Medical futility DNR

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Medical Futility

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Resuscitation (DNR)
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Dr. Sreedharan V. Koliyadan. MS; DNB; FRCS
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Consultant; Department of Surgery
Sultan Qaboos University
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sreesurgery@gmail.com
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28-12-2011 Sree/Futility&DNR 1

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First I will define what I conceive medicine

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to be. In general terms, it is to do away with

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the sufferings of the sick, to lessen the

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violence of their diseases, and to refuse to

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treat those who are overmastered by their

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disease, realizing that in such cases
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medicine is powerless.
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— The Hippocratic Corpus
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Medical Futility & Do-Not-Resuscitate

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Medical Futility:

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Definition

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Types

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Purposes

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Limitations

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Estimation

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Process

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Do-Not-Resuscitate Orders:
Definition
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Purpose
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Limitations
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Process
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Policies: RH/SQUH
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DNR: Islamic perspectives :
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Futility

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Definition:

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Futile (adj): incapable of producing any

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useful result; pointless (Oxford dictionary)

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Futility (noun): pointlessness or

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uselessness:
Medical Futility: a judgment that
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further medical treatment of a patient
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would have no useful result.
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Origin: Futili (Latin) from Greek
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Futility: Types

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Quantitative: likelihood of survival

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Qualitative: likelihood of quality of life after

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survival

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Trotter G. Editorial Introduction : Futility in the 21 st Century. HEC Forum. 2007;19:1–12.
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Chwang E. Futility clarified. The Journal of law, medicine & ethics : a journal of the American Society of Law, Medicine & Ethics [Internet]. 2009 Jan;37(3):487–95,
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Futility: Types

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1. Physiological

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2. Imminent demise

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3. Lethal condition
4. Qualitative y &D
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Slosar JP. Medical Futility in the Post-Modern Context. HEC Forum. 2007;19(1):67–82.
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Futility: Purpose

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Decide Interventions

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Reasons for the concept of medical futility:

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1. Absence of beneficence

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2. Creation of harm

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3. Respect for autonomy of patient/ surrogate
4. Distributive justice
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5. Autonomy of physician
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Joseph R. Hospital policy on medical futility - does it help in conflict resolution and ensuring good end-of-life care? Annals of the Academy of Medicine, Singapore
[Internet]. 2011 Jan;40(1):19–7.
Baily MA. Futility, Autonomy, and Cost in End-of-Life Care. Journal of Law , Medicine and Ethics. 1989;00:172–82.
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Futility: Estimation

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:
1. The AHA Guidelines for CPR and Emergency

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Cardiac Care:

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"no survivors after CPR have been reported

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under the circumstances in well-designed studies."

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2. Schneiderman(1990):

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Intervention is futile if it has failed the last 100
times it has been attempted
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3. The American Thoracic Society
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" intervention futile if it is highly unlikely to
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result in meaningful survival"
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[Editorial]. W hen Is CPR Futile ? Journal Of The American Medical Association. 1995;273(2):156–8.
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Overall survival to home after CPR: 18%

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Futility: Quantitative criteria:

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<1/100
< 13% Survival

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<5% survival

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Futility: Individual diseases:

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Hypotension: survival 2%

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Renal failure: 3%
AIDS: 2%
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>70yrs: 4%
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Other Scales:
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APACHE II
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ASA
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Ehlenbach WJ, Barnato AE, Curtis JR, Kreuter W, Koepsell TD, Deyo R a, et al. Epidemiologic study of in-hospital cardiopulmonary resuscitation in the elderly.
The New England journal of medicine [Internet]. 2009 Jul 2;361(1):22–31.
Lawson a. Futility. Current Anaesthesia & Critical Care [Internet]. 2004 Aug [cited 2011 Dec 23];15(3):219–23.
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Futility: Limitations

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Futility of Physician vs. Futility of

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patient/SDM

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Estimation of Quantitative Futility

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Estimation of Qualitative Futility (Values) ilit
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Luce J. Physicians do not have a responsibility to provide futile or unreasonable care if a patient or family insists. Critical Care. 1995;23(4):760–6.
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Unilateral vs Bilateral Decisions

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“Physicians are NOT obliged to provide care when there
is scientific and social consensus that the treatment is

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ineffective.”

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American Heart Association

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“Physicians are under no ethical obligation to render

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treatments that they judge have no realistic likelihood of

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medical benefit to the patient”
American College of Emergency Physician, 1998
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CPR maybe withheld even if requested by the patients
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“when efforts to resuscitate a patient are judged by
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the treating physician to be futile”
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AMA Council on Ethical and Judicial Affairs, 1991
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“Whereas patients have a right to refuse treatment, they do not have

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automatic right to demand treatment; they cannot insist that resuscitation

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must be attempted in any circumstances”
European Resuscitation Council, Resuscitation Guidelines 2005

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…“futility is a professional judgment that takes precedence over patient

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autonomy and permits physicians to withhold or withdraw care deemed

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to be inappropriate without subjecting such a decision to patient

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approval.”

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Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and
ethical implications. Ann Intern Med. 1990 Jun 15;112(12):949-54.
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If general medical opinion considers a particular treatment futile (not
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altering the patient’s immediate survival nor offering any advantage over
alternative treatments), then this alternative need not be performed or
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even discussed with the patient and/or his surrogate (1990, p. 952).
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American College of Chest Physicians and the Society of
Critical Care Medicine’s Consensus Panel published “Guidelines for the
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Initiation, Continuation, and Withdrawal of Intensive Care.”
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Unilaterally taking the treatment option off

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the table for discussion or unilaterally

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refusing to provide it— when there are real

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potential value conflicts at stake—can no

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longer be an acceptable answer.

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Rubin SB. If We Think It ’ s Futile , Can ’ t We Just Say No ? HEC Forum. 2007;19:45–65.
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Futility: Fair Process Approach

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[Council on Ethical and Judicial Affairs A medical A. Medical Futility in End-of-Life Care: Report of the Council on Ethical and Judicial Affairs. JAMA: The Journal of the
28-12-2011
American Medical Association. 1999;281(10):937–41. Sree/Futility&DNR 16

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Do-Not-Resuscitate Order (DNR)

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Definition:

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Alternative terms: DNAR; AND

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Bishop JP, Brothers KB, Perry JE, Ahmad A. Reviving the conversation around CPR/DNR. The American journal of bioethics : AJOB [Internet]. 2010 Jan [cited 2011
Dec 23];10(1):61–7. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20077345
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DNR: Policy

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Purpose:

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Limit unnecessary CPR based on Futility

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In-hospital survival: 13%

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Out of Hospital survival: 1%
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Protect physician
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Withholding treatment
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Instituting treatment
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Tomlinson T, Czlonka D. Futility and hospital policy. Hastings Center Report. 1995;25(3):28–35.
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Ewy GA. Cardiac Resuscitation — When Is Enough Enough ? New England Journal of Medicine. 2006;355(5):510–2.

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DNR Policy: Limitations

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CPR if no DNR order

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Communication on End-of-Life issues

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Estimation of Futility

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Assessment of Values & Goals
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Paternalism vs Autonomy
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Hackler C. It ’ s Bigger Than CPR and Futility : Withholding Medically Inappropriate Care It ’ s Bigger Than CPR and Futility : Withholding Medically
Inappropriate. The American Journal of Bioethics. 2010;10:70–1.
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DNR : Process

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S= Subjective values of the patient / SDM

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O=Objective data gathered by physician

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A= Assessment putting the S & O together
P=Plan of intervene or not. y
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Rubin SB. If We Think It ’ s Futile , Can ’ t We Just Say No ? HEC Forum. 2007;19:45–65 .
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DNR Policy: Process

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1. Education of patient/SDM:

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2. Estimate success of CPR in that patient

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3. Evaluate potential QOL after successful CPR

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4. Problems of instituting CPR
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5. Time for reflections
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Kind V. Case Study CPR and DNR Decision Making. Age in Action. 2010;:1–5.
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DNR Policy

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“Slow code”

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“DNR without Consent”

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“Futile DNR”
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David P Eisenman. DNR orders and Medical Futility. Journal Of The American Medical Association. 1995;274(4):299–300.
Luce JM. Clinical Commentary Making Decisions About the Forgoing of Life-sustaining Therapy. Critical Care Medicine. 1993;:1–4.
Truog RD. Is it always wrong to perform Futile CPR? New England Journal of Medicine. 2010;362(6):477–9.
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DNR: Islamic perspectives

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"Anyone who has saved a life, it is as

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if he has saved the life of whole

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mankind" (5:32).
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DNR: Islamic Perspectives

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Purposes of Law:

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1. Certainty of Futility:

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2. Preservation of life (ḥifẓ al-nafs):
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3. Consent:
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4. Abuse:
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Kasule OH. DNR: An Islamic Formulation. Journal of Islamic Medical Association. 2010;42(March):36–7.
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The Presidency of the Administration of Islamic

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Research and Ifta, Riyadh, Kingdom of Saudi

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Arabia (KSA): Fatwa No. 12086

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Takrouri MSM, Halwani TM. An Islamic Medical and Legal Prospective Of Do Not Resuscitate Order In Critical Care Medicine. The Internet Journal of Health.
2008;7(1).
Saleem Saiyad. Do Not Resuscitate: A case study from islamic view point. Journal of Islamic Medical Association [Internet]. 2009 Jan;41:109–13
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Out of 659 neonatal admissions in

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Oman (RH), 39 (6%) parents

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consented for DNR.
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da Costa DE, Ghazal H, Al Khusaiby S. Do Not Resuscitate orders and ethical decisions in a neonatal intensive care unit in a Muslim community. Archives of disease
in childhood. Fetal and neonatal edition [Internet]. 2002 Mar;86(2):F115–9.
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DNR Policy: RH

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Medical Futility & Do-Not-Resuscitate

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Medical Futility:

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Definition

12
Types

8
Purposes

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Limitations

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Estimation

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Process

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Do-Not-Resuscitate Orders:
Definition
y
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Purpose
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Limitations
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Process
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Plicies: RH/SQUH
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DNR: Islamic perspectives :
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