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Palliative care: Medically futile and potentially inappropriate therapies of questionable benefit

Laura Miller-Smith, MD
John D Lantos, MD
Thaddeus M Pope, JD, PhD
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, health care 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, health care 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 has not occurred. Instead, clinicians continue to struggle with both the definition and 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 issues that arise in the intensive care unit from a critical care perspective are presented separately, 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 [4,5]. 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".)

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Literature review current through: Nov 2017. | This topic last updated: Aug 14, 2017.
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  1. Luce JM, White DB. A history of ethics and law in the intensive care unit. Crit Care Clin 2009; 25:221.
  2. Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement. N Engl J Med 2000; 343:293.
  3. McAndrew NS, Leske JS. A Balancing Act: Experiences of Nurses and Physicians When Making End-of-Life Decisions in Intensive Care Units. Clin Nurs Res 2015; 24:357.
  4. Uhlmann RF, McDonald WJ, Inui TS. Epidemiology of no-code orders in an academic hospital. West J Med 1984; 140:114.
  5. Pope TM. Certified Patient Decision Aids: Solving Persistent Problems with Informed Consent Law. J Law Med Ethics 2017; 45:12.
  6. Blackhall LJ. Must we always use CPR? N Engl J Med 1987; 317:1281.
  7. Miles SH. Autonomy's responsibility. A gloss on the Wanglie affair. Health Prog 1991; 72:30.
  8. Blake DC, Maldonado L, Meinhardt RA. Bioethics and the law: the case of Helga Wanglie: a clash at the bedside -- medically futile treatment v. patient autonomy. Whittier Law Rev 1993; 14:119.
  9. In re the conservatorship of Helga M. Wanglie, No. PX-91-283, District Probate Division, 4th Judicial district Hennepin County, Minnesota, reprinted Issues L Med 1991; 7:369.
  10. U.S. District Court, E.D. Virginia, Alexandria Division. In re Baby K. Fed Suppl 1993; 832:1022.
  11. In re Baby K, 16 F.3d 590 (4th Cir. 1994).
  12. Greenhouse L. Hospital Appeals Ruling on Treating Baby Born With Most of Brain Gone. New York Times September 24, 1993 http://www.nytimes.com/1993/09/24/us/hospital-appeals-ruling-on-treating-baby-born-with-most-of-brain-gone.html (Accessed on January 23, 2015).
  13. Ariadne's Thread: A Guide to International Tales Found in Classical Literature, Cornell University Press, Ithaca, NY 2002.
  14. Brody BA, Halevy A. Is futility a futile concept? J Med Philos 1995; 20:123.
  15. Jones JW, McCullough LB. Extending life or prolonging death: when is enough actually too much? J Vasc Surg 2014; 60:521.
  16. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med 1990; 112:949.
  17. Schneiderman LJ, De Ridder M. Medical futility. Handb Clin Neurol 2013; 118:167.
  18. Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: response to critiques. Ann Intern Med 1996; 125:669.
  19. Kadooka Y, Asai A, Bito S. Can physicians' judgments of futility be accepted by patients? A comparative survey of Japanese physicians and laypeople. BMC Med Ethics 2012; 13:7.
  20. Gabbay E, Calvo-Broce J, Meyer KB, et al. The empirical basis for determinations of medical futility. J Gen Intern Med 2010; 25:1083.
  21. Bernat JL. Medical futility: definition, determination, and disputes in critical care. Neurocrit Care 2005; 2:198.
  22. 18 Vt. Stat. Ann. § 9708.
  23. Code Md. Regs § 10.01.21.
  24. Truog RD. Progress in the futility debate. J Clin Ethics 1995; 6:128.
  25. Gatter RA Jr, Moskop JC. From futility to triage. J Med Philos 1995; 20:191.
  26. Jecker NS, Schneiderman LJ. Futility and rationing. Am J Med 1992; 92:189.
  27. Bosslet GT, Pope TM, Rubenfeld GD, et al. An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units. Am J Respir Crit Care Med 2015; 191:1318.
  28. Schuster RA, Hong SY, Arnold RM, White DB. Do physicians disclose uncertainty when discussing prognosis in grave critical illness? Narrat Inq Bioeth 2012; 2:125.
  29. Politi MC, Légaré F. Physicians' reactions to uncertainty in the context of shared decision making. Patient Educ Couns 2010; 80:155.
  30. Knaus WA, Zimmerman JE, Wagner DP, et al. APACHE-acute physiology and chronic health evaluation: a physiologically based classification system. Crit Care Med 1981; 9:591.
  31. Atkinson S, Bihari D, Smithies M, et al. Identification of futility in intensive care. Lancet 1994; 344:1203.
  32. McNelis J, Marini C, Kalimi R, et al. A comparison of predictive outcomes of APACHE II and SAPS II in a surgical intensive care unit. Am J Med Qual 2001; 16:161.
  33. Wilkinson D. The self-fulfilling prophecy in intensive care. Theor Med Bioeth 2009; 30:401.
  34. Poses RM, Bekes C, Copare FJ, Scott WE. The answer to "What are my chances, doctor?" depends on whom is asked: prognostic disagreement and inaccuracy for critically ill patients. Crit Care Med 1989; 17:827.
  35. Solomon MZ. How physicians talk about futility: making words mean too many things. J Law Med Ethics 1993; 21:231.
  36. Medical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs. JAMA 1999; 281:937.
  37. AAHPM. Statement on Withholding and Withdrawing Nonbeneficial Medical Interventions, 2011 http://aahpm.org/positions/withholding-nonbeneficial-interventions (Accessed on January 23, 2015).
  38. Lewis-Newby M, Wicclair M, Pope T, et al. An official American Thoracic Society policy statement: managing conscientious objections in intensive care medicine. Am J Respir Crit Care Med 2015; 191:219.
  39. Protection of human subjects; reports of the President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research--Office of the Assistant Secretary for Health, HHS. Notice of availability of reports. Fed Regist 1983; 48:34408.
  40. Halevy A, Brody BA. A multi-institution collaborative policy on medical futility. JAMA 1996; 276:571.
  41. Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med 1997; 25:887.
  42. Fine RL. The Texas Advance Directives Act of 1999: politics and reality. HEC Forum 2001; 13:59.
  43. Heitman E, Gremillion V. Ethics committees under Texas law: effects of the Texas Advance Directives Act. HEC Forum 2001; 13:82.
  44. Pope TM. Procedural due process and intramural hospital dispute resolution mechanisms: the Texas Advance Directives Act. St Louis U J Health Law Policy 2017; 10:93.
  45. Fine RL, Mayo TW. Resolution of futility by due process: early experience with the Texas Advance Directives Act. Ann Intern Med 2003; 138:743.
  46. Jacobs HC. The Texas Advance Directives Act--is it a good model? Semin Perinatol 2009; 33:384.
  47. Truog RD. Counterpoint: The Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process. Chest 2009; 136:968.
  48. Smith ML, Gremillion G, Slomka J, Warneke CL. Texas hospitals' experience with the Texas Advance Directives Act. Crit Care Med 2007; 35:1271.
  49. Cederquist C. Model Policy on “Non-beneficial Treatment,” 2009 http://www.thaddeuspope.com/images/Model_Policy_on_Non-beneficial_Treatment_San_Diego_County_Medical_Society.pdf (Accessed on January 23, 2015).
  50. Moss AH. Revised dialysis clinical practice guideline promotes more informed decision-making. Clin J Am Soc Nephrol 2010; 5:2380.
  51. Snyder L, American College of Physicians Ethics, Professionalism, and Human Rights Committee. American College of Physicians Ethics Manual: sixth edition. Ann Intern Med 2012; 156:73.
  52. Rosa RF, Rosa RC, Zen PR, et al. Trisomy 18: review of the clinical, etiologic, prognostic, and ethical aspects. Rev Paul Pediatr 2013; 31:111.
  53. Janvier A, Farlow B, Wilfond BS. The experience of families with children with trisomy 13 and 18 in social networks. Pediatrics 2012; 130:293.
  54. McGraw MP, Perlman JM. Attitudes of neonatologists toward delivery room management of confirmed trisomy 18: potential factors influencing a changing dynamic. Pediatrics 2008; 121:1106.
  55. A definition of irreversible coma. Report of the Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. JAMA 1968; 205:337.
  56. Pope TM. Brain death forsaken: growing conflict and new legal challenges. J Leg Med 2017.
  57. Lewis A, Pope TM. Physician Power to Declare Death by Neurologic Criteria Threatened. Neurocrit Care 2017; 26:446.
  58. Miles SH, Cranford R, Schultz AL. The do-not-resuscitate order in a teaching hospital: considerations and a suggested policy. Ann Intern Med 1982; 96:660.
  59. Muller JH. Shades of blue: the negotiation of limited codes by medical residents. Soc Sci Med 1992; 34:885.
  60. Lantos JD, Meadow WL. Should the "slow code" be resuscitated? Am J Bioeth 2011; 11:8.
  61. Frader J, Kodish E, Lantos JD. Ethics rounds. Symbolic resuscitation, medical futility, and parental rights. Pediatrics 2010; 126:769.
  62. Paris JJ, Moore MP. The resuscitation of "slow codes": fraud, lies, and deception. Am J Bioeth 2011; 11:13.
  63. Mueller PS, Hook CC, Fleming KC. Ethical issues in geriatrics: a guide for clinicians. Mayo Clin Proc 2004; 79:554.
  64. Lucente FE. Ethical challenges in geriatric care. Otolaryngol Head Neck Surg 2009; 140:809.
  65. Pope TM. Legal briefing: the new Patient Self-Determination Act. J Clin Ethics 2013; 24:156.
  66. Brinkman-Stoppelenburg A, Rietjens JA, van der Heide A. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med 2014; 28:1000.
  67. Teno J, Lynn J, Wenger N, et al. Advance directives for seriously ill hospitalized patients: effectiveness with the patient self-determination act and the SUPPORT intervention. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. J Am Geriatr Soc 1997; 45:500.
  68. Fromme EK, Zive D, Schmidt TA, et al. Association between Physician Orders for Life-Sustaining Treatment for Scope of Treatment and in-hospital death in Oregon. J Am Geriatr Soc 2014; 62:1246.
  69. Jacobsen J, Billings A. Easing the burden of surrogate decision making: the role of a do-not-escalate-treatment order. J Palliat Med 2015; 18:306.
  70. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). The SUPPORT Principal Investigators. JAMA 1995; 274:1591.
  71. Fins JJ, Solomon MZ. Communication in intensive care settings: the challenge of futility disputes. Crit Care Med 2001; 29:N10.
  72. Prendergast TJ. Resolving conflicts surrounding end-of-life care. New Horiz 1997; 5:62.
  73. Brimblecombe C, Crosbie D, Lim WK, Hayes B. The Goals of Patient Care project: implementing a proactive approach to patient-centred decision-making. Intern Med J 2014; 44:961.
  74. Kon AA. The shared decision-making continuum. JAMA 2010; 304:903.
  75. Kon AA. Informed non-dissent: a better option than slow codes when families cannot bear to say "let her die". Am J Bioeth 2011; 11:22.
  76. Quill TE, Arnold R, Back AL. Discussing treatment preferences with patients who want "everything". Ann Intern Med 2009; 151:345.
  77. Shrime MG, Ferket BS, Scott DJ, et al. Time-Limited Trials of Intensive Care for Critically Ill Patients With Cancer: How Long Is Long Enough? JAMA Oncol 2016; 2:76.
  78. Rinehart A. Beyond the futility argument: the fair process approach and time-limited trials for managing dialysis conflict. Clin J Am Soc Nephrol 2013; 8:2000.
  79. Quill TE, Holloway R. Time-limited trials near the end of life. JAMA 2011; 306:1483.
  80. O'Mahony S, McHenry J, Blank AE, et al. Preliminary report of the integration of a palliative care team into an intensive care unit. Palliat Med 2010; 24:154.
  81. Schneiderman LJ, Gilmer T, Teetzel HD, et al. Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial. JAMA 2003; 290:1166.
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