance where previously lacking. There have also been important developments on a global scale, including in low-to-middle income countries such as in South America. Although variability in protocols and practice still exists, new efforts are underway to reduce inconsistencies and better train practitioners in accurate and sound BD/DNC determination. Various legal challenges have required formal responses from national societies, and the American Academy of Neurology has filled this void with much needed guidance. Questions remain regarding concepts such as ‘whole brain’ versus ‘brainstem’ death, and the intersection of BD/DNC and rubrics of medical futility. These concepts are the subject of this review.