Ten Common Questions (and Their Answers)
on Medical Futility
Keith M. Swetz, MD, MA; Christopher M. Burkle, MD, JD; Keith H. Berge, MD;
and William L. Lanier, MD
Abstract
The term medical futility is frequently used when discussing complex clinical scenarios and throughout the
medical, legal, and ethics literature. However, we propose that health care professionals and others often
use this term inaccurately and imprecisely, without fully appreciating the powerful, often visceral,
response that the term can evoke. This article introduces and answers 10 common questions regarding
medical futility in an effort to de fine, clarify, and explore the implications of the term. We discuss multiple
domains related to futility, including the biological, ethical, legal, societal, and financial considerations that
have a bearing on de finitions and actions. Finally, we encourage empathetic communication among cli-
nicians, patients, and families and emphasize how dialogue that seeks an understanding of multiple points
of view is critically important in preventing or attenuating con flict among the involved parties.
ª2014 Mayo Foundation for Medical Education and Research nMayo Clin Proc. 2014;89(7):943-959
Futile medical care and disagreements
(eg, among physicians, family members,
and others) about whether an individual
patient ’s health care is futile constitute the
main ethical health care erelated challenges
faced by the public today.1Despite progressive
efforts to prevent disputes, con flicts will likely
continue to increase as the aged population in-
creases1,2and if patients are offered a list of
treatment options dand treatment and tech-
nology imperatives din a misdirected, inap-
propriate, and wasteful fashion.3In these
instances, the term medical futility is often
used. The following article attempts to provide
health care practitioners and the public with
an overview of this topic by introducing 10
questions regarding medical futility and offer-
ing answers to those questions on the basis
of the existing literature, common values
gleaned from multiple relevant fields (eg, med-
icine, ethics, economics, and the law), and the
authors ’own experiences. The ultimate goal of
this overview is to provide readers information
on the common concepts, language, and con-
troversies to enhance future discussions and
debate.
QUESTION 1: WHAT IS THE DEFINITION OF
MEDICAL FUTILITY?
The term medical futility is often invoked when an
otherwise curative or disease-arresting therapyor intervention is directed toward a seriously ill
patient who has a low likelihood of recovery.
Merriam-Webster ’sD i c t i o n a r yd e fines futile as
“serving no useful purpose; completely ineffec-
tive, ”but it does not contain a separate listing
formedical futility .4Despite the relevance and
importance of these terms to discussions within
contemporary medicine, ethics, and economics,
medical futility is often underaddressed, and op-
portunities exist to educate those direly in need
of information.1
Medical writers, clinicians, and ethicists
have noted that de finitions of medical futility
(herein referred to simply as futility ) can be
“confusing, inconsistent, and controversial ”5
because the de finition is often slanted to re flect
the de finer ’s point of view. Any working de fi-
nition of futility should be accessible to users
with different backgrounds and testable
against existing standards and practices.
For example, Schneiderman et al6consid-
ered experience and quantity in their de finition
of medical futility: “when physicians conclude
(either through personal experience, experi-
ences shared with colleagues, or consideration
of reported empiric data) that in the last 100
cases, a medical treatment has been useless,
they should regard that treatment as futile. ”
Alternatively, Youngner7defined futility via 3
major domains: quantitative (as with Schnei-
derman et al6), qualitative, and physiologic.From the Department of
Medicine, Section of Palli-
ative Medicine and
Biomedical Ethics Program
(K.M.S.), and Department
of Anesthesiology (C.M.B.,
K.H.B., W.L.L.), Mayo
Clinic, Rochester, MN.
Mayo Clin Proc. nJuly 2014;89(7):943-959 nhttp://dx.doi.org/10.1016/j.mayocp.2014.02.005
www.mayoclinicproceedings.org nª2014 Mayo Foundation for Medical Education and Research943SPECIAL ARTICLE Physiologic futility examines whether a
treatment or technology is ef ficacious in meeting
its intended purpose on a given patient. Clini-
cians are typically the arbiters of physiologic fu-
tility, which is relatively easy to assess in an
objective manner. Examples include whether a
ventricular assist device is effectively supporting
cardiac output and reversing cardiogenic shock
or whether hemodialysis is adequately replacing
renal function.
In contrast, the quantitative and qualitative
aspects of futility are often challenging for clini-
cians to parse out because these aspects rely on
value judgments on the quality of life and its
role in assessing the virtue of longevity.7What
a patient or surrogate de fines as quality or quan-
tity may differ from the clinician ’s perspective,
and one can argue that qualitative futility is
only met if a treatment does not allow a patient
to live his/her life according to his/her goals,
preferences, and values, which we believe can-
not be determined clinically or by how the last
100 patients responded in a given situation.
Clinicians are best able to accurately com-
ment on the physiologic aspects of medical
care that are not value laden.7With this ten-
sion, the American Medical Association Coun-
cil on Ethical and Judicial Affairs attempted to
be more de finitive but recognized the limita-
tions of de fining futility as a value-based
concept; instead, they determined that “a fully
objective and concrete de finition of futility is
unattainable. ”8Reflecting on the dif ficulty in
defining other elusive terms, such as loveand
art, Kwiecinski8commented that “most physi-
cians now know it [futility] when they see it. ”
Acknowledging these dif ficulties, we intro-
duce, as a framework for the remainder of our
discussion, the following recognizably non-
comprehensive de finition of medical futility:
excessive (in terms of effort and finances) med-
ical intervention with little prospect of altering
a patient ’s ultimate clinical outcome.
QUESTION 2: HOW DO CHALLENGES IN
PROGNOSTICATION CONTRIBUTE TO
MEDICAL FUTILITY?
Just as it is dif ficult to precisely de fine futility, it
is difficult to de fine how often care is provided
that is deemed futile, particularly when analyzed
from the perspective of observers ’diverse views
on what is and is not futile care. A crude approx-
imation can be surmised because 25% of USMedicare dollars are spent in the final year of
life. This reasoning is somewhat circular, how-
ever, in that sick people require health care re-
sources, sicker people require more expensive
resources, and the sicker one is, the more likely
one is to die. Although it is impossible to be
certain that someone has entered the final year
of life, multiple prognostic scoring systems
have been developed to more precisely predict
the likelihood of patients ’survival when they
are receiving intensive care. Although tools
such as the Acute Physiology and Chronic
Health Evaluation (APACHE) have tried to link
physiology, resource utilization, and likelihood
of death, they have failed to be de finitively useful
for this role, particularly when applied to
outcome in a single patient.9-11
Berge et al12used the physiologic data e
based APACHE III system in an effort to iden-
tify futile medical care by looking at a group of
extremely ill intensive care unit (ICU) patients
(ie, study patients had predicted single-day mor-
tality rates of /C2195% on 2 consecutive days). A
total of 248 patients (0.68%) of 38,165 ICU ad-
missions achieved this status. In fact, the sur-
vival rates exceeded the predicted rates by a
significant margin, with 23% surviving to hospi-
tal discharge. However, all but one of these pa-
tients was ranked as “severely disabled ”at
discharge, and most (90%) died within the sub-
sequent year, never having left a skilled nursing
facility.12Interestingly, Berge et al reported that
the opinions of experienced ICU physicians (as
recorded in narrative notes within the hospital
record) appeared to more accurately predict in-
dividual patient ’s survival than did the most
finely calibrated, then-state-of-the-art, com-
puter-based prognostic scoring system (ie,
APACHE III). The report of Berge et al docu-
ments that although prognostic scoring systems
are increasingly used to attempt to predict the
clinical course of the sickest patients, they still
are unable to determine when an individual
therapy is futile.12A review of these and other
scoring systems, including the Simpli fied Acute
Physiology Score 3 and the Mortality Probability
Model 3, reveals that these models may predict
mortality reasonably well at a population level
but tend to be less effective for individual patient
prognostication.13Taken together, clinicians
and the prognostic tools they use are limited in
their ability to predict outcomes for individual
patients, which can lead to uncertainty andMAYO CLINIC PROCEEDINGS
944 Mayo Clin Proc. nJuly 2014;89(7):943-959 nhttp://dx.doi.org/10.1016/j.mayocp.2014.02.005
www.mayoclinicproceedings.org the continuation of treatments with marginal
efficacy.
QUESTION 3: WHAT AND WHO ARE THE
PRINCIPAL MOVERS ENCOURAGING
MEDICAL CARE THAT MAY BE CONSIDERED
FUTILE?
Berge et al12found that the best predictor of
prolonged and expensive ICU care in patients
from whom survival was unlikely (perhaps
meeting a de finition of futility) was medical re-
cord documentation of “unrealistic family ex-
pectations. ”However, the source of these
expectations can be multiple and variable.
Sources include cultural or spiritual values
and personal convictions of patients, families,
or clinicians, and they also can result from
an inaccurate interpretation of medical infor-
mation that is presented unclearly by clini-
cians or alternative sources of information.
The popular media and entertainment in-
dustry have an important in fluence on inaccu-
rate expectations for outcomes. For example,
one study14researched television medical
dramas to determine how often cardiopulmo-
nary resuscitation (CPR) is depicted as success-
ful (ie, survival to hospital discharge with no
neurologic de ficits) and compared the results
with those from medical studies. Although a
successful outcome of CPR is no better than
10% to 15% in most situations, the television
dramas depicted it as successful in an unrealis-
tic 75% of immediate survival cases, with 67%
surviving to hospital discharge.14Regardless of
the penetration of the media and entertainment
industries in producing erroneous views on
CPR ef ficacy, the erroneous views are widely
held. For example, even those with medical
training routinely overestimate the bene fits of
CPR.15,16
The rare instances when extended resuscita-
tions yield a successful outcome are reported in
the medical literature17-19and often ampli fied in
media reports.20,21(As one might suspect, fail-
ures rarely receive such attention.) That reports
of such successes represent extreme outliers is
generally not appreciated by the lay public or
emphasized by media stories about such resusci-
tations.20,21For some patients and caregivers,
hopes for miraculous recoveries may persist.
The hope for an extremely improbable favorable
outcome (sometimes perceived as a miracle
outcome), although not a commonly articulatedsentiment of patients or surrogates, neverthe-
less can enter into the decision making of physi-
cians, many of whom have during their careers
witnessed or heard about one of these rare
events.
Sometimes physicians, nurses, and other
health care professionals may experience moral
distress, feeling pressured to provide aggressive
care as encouraged by technology imperatives,
even though the outcome will not be altered
by such interventions.22These imperatives
(ie, the inexorable inertia toward intensi fication
of care geared at life prolongation) are dis-
cussed further below.
False hopes also can be created by media
and tabloid reports of the occasional “miracle ”
emergence from prolonged comas, such as
persistent vegetative states. Wijdicks and Wij-
dicks23made it clear that such cases arise
from initial misdiagnosis or media mislabeling
of the actual form of coma and that the diag-
nosis of the exact nature of a coma is a subtle
matter best left to neurologists with special
expertise in coma diagnosis.24,25In correctly
diagnosed persistent vegetative states lasting
for 6 months to 1 year, there is in fact no
hope for the recovery of consciousness.24Un-
fortunately, in reports of possible outliers, the
media may promote sensationalism over clear,
technically accurate reporting.
The misuse of aggressive end-of-life treat-
ments that, in turn, impose an undue financial
burden to the health care system is a multifac-
eted problem. Often, these exercises result in
the deployment of multiple high-tech, and often
unproven, therapies that may cause patients and
families to miss an opportunity to spend time,
money, and effort on useful alternatives, such
as palliative care or hospice care. From a clini-
cian perspective, Mueller and Hook3editorialize
that when faced with impending mortality in a
patient, it is often dif ficult for physicians to avoid
bowing to interventions encouraged by “techno-
logical and treatment imperatives. ”
In this case, treatment imperative refers to
the propensity of clinicians and patients or sur-
rogates to feel obligated to use any intervention,
even if that intervention may not help the pa-
tient (eg, offering vasopressors, antimicrobial
drugs, or surgical intervention simply because
they are at our disposal). Similarly, technological
imperative refers to the propensity to use tech-
nological interventions when they exist, evenCOMMON QUESTIONS ON MEDICAL FUTILITY
Mayo Clin Proc. nJuly 2014;89(7):943-959 nhttp://dx.doi.org/10.1016/j.mayocp.2014.02.005
www.mayoclinicproceedings.org945
