A 45-year-old woman with widely metastatic non–small cell lung cancer is admitted to the intensive care unit with worsening respiratory distress. The patient's cancer has progressed rapidly despite multiple rounds of second- and third-line chemotherapy. Her oncologist and primary treating team agree that her prognosis is poor and that she is not a candidate for clinical trials. When discussions about goals of care are initiated, the patient and her surrogate decision-maker express preferences and sign an advance directive indicating that the treating physicians should do "everything possible" to treat the patient, including cardiac resuscitation and all potentially curative treatments. Subsequently, she sustains a large myocardial infarction with resulting anoxic brain injury. Upon learning of the patient's diagnosis, the surrogate decision-maker asks the physician whether cardiac catheterization can be performed to treat the myocardial infarction. Which of the following best describes the physician's ethical obligation to comply with the surrogate's request?
A medically futile treatment clearly offers no benefit (eg, physiologic improvement, reduction in suffering) and cannot accomplish intended goals. Medical futility can be defined as follows:
Physiologic futility: Treatment cannot improve physiologic condition or reach a physiologic goal (including promoting palliation or comfort).
Qualitative futility: Treatment offers marginal benefits that are substantially outweighed by the likelihood of significant pain and suffering.
In this patient with advanced cancer who sustained a large myocardial infarction complicated by anoxic brain injury, cardiac catheterization is unlikely to adequately treat her infarction, alleviate her brain injury, or improve comfort; therefore, it is both physiologically and qualitatively futile.
Physicians have no ethical obligation to administer futile treatments because doing so counters the ethical obligations of beneficence (ie, benefiting the patient) and nonmaleficence (ie, not harming the patient). When a patient (or surrogate decision-maker) requests a futile treatment, the physician should attempt to understand the reasons for the request (eg, distrust, concern for abandonment, overestimating treatment benefits) and empathetically explain why the treatment is futile.
In contrast, therapies that are high risk but offer some benefit (eg, prolongation of life via cardiopulmonary resuscitation in some patients without a terminal diagnosis) are not clearly futile. In such cases, the physician should offer clear guidance but cannot refuse treatment if it is requested by an informed and competent patient or surrogate.
(Choices A and B) Resource stewardship refers to cost-effective resource allocation. It is considered an insufficient standard for determining futility because treatment benefits should also be considered and sometimes justify resource-intensive care. Similarly, impact on prognosis is an insufficient standard for justifying treatment refusal because treatment benefits may occur in ways other than improvement of prognosis. For example, some palliative treatments improve quality of life but do not alter prognosis. Cardiac catheterization will likely neither alleviate this patient's brain injury nor meaningfully improve quality of life.
(Choices D and F) Although physicians have an ethical obligation to respect autonomy as expressed directly or in an appropriate advance directive document, this does not obligate them to provide a treatment that is clearly futile.
(Choice E) Palliative care or ethics committee consultation may be appropriate when there is disagreement about a treatment's futility. There had not yet been a discussion between the physician and the surrogate regarding the futility of treatment; if there is disagreement following this discussion, consultation may be appropriate.
Educational objective:
A medically futile treatment offers no qualitative or quantitative benefits and cannot accomplish intended goals. Physicians have no ethical obligation to administer medically futile treatments because doing so counters the ethical obligations of beneficence and nonmaleficence.