Futility I

Medical futility refers to an intervention that has no expectation to help at all. It is often raised in circumstances near the end of life when families push for treatments that physicians feel are futile. Ethically, a treatment does not have to be rendered - even if requested by a patient or family member - if it is futile. As a silly example, if a patient asked me for antibiotics for migraine treatment, I could decline simply because it is futile. Since it has no benefit, there is no circumstance in which the benefits outweigh the risks. This becomes infinitely more complex in the case of a terminal illness. In someone with end-stage cancer, how do you know that antibiotics won't help? Or herbal treatments? Or surgery? But if a physician feels these are futile, they need not be entertained.

A patient is admitted with fulminant liver failure; she is confused from hepatic encephalopathy, has gained 20 pounds, has massive fluid in her abdomen, and begins to bleed. No one knows why her liver has failed; she has cryptogenic cirrhosis. Subsequently, she develops hepatorenal syndrome and requires dialysis. During the hospitalization, she has a cardiac arrest requiring chest compressions; she's intubated and placed on a mechanical ventilator. She is admitted to the ICU where I meet her. With tenuous blood pressures, she no longer tolerates hemodialysis and requires CVVH. Unfortunately, because of her medical comorbidities, she is denied a liver and kidney transplant. Despite maximizing all our medical interventions, she does not get better, and now that she cannot get a transplant, we have nothing left to offer. She will die from multiorgan system dysfunction, and though our interventions can stave off that moment, none have the possibility of stopping it. This is, we feel, futile care.