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Abstract & Commentary
Synopsis: Utmost caution has to be applied when future quality of life as presumed by nurses and doctors is used as an argument for withholding or withdrawing further treatment.Source: Frick S, et al. Medical futility: Predicting outcome of intensive care unit patients by nurses and doctors—A prospective, comparative study. Crit Care Med. 2003;31:456-461.
The decision not to provide a useless therapy requires 2 sets of value judgments.1 First, any assertion that a therapy will be useless is a matter of probability, not certainty. Secondly, usefulness and futility are judged only relative to an end that should be focused on the unique situation and needs of the patient. Ultimately, then, the judgment that further treatment would be futile is not a conclusion. Instead, it should initiate the difficult task of discussing the situation with patients and families.2 The study of Frick and colleagues reinforces this idea.
Frick et al carried out a study to assess the pattern of the prediction of intensive care patients’ outcome with regard to survival and quality of life by nurses and doctors and, second, to compare these predictions with the quality of life reported by the surviving patients. During 1 year, all patients admitted for more than 24 hours to a 6-bed adult medical ICU in Geneva (Switzerland) were included in the study. A prospective daily prognostic judgment on the patient’s eventual outcome by ICU nurses and doctors was recorded in a special questionnaire added to the patient’s chart. Survival was assessed for all patients at ICU discharge, at hospital discharge, and at 6 months. Quality of life and functional status as judged by the patients were assessed by telephone interviews 6 months after ICU admission.
Data regarding 521 patients including 1932 daily judgments by nurses and doctors were analyzed. Nurses and doctors agreed in their appreciation of eventual futility of medical interventions in the vast majority of patients, but this was the case in only half of their daily judgments. The sicker the patients were, and the longer they stayed in the ICU, the more these judgments diverged. For instance, there was a divergent opinion between nurses and doctors in 79% of patients with septic shock. Overall, nurses were more pessimistic than doctors.
On the other hand, nurses’ and doctors’ appreciation of their patients’ future quality of life proved to be unreliable. According to Frick et al, only 15% of survivors for whom nurses and 9% for whom doctors had considered treatment eventually futile with regard to the future quality of life reported bad quality of life 6 months later. Moreover, for the 24 patients who qualified their quality of life as "bad" 6 months after ICU, treatment had been judged futile with respect to quality of life in only 8% by the nurses and 4% by doctors and as questionably futile in 25% by the nurses and in 12.5% by doctors.
Comment by Francisco Baigorri, MD, PhD
Few will dispute the claim that we do not have an adequate definition of futility, and that it is doubtful we will find one. The study of Frick et al again shows us that health care workers may misunderstand the probability of survival, and may fail to determine what quality of life is acceptable to their patients. Scores based on severity-of-illness models have been developed, but these must be used with caution when applied to individual patients rather than to populations. Moreover, the probability of survival is only one of the factors that must be considered in determining whether intensive care is an appropriate treatment for an individual patient.
The fact of the matter is that withholding and withdrawing life support have become common practice in ICUs in Western countries,3 but there is substantial variability among individual ICUs. Most of the variability is probably related to differences in the beliefs and behavior of physicians.4 However, physicians should exercise professional responsibility by not offering invasive interventions at the end of life that promise great harm and no benefit to the patient.
Communication is the key to resolve this dilemma—communication with patients and families and among the ICU team members. Most recent attempts to establish policies in this area have emphasized processes for discussing futility rather than the means of implementing decisions about futility.2 We should work toward developing a culture and physical environment in the ICU that enhance communication and facilitate comfort of our patients, regardless of whether the probability for cure seems high or nonexistent.5 It seems to me that this is a prerequisite for shared decision-making about the forgoing of life-sustaining therapy.
Dr. Baigorri is Corporacio Sanitaria Parc Tauli Sabadell, Spain.
1. Nyman DJ, Sprung CL. End-of-life decision making in the intensive care unit. Intensive Care Med. 2000;26: 1414-1420.
2. Helft PR, et al. The rise and fall of the futility movement. N Engl J Med. 2000;343:293-296.
3. Esteban A, et al. Withdrawing and withholding life support in the intensive care unit: A Spanish prospective multi-centre observational study. Intensive Care Med. 2001;27:1744-1749.
4. Cook DJ, et al. Determinants in Canadian health care workers of the decision to withdraw life support from the critically ill. JAMA. 1995;273:703-708.
5. Truog RD, et al. Recommendations for end-of-life care in the intensive care unit: The Ethics Committee of the Society of Critical Care Medicine. Crit Care Med. 2001; 29:2332-2338.