AMA Journal of Ethics^®

In the course of clinical care of a critically ill patient, it may become clear that the patient's condition is terminal and that further intervention will do no more than prolong the dying process. At this point, further intervention is often described as "futile," a term whose meaning depends on a subjective judgment. This judgment arises from considerations about quality of life, which Opinion 2.17, "Quality of Life," clearly leaves to patients: "quality of life, as defined by the patient's interests and values, is a factor to be considered in determining what is best for the individual." Nevertheless, patient decisions about futile or non-futile care do not compel physicians to comply with requests that, in the physician's judgment, meet no treatment or care goals.

For non-terminal situations, Opinion 2.035 defines the limits of physician obligations when patients request an unindicated treatment.

Opinion 2.035, "Futile Care"

Physicians are not ethically obligated to deliver care that, in their best professional judgment, will not have a reasonable chance of benefiting their patients. Patients should not be given treatments simply because they demand them. Denial of treatment should be justified by reliance on openly stated ethical principles and acceptable standards of care.

For patients with a terminal prognosis, the AMA recommends defining futility on a case-by-case basis, taking full account of the context and individuals involved. The Code, in Opinion 2.037, "Medical Futility in End-of-Life Care," outlines a due process approach to achieving this case-by-case determination:

Opinion 2.037, "Medical Futility in End-of-Life Care"

To assist in fair and satisfactory decision-making about what constitutes futile intervention:

(1) All health care institutions, whether large or small, should adopt a policy on medical futility; and
(2) Policies on medical futility should follow a due process approach. The following seven steps should be included in such a due process approach to declaring futility in specific cases.

(a) Earnest attempts should be made in advance to deliberate over and negotiate prior understandings between patient, proxy, and physician on what constitutes futile care for the patient, and what falls within acceptable limits for the physician, family, and possibly also the institution
(b) Joint decision-making should occur between patient or proxy and physician to the maximum extent possible.
(c) Attempts should be made to negotiate disagreements if they arise, and to reach resolution within all parties' acceptable limits, with the assistance of consultants as appropriate.
(d) Involvement of an institutional committee such as the ethics committee should be requested if disagreements are irresolvable.
(e) If the institutional review supports the patient's position and the physician remains unpersuaded, transfer of care to another physician within the institution may be arranged.
(f) If the process supports the physician's position and the patient/proxy remains unpersuaded, transfer to another institution may be sought and, if done, should be supported by the transferring and receiving institution.
(g) If transfer is not possible, the intervention need not be offered.

This procedural approach (or "due process" as it is referred to above) is preferable because in cases of patient-physician disagreement, it can incorporate institutional and community standards for patient benefit. It also allows a hearing for patient or proxy assessments of worthwhile outcomes, and for physicians' or other professionals' intention in treating the patient. Finally, it has the advantage of providing a system for addressing the ethical dilemmas around end-of-life care without immediate recourse to the court system.