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Palliative care: Medically futile and potentially inappropriate/inadvisable therapies

Laura Miller-Smith, MD
John D Lantos, MD
Section Editor
Robert M Arnold, MD
Deputy Editor
Diane MF Savarese, MD


The concept of medical futility is an ancient one. Hippocrates counseled clinicians not to treat patients who were “overmastered by their disease.” The idea that doctors should not recommend or provide treatments that could not help a patient has been a part of most codes of medical ethics for centuries.

Modern controversies about medical futility arise when doctors and patients (or family members) disagree about whether a particular treatment is futile or inappropriate/inadvisable in a particular circumstance. These conflicts reflect the ways in which advanced medical technology has created uncertainty about what interventions are appropriate or potentially beneficial for which specific patient populations [1]. Technologies such as dialysis, mechanical ventilation, ventricular assist devices, and parenteral nutrition enable us to sustain life beyond what was previously believed to be possible. However, in using such technologies, healthcare providers must balance the potential benefits of continued pursuit of medical treatment against the effects on quality of life for the individual, and whether such treatment is consistent with the patient’s personal values and beliefs. As a result, healthcare providers routinely participate in end-of-life decisions that may cause moral distress and are surrounded by ethical uncertainty. Although doctors and policy makers had hoped that recognition of the point at which such technologies become medically futile would lessen that moral distress and reduce ethical uncertainty, this hasn’t occurred. Instead, clinicians continue to struggle with both the definition and the application of the concept of medical futility and appropriateness of care [2], particularly in the intensive care unit [3].

This topic review will cover the concept of medical futility as it applies to palliative care patients. Ethical issues related to futile and potentially inappropriate treatments that are specific to patients treated in the intensive care unit are presented elsewhere, as is a more extensive discussion of ethical issues that arise in palliative care. (See "Ethics in the intensive care unit: Responding to requests for potentially inappropriate therapies in adults" and "Ethical issues in palliative care".)


The concept of patient autonomy emerged in the last half of the 20th century. Prior to that, doctors would routinely make unilateral decisions about what treatments to offer and what to withhold [4]. There was no legal or (perceived) ethical need to discuss such decisions with patients or families. That began to change when the concept of "informed consent" became embedded in the law governing doctor-patient communication. To ensure informed consent, the doctor was required to explain the risks and benefits of treatment to patients and family members. (See "Ethical issues in palliative care", section on 'Framework for ethical reasoning' and "Informed procedural consent".)

The late 20th century also saw the invention and promulgation of life-sustaining medical technologies that enabled the prolongation of life in patients who were far too sick to survive without such technologies [1]. These technological developments were synergistic with the legal and ethical changes in medical practice described above in changing the landscape of medical ethics. There were more choices to be made, and there was more of a need to include patients and families in the decision-making process. However, this had advantages and disadvantages. While patients and families were now allowed to discontinue treatment they deemed to be at odds with their goals, they were also allowed to request treatments that clinicians believed to be inappropriate or futile. In the 1980s and 1990s, reports began to be published of patients and families insisting on medical interventions that would not be able to achieve the ends of reversing death and sustaining meaningful life. Many began to argue that clinicians should be allowed to unilaterally withhold treatments that they considered futile or potentially inappropriate [5]. Decisions in many of the early cases were made by courts of law.


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Literature review current through: Sep 2016. | This topic last updated: Apr 1, 2016.
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