Words Matter...

"The other conflict experienced was trying to temper my sense of futility with the family's hopefulness."

"I want everything done for my baby" is one of the most profoundly life-changing comments a parent can make."

The above quotes highlight two words with contested definitions in critical care medicine, futility, and everything. No two words, in my opinion, carry more weight in the day-to-day discussions at a baby's bedside. We'll tackle futility first.

The word futility is derived from the Greek "futilis," meaning easily meltable or pourable. The most common usage of the word, however, comes from the Greek legend of Danaus. In the myth, Danaus's daughters kill their husbands and are destined to fetch water in leaky buckets. In this sense, if they intended to bring water somewhere, their leaky buckets make this task impossible. This parable is the classic definition of futility, but we would not have a post dedicated to words if it were that easy.

If the intent of medicine and nursing is to benefit the patient, the presence of futility is the absence of benefit. Several definitions of futility have been proposed, and we will discuss them here along with their drawbacks. We will finally end the futility section with a proposal to use different words when describing seemingly futile medical interventions.

Physiologic futility describes a situation in which further interventions cannot lead to an intended physiologic objective. For example, if healthcare providers intubate a baby at 22 weeks' gestation, and the baby does not respond to positive pressure ventilation through the ETT at all, this is physiologically futile. The problem with this definition may not be immediately apparent but, to deem the above intervention as futile, it was tried in the first place. This is to say, futility is often defined retrospectively and not prospectively.

If, in the above scenario, the healthcare providers decide not to intubate the patient because they deem such an action as futile, they may be correct. Still, it may not have been a decision based on the physiologic definition of futility. Herein lies a problem with the physiologic definition of futility. A values-based judgment sneaks in before the healthcare provider takes action. We know from a robust body of literature that intubation PPV for infants born at 22 weeks' gestation often successfully leads to admission to the NICU.

Distinct from the physiologic definition are those definitions proposed by the late Dr. LJ Schneiderman. Dr. Schneiderman proposed both qualitative futility and quantitative futility. We will discuss each. Qualitative futility refers to medical treatments that merely prolong living in an unconscious state. Also included are cases wherein the patient cannot wean from intensive care therapies. Critics of such a definition point out that many in the lay public (and many physicians and nurses) value life at all costs, no matter the condition. Deeming such care as futile would invalidate their beliefs.

Quantitative futility, as proposed by Dr. Schneiderman, is fascinating. For an action to meet the definition of quantitative futility, it must have been unsuccessful 100 times in the past. Some problems immediately arise, especially for neonates with rare conditions. Very few of our most complex babies have the benefit of 100 similar patients in the medical literature for us to reference, let alone 100 patients in which healthcare providers tried and failed to keep them alive using a unique treatment. Let us assume a low-risk; low-cost treatment has a low side effect profile and a high risk to reward ratio. With the treatment, the patient may live. Without it, they will surely die. Their current condition will not worsen with the treatment. If the treatment's predicted success is 1 in 200, according to Dr. Schneiderman's definition of quantitative futility, it should not be provided. Clearly, this would be a discussion with the family and not a unilateral decision against therapy provision.

In the sense that futility obviates healthcare providers from providing care they deem ineffectual, the term runs the risk of paternalization of decisions. For example, suppose a treatment is unlikely to prove a benefit, and the healthcare provider simply disagrees with the patient's stated values. In that case, it is not hard to imagine using the word futility as a trump card to avoid further treatment. To combat such scenarios, the Society for Critical Care Medicine separated futility from potentially inappropriate therapy in the release of their Multi-organization Policy Statement.

In the statement, treatments that have some chance of achieving the effect the patient desires but the healthcare providers object given competing ethical obligations are named potentially inappropriate. In such cases, healthcare providers should advocate for the care they believe is appropriate and avoid the use of futility, given it may provide them with more power over healthcare decisions. Inappropriate treatments refer to differences in values. The prolongation of life for a neonate reliant upon the ventilator with no hope of weaning is undoubtedly inappropriate for many but, perhaps, not for the parents. Further exploration and communication between healthcare providers and parents in such cases is needed. Mechanisms to resolve intractable cases of the provision of potentially inappropriate treatments exist and ought to be utilized when appropriate.

What follows below is an essay from 2016. I wrote it as part of an invitation from a friend a colleague. The theme of the essays was words we use in everyday medicine with nebulous meanings. My piece starts on page 13 and runs to page 14. I suggest reading the essays from others, including one from a parent. Please also watch the video below regarding the word, "candidate."

Bioethics Fall 2016.pdf

Download PDF • 852KB

References:

Ardagh M. Futility has no utility in resuscitation medicine. JME. 2000;26

Kon AA. Futile and potentially inappropriate interventions: Semantics matter. Perspectives in Biology and Medicine. 2017. 60;3

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