Medical futility in the era of evidence-based medicine

One definition of futility is any treatment that merely preserves permanent unconsciousness or fails to end total dependence of a patient on intensive medical care However, no agreement has ever been reached on what the exact defmition of futility is, as it is not only based on temporary values but also evolves into different subtypes, making it harder to define. The difficulty in dealing with futility problem is how doctors evaluate the futile situation, which is further complicated by lack of standards for specific diseases and experience-based prognosis, leading to subjectivity in evaluation for futility.

Autonomy and authority in medical futility

Medical futility has been proposed for many years to define the procedure that simply prolongs the suffering of patients but heals nothing.To deal with the decision procedure for treatment,two ideas arise：patients＇autonomy and doctors＇authority.Widely recognized in 1960s,patients＇autonomy respected patients＇willingness over treatment,requiring specific consent for treatment and right to choose during medical procedure.Another idea for futility is doctors＇authority,explained from the paternalistic perspective as well.

Factors predicting futility of liver transplant in elderly recipients:A single-center experience

BACKGROUND As the population of the United States ages,there has been an increasing number of elderly patients with cirrhosis listed for transplant.Previous studies have shown variable results in terms of the relative survival benefit for elderly liver transplant(LT)recipients.There may be factors that are associated with a poor post-transplant outcome which may help determine which elderly patients should and should not be listed for LT.AIM To identify factors associated with futility of transplant in elderly patients.METHODS This was a retrospective study of all patients above the age of 45 who underwent liver transplantation at our tertiary care center between January 2010 and March 2020(n=1019).“Elderly”was defined as all patients aged 65 years and older.Futile outcome was defined as death within 90 d of transplant.Logistic regression analysis was performed to determine what variables,if any were associated with futile outcome in elderly patients.Secondary outcomes such as one year mortality and discharge to facility(such as skilled nursing facility or long-term acute care hospital)were analyzed in the entire sample,compared across three age groups(45-54,55-64,and 65+years).RESULTS There was a total of 260 elderly patients who received LT in the designated time period.A total of 20 patients met the definition of“futile”outcome.The mean Model of End-Stage Liver Disease scores in the futile and non-futile group were not significantly different(21.78 in the futile group vs 19.66 in the“non-futile”group).Of the variables tested,only congestive heart failure was found to have a statistically significant association with futile outcome in LT recipients over the age of 65(P=0.001).Of these patients,all had diastolic heart failure with normal ejection fraction and at least grade I diastolic dysfunction as measured on echocardiogram.Patients aged 65 years and older were more likely to have the outcomes of death within 1 year of LT[hazard ratio:1.937,confidence interval(CI):1.24-3.02,P=0.003]and discharge to facility(odds ratio:1.94,CI:1.4-2.8,P<0.001)compared to patients in younger age groups.CONCLUSION Diastolic heart failure in the elderly may be a predictor of futility post liver transplant in elderly patients.Elderly LT recipients may have worse outcomes as compared to younger patients.

Who decides in withdrawal of treatment in a critical care setting? A case study on ethical dilemma

Case description:Withdrawal of treatment is a common practice in critical care settings,perticularly when treatment is considered futile.The case study demonstrates an ethical dilemma,in which Danny is unlikely to make a functional recovery because of multiple organ dysfunction syndromes.Under such a circumstance,withdrawal of treatment will inevitably be considered,although his family refused to do so.Consequently,acritical question must be answered:Who should make the decision?Ethical dilemma identification:Danny decided to withdraw the use of life-support,whilst his wife and adult children refused to do so.The ethical dilemma is illustrated by the following question:Who decides the withdrawal of treatment in a critical care setting?Analysis:To provide an opotional solution to this case and make the best moral decision,the current study will critically discuss this issue in conjunction with ethical principles,philosophical theories and the values statement of the European and Chinese nurses'codes of ethics.Additionally,the associated literature relative to this case are analysed before the decision-making.Ethical decision-making:The best ethical decision is Danny can decide whether to withhold or withdraw life-sustaining treatment.If his family is involved in the discussion,the medical staff should balance the ethical principles when they make the decision and allocate reasonable resources for patients.Results:In Danny's case,health professionals opted to respect his decision to withdraw treatment.The medical staff maintained an effective communication with the family involved,and provided the appropriate intervention to collaborate with other health care professionals to perfect further care.

Difficult Conversations and Painful Decisions: When Should Patients with Progressive Cancer Stop Chemotherapy?

Introduction: The decision to stop anti-cancer treatment is fraught with many challenges for the oncologist, the patient, and their caregivers. This review examines the special considerations surrounding the decision to cease chemotherapy in terminally ill cancer patient. Methods: A comprehensive literature search was conducted to find relevant publications on chemotherapy cessation. A total of 2700 records were retrieved and 141 were identified as eligible for inclusion in this review. Results: Palliative chemotherapy does not achieve the goal of tumor-related symptom reduction for patients who have experienced progressive disease with more than two prior lines of chemotherapy. ECOG performance status is a crucial predictor of response to therapy and chemotherapy-related complications. Challenges to stopping chemotherapy at the end of life are multifactorial and are both patient and physician-driven. Racial, ethnic, and income-based disparities are seen in the timing and quality of end-of-life conversations offered by physicians to their patients. Conclusions: The decision to cease chemotherapy is one that should be approached with careful consideration and accurate information. Clear communication, compassion and empathy are important components to the therapeutic relationship. Early involvement of palliative care and clear conversations about prognosis and the expected utility of further chemotherapy is essential to conduct the best possible care for cancer patients at the end of life.