Medical futility in the era of evidence-based medicine

Zhengyu Jing,Lu Yng,Pinho Guo,Shnshn Gong

aCompany Twelve,Students Brigade,the Second Military Medical University,Shanghai 200433,China;

bDepartment of Foreign Languages,the Second Military Medical University,Shanghai 200433,China.

Medical futility in the era of evidence-based medicine

Zhengyu Jianga,△,Lu Yanga,△,Pinhao Guoa,Shanshan Gongb,✉

aCompany Twelve,Students Brigade,the Second Military Medical University,Shanghai 200433,China;

bDepartment of Foreign Languages,the Second Military Medical University,Shanghai 200433,China.

One definition of futility is any treatment that merely preserves permanent unconsciousness or fails to end total dependence of a patient on intensive medical care[1]. However,no agreement has ever been reached on what the exact definition of futility is,as it is not only based on temporary values but also evolves into different subtypes, making it harder to define[2].The difficulty in dealing with futility problem is how doctors evaluate the futile situation,which is further complicated by lack of stan–dards for specific diseases and experience–based prog–nosis,leading to subjectivity in evaluation for futility.

Since judgment and decision making by physicians play an overwhelmingly dominant role in the estima–tion of futility,evidence–based medicine(EBM)should be included as a general guideline,incorporating indi–vidual experience and the best current evidence[3]. EBM draws heavily from current research findings–especially from large randomized control trials (RCT)[4].Furthermore,this concept is evolving with the deepeninganddevelopment ofresearch,beingan evolu–tion itself.However,it is worthwhile to point out that EBM only predicts the effectiveness of an intervention byadjustingtheearlierconclusionaccordingtothenew–est results of recent research,but it cannot work in every particular case even in an approximation formula[5].

Cardiopulmonary resuscitation(CPR)in the intensive care unit(ICU)is likely a futile exercise if indiscrimi–nately practiced in patients,especially those who are unlikely to survive to hospital discharge.Despite the widespread use of do–not–resuscitate(DNR)orders, introduced nearly a half century ago,the outcome fol–lowing CPR has not been substantially improved[6]. Therefore,evidence–based selection of patients who will benefit from CPR is of paramount importance in avoid–ing medical futility.CPR is predicated on the assump–tion that CPR will be successful in maintaining the sacred life of a patient;to guard against its indiscrimi–nate and sometimes excessive use,we should garner clinical evidence through clinical trials and development of prediction models and scoring systems such as the Good Outcome Following Attempted Resuscitation (GO–FAR)score to guide physicians in making informed decision on the use of CPR[7].On the other hand,the DNR order requires patient consent to prevent a medical procedure from being performed;many patients or surrogates may overestimate the effects of CPR[8]and may oppose a DNR order by the physician.

Clinical studies are mainly classified into two cate–gories:studies that confirm that treatment in a specific situation is futile,meaning that the result supports the futility diagnosis,and studies that show potential effectiveness of a treatment,meaning that the result refutes the futility diagnosis[9].Futility usually focuses on two principles–improving the rate of survival and the quality of prolonged life[9].Physicians may con–sider whether further intervention will abide by the two principles,and if not,futility ensues.

However,sufficient and conclusive data from EBM, to some extent,is still lacking.Before conclusive data becomes available from EBM,physicians may have to rely on existing guidelines and professional judgment with consideration of patient autonomy to make an informed share decision in cases where medical futility may occur.

References

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[2] Wilkinson DJ,Savulescu J.Knowing when to stop: futility in the ICU.CurrOpinAnaesthesiol 2011;24: 160–5.

[3] Metzdorff MT.Evidence–based medicine:what it is,what it isn′t,and are we practicing it?J Trauma Acute Care Surg 2013;75:927–35.doi:10.1097/TA.0b013e3182932bac.

[4] Barrett B.Evidence,values,guidelines and rational deci–sion–making.J Gen Intern Med 2012;27:238–40.doi: 10.1007/s11606–011–1903–6.Epub 2011 Oct 5.

[5] Nordmann AJ,Kasenda B,Briel M.Meta–analyses:what they can and cannot do.Swiss Med Wkly 2012;9;142: w13518.doi:10.4414/smw.2012.13518.

[6] Marik PE,Craft M.An outcomes analysis of in–hospital cardiopulmonary resuscitation:the futility rationale for do not resuscitate orders.J Crit Care 1997;12:142–6.

[7] Ebell MH,Jang W,Shen Y,Geocadin RG.Development and validation of the Good Outcome Following Attempted Resuscitation(GO–FAR)score to predict neuro–logically intact survival after in–hospital cardiopulmonary resuscitation.JAMA internal medicine 2013;173(20): 1872–8.

[8] Michigan Employment Relations Commission.Decisions, findings of fact,conclusions of law and orders,volume 3.

[9] Gabbay E,Calvo–Broce J,Meyer KB,Trikalinos TA, Cohen J,Kent DM.The empirical basis for determinations of medical futility.J Gen Intern Med 2010;25:1083–9.

[10]Gristina GR,De Gaudio R,Mazzon D,Curtis JR.End of life care in Italian intensive care units:where are we now? Minerva Anestesiol 2011;77:911–20.

Received 29 April 2014,Revised 16 June 2014,Accepted 02 July 2014,Epub 10 July 2014

This paper was presented on the Fifth English Forum on Medical Humanities held at the Second Military Medical University,Shanghai, China,on 9 November 2013.

△These authors contribute equally to this paper.

✉Corresponding author:Shanshan Gong,Department of Foreign Languages,the Second Military Medical University,Shanghai 200433, China.Tel:+86–21–81870931,E–mail:anniegong0624@163.com.

The authors reported no conflict of interests.

©2014 by the Journal of Biomedical Research.All rights reserved.

10.7555/JBR.28.20140067