INTRODUCTION — Clinicians are sometimes faced with requests to provide treatments for patients in the intensive care unit (ICU) that they judge to be ill-advised. These requests often arise due to poor communication regarding prognosis and treatment goals between the treating team and the patient and/or his or her surrogates. Sometimes, such requests arise because of value disagreements between the clinicians, the patient, and/or his or her surrogates about what the goals of care should be in light of a serious medical situation.
Issues related to requests for potentially inappropriate treatments and strictly futile interventions are reviewed here. Throughout the discussion, the term "surrogates" will include the person named by the patient to make health care decisions plus any person involved in making decisions for an incapacitated patient. Other issues related to issues that arise in the ICU, palliative care, and end of life care are discussed separately.
●(See "Communication in the ICU: Holding a meeting with families and caregivers".)
●(See "Palliative care: Issues in the intensive care unit in adults".)
●(See "Ethics in the intensive care unit: Informed consent".)
●(See "Sedative-analgesic medications in critically ill adults: Selection, initiation, maintenance, and withdrawal".)
●(See "Withholding and withdrawing ventilatory support in adults in the intensive care unit".)
●(See "Palliative sedation".)
●(See "Overview of comprehensive patient assessment in palliative care".)
●(See "Communication of prognosis in palliative care".)
●(See "Survival estimates in advanced terminal cancer".)
●(See "Legal aspects in palliative and end-of-life care in the United States" and "Ethical issues in palliative care".)
DEFINITIONS — The term futile has often been used by clinicians to describe any treatments that they think should not be administered to a patient with advanced illness. We suggest that the term "futile treatment" be reserved for a much rarer class of cases in which the treatment cannot accomplish the intended physiological goals and that the term "potentially inappropriate treatment" be used in the vast majority of cases that arise in intensive care units (ICUs).
●The term "futile" or "futility" should be used only to describe treatments that simply cannot accomplish the intended physiological goals . In general, very few conflicts in the ICU arise because of requests for truly futile treatments. Instead, most conflicts arise from disagreements over what treatment goals are reasonable and what chances of success are high enough to warrant treatment.
Clinicians should not label interventions as futile simply because they believe the treatment is not cost-effective or think that the potential benefits are too unlikely or too small to outweigh the burdens.
●The term "potentially inappropriate" refers to treatments that have at least some chance of accomplishing their intended goal, but the clinicians judge the treatment is outside the boundaries of accepted practice due to other ethical considerations. These reasons could include that the treatment is exceedingly unlikely to accomplish the patient's goals, represents an unfair allocation of scarce resources, or is intended to achieve a goal that is contrary to accepted medical goals [2,3].
An individual clinician's judgment that a requested treatment is inappropriate should trigger careful conversations with surrogates and, if the conflict persists, a fair process of conflict resolution, as described below (see 'Conflict resolution' below). The rationale for this change in terminology is that there is an important ethical distinction between interventions that simply cannot work (futile interventions) and interventions that might achieve some effects sought by the patient or family but clinicians nonetheless raise ethical objections (potentially inappropriate treatment). There is no single measure of what is "beneficial" or "valuable," especially in a pluralistic society. Decisions about potentially inappropriate interventions require complex judgments taking into account the clinicians', patients', and surrogates' diverse and personal conceptions of what gives life meaning [4,5]. The term potentially inappropriate treatment more clearly conveys the value-laden nature of these judgments.
For example, a clinician may believe that the most respectful way to care for a patient with advanced dementia and multi-organ failure is to pursue a course of treatment focused on comfort, without the use of life prolonging therapies. However, a particular patient may have a deeply held moral or religious belief that the best way to respect the sanctity of life is to attempt to extend the patient's life even in end-stage disease.
PREVALENCE — Several observational studies suggest that it is not rare that clinicians are confronted with requests by surrogates for treatment they judge to be inappropriate or futile [6-8]. For example, one prospective study in five intensive care units (ICUs) reported the frequency with which the attending physician believed treatment to be futile, using a broad definition of futile (in contrast to what we recommend) . During a three-month period, among the 1136 patients, 20 percent were perceived as receiving therapy that was probably futile (9 percent) or futile (11 percent). Two-thirds of those perceived as receiving futile therapy died before hospital discharge and the remaining one-third either died in the subsequent six months or remained in a severely compromised state of health. This study also illustrated that these cases often hinge on judgments about whether the burdens of intensive treatment outweigh the benefits, rather than whether treatment is strictly futile (ie, stands no chance of accomplishing the patient's goals).
PREVENTION OF CONFLICTS — Studies suggest that most clinician-surrogate conflicts can be resolved collaboratively through ongoing dialogue [9,10] or with the help of expert consultation, such as ethics or palliative care consultants [11-15]. Most clinician-surrogate disagreements do not arise from true value conflicts (ie, differences in deeply held values and beliefs about treatment goals), but instead are a result of inadequate communication and support in the face of a life threatening illness [9,10].
In order to prevent potential conflicts around treatment decisions, a collaborative team that involves members of the health care team, the patient, and his or her surrogates should be assembled (algorithm 1) . In addition, clinicians should communicate with the patient and/or his or her surrogates empathetically in order to foster a dialogue in which the values and goals of both sides are explored. These conversations are often best handled in the context of a family meeting. (See "Communication in the ICU: Holding a meeting with families and caregivers".)
Important aspects that should be addressed include:
●A careful delineation of the patient's medical situation and prognosis. (See "Communication of prognosis in palliative care" and "Survival estimates in advanced terminal cancer".)
Clinicians should communicate using culturally-sensitive language and make a special effort to avoid medical terminology. This can ensure the discussion is easily understood by all parties involved. (See "Communication in the ICU: Holding a meeting with families and caregivers", section on 'Sharing clinical information'.)
●Discussion of the patient's treatment preferences, health related values, and interests. As in other areas of medicine, the patient's wishes should be given substantial weight in decision making. When patients have not communicated clear treatment preferences, clinicians should facilitate a process in which surrogates make judgments about what treatment pathway is most consistent with the patient's values and interests. (See "Palliative care: Issues in the intensive care unit in adults", section on 'Communication issues' and "Legal aspects in palliative and end-of-life care in the United States", section on 'Surrogate decision makers'.)
●Determination of the goals of treatment and care by the patient and/or his or her surrogates. This may be for prolongation of life, relief of pain and suffering, avoidance of prolonged dependence on life support, and/or ensuring a peaceful death.
●Discussion of medically reasonable treatment options available to achieve the goals of care, including a review of the risks and benefits of each treatment. This may be a difficult discussion given that clinicians and patients (or their surrogates) occasionally disagree about whether the risks of harm outweigh the chances of benefit. During these discussions, strictly futile interventions should not be offered.
The prevention of conflict is an important aspect of care in intensive care units (ICUs), particularly for clinicians, because such conflicts are associated with moral distress and burnout [6,17]. In one study conducted across 82 ICUs, the provision of inappropriate care by clinicians (reported by approximately 30 percent) was independently associated with the intent to leave his or her job (odds ratio 1.65, 95% CI 1.04-2.63) .
CONFLICT RESOLUTION — We agree with the conflict resolution process that was published as a joint policy statement by five North American and European professional societies, which is summarized below  and a similar statement issued by the Society of Critical Care Medicine . (See 'Responding to requests for potentially inappropriate interventions' below and 'Six-step process to conflict resolution' below.)
A central point of the recommendations is that there should be different conflict resolution pathways for requests for potentially inappropriate treatments and requests for strictly futile treatments. Nonetheless, in both instances it is important that a respectful relationship and open lines of communication be maintained between the treatment team and the patient and/or his or her surrogates. In addition, other means of support (eg, palliative care consultants, hospital chaplains) should be called upon as needed. In all cases in which the processes outlined are used, we recommend that clinicians and administrators analyze the cases to foster learning within the intensive care unit and help to identify strategies to prevent similar occurrences.
Responding to requests for potentially inappropriate interventions — If patients (or their surrogates) request treatments that the clinician feels are potentially inappropriate, efforts to find a negotiated agreement should be made through both intensive communication between the clinical team and the patient/family and through the involvement of expert consultants (eg, hospital ethics committees, palliative care consultants, or mediation experts) .
Clinicians should not simply acquiesce to requests for treatments that they believe violate accepted medical practice, since this violates the ethical obligations to practice with professional integrity, refrain from harming patients, and fairly allocate scarce medical resources. Clinicians also should avoid acting alone when making decisions about whether a requested treatment is inappropriate. There may be legitimate uncertainty about what is appropriate treatment, particularly in patients who are near the end of life, and individual clinicians may not be well-positioned to make such judgments independently.
Six-step process to conflict resolution — The multi-professional society guidelines recommend a six step process to manage conflicts that remain intractable despite intensive communication and expert consultation (algorithm 2). This approach is similar to the approach recommended by the American Medical association (AMA) . The results of one or more steps of the dispute resolution process may result in a shared decision between the treatment team and the patient and his or her surrogates. (See "A patient-centered view of the clinician-patient relationship".)
●Inform the surrogate about the conflict resolution process – The patient and/or surrogates should be informed that a process-based resolution procedure has been initiated. They should also be informed about the steps involved in such a process, and the anticipated timeline.
●Request review by a multidisciplinary hospital committee – The clinical team should request that the case be reviewed by a multidisciplinary hospital committee, usually the hospital ethics committee. Such a committee should be interprofessional in nature and should strive to have community representation. Both the clinicians and the patient/surrogate should be asked to explain the reasons underlying their beliefs about the correct treatment plan. The opinions of the committee should be provided in writing to the treatment team and to the surrogate, and should include reasons for the committee's determination.
●Encourage ongoing dialogue – An important goal of the resolution process is to mediate a mutually agreeable solution. This may be done by encouraging clinicians and the patient (and/or his or her surrogates) to continue to talk together with the goal to hopefully reconsider their positions. This is particularly important as new information becomes available or the specific clinical situation changes.
●Attempt to transfer the patient to a willing provider – If an agreement cannot be reached, the clinician should offer the patient and/or his or her surrogates the opportunity to transfer care to a willing provider. This step is important because, with the exception of treatments that are strictly futile, there is often uncertainty about what are boundaries of acceptable practice in patients with advanced critical illness.
Clinicians and the institution should offer to share responsibility for seeking an alternative provider because genuine efforts to facilitate transfer require expertise that patients and surrogates generally do not have. This includes identifying and contacting alternative providers, explaining the clinical situation to them, and assisting with the logistics of the transfer process.
•If a willing provider is found and the patient is medically stable to permit it, the patient should be transferred.
•If no willing provider can be found after a diligent search, a stronger case can be made that the requested treatments are inappropriate.
●If no willing provider can be found at other institutions, inform surrogates of their right to seek legal intervention. The rationale for this step is that a central element of procedural fairness is preserving the opportunity for appeal of the decision to a legitimate, impartial body, which may not always be achieved with existing institutional review processes.
Although case review by a multidisciplinary hospital committee accomplishes the goal of gaining the perspective of individuals not directly involved in the patient's care, some have argued that this review may yield a biased conclusion in favor of the treatment team, because the membership on such hospital committees tends to be dominated by employees of the hospital . In the United States, independent legal intervention has traditionally been filled by the courts, although other appeals processes are theoretically possible, such as non-judicial appeals boards  or mechanisms similar to the Ontario Capacity and Consent Board .
●Take the appropriate action:
•If the hospital review committee concurs with the clinicians' judgment, clinicians are ethically justified to refuse to provide the requested treatments, particularly if no willing provider can be located and the family chooses not to seek legal intervention.
•If the review committee concurs with the surrogates' judgment, or if a willing provider is located, the treatment in question should be continued or the patient transferred to a willing provider.
Outside of the state of Texas , this procedural approach does not guarantee legal protection for clinicians. Therefore, it is important that the hospital leadership of the institution in which the patient is being cared for supports the dispute resolution process. As an example, the policy at Children's Hospital in Boston is to label such decisions as "institutional," rather than "individual" decisions made by a specific provider .
TIME PRESSURED DECISIONS — Whenever possible, discussion about treatments and goals should be carried out before a crisis situation supervenes, including documentation of advance directives. (See "Advance care planning and advance directives".)
Occasionally, surrogates may request treatments that clinicians deem inappropriate and, because of the urgency of the clinical situation, there may be insufficient time to undertake a formal conflict resolution process such as the one discussed previously. (See 'Six-step process to conflict resolution' above.)
The multi-professional policy statement recommends that there are certain circumstances in which clinicians should be permitted to refuse to provide a requested treatment even if time-pressures make it infeasible to complete the six-step resolution process outlined above . (See 'Six-step process to conflict resolution' above.)
The ethically important features to managing time-pressured decisions are:
●That clinicians should only use this pathway when there is a high degree of certainty that what is being requested is outside the boundaries of accepted practice
●That treatment refusals over the objections of surrogates are managed using as much of the six-step conflict resolution process as is possible given the clinical circumstances
●There is retrospective review of such cases
●This approach should only be used in exceptional circumstances, and only as a last resort
As an example, a surrogate may be present during an unexpected cardiopulmonary arrest that results in ongoing cardiopulmonary resuscitation (CPR) of their loved one. Despite multiple unsuccessful rounds of CPR, the surrogate may insist that CPR continue. In such a circumstance we believe it is important that the treating team achieve a consensus on whether continuation of CPR is outside the boundaries of accepted practice. If the team agrees that continuing CPR would be inappropriate, a designated member of the clinical team should inform the surrogate of this decision and give the reasons behind the decision. Following this, resuscitative efforts should be ceased, and the case should be retrospectively reviewed to identify areas in which care process can be improved.
Responding to requests for physiologically futile interventions — When faced with requests to provide intervention(s) that cannot accomplish the intended physiological goals, clinicians should seek to understand the reasons underlying such requests, address misperceptions, provide emotional support, and explain why they feel that the requested interventions should not be provided. The involvement of consultants or ancillary services, such as palliative care or ethics consultants or hospital chaplains may be helpful during these discussions.
If this approach does not lead to consensus or if there is any uncertainty on whether or not a treatment is futile (expressed by any member of the treatment team), clinicians should seek a second opinion from a qualified and independent provider.
Ultimately, there is widespread agreement that clinicians are not obligated to provide futile treatments on the following grounds:
●Providing futile therapy goes against the ethical obligation of physicians to act to benefit their patients and to refrain from harming them [1,27].
●Clinicians have a legitimate interest in safeguarding their profession's integrity and trustworthiness, which would be undermined if clinicians administered interventions that they knew cannot achieve the intended physiological goals.
CONSCIENTIOUS OBJECTION AND REQUESTS FOR POTENTIALLY INAPPROPRIATE TREATMENT — In rare instances in which a fair process of conflict resolution is pursued, the outcome will be a recommendation to provide or discontinue the requested treatments; an individual clinician may have a deep moral disagreement with doing so. Such conscience-based refusals by clinicians deserve respect and careful consideration; they also should not be allowed to impose an undue burden on the patient, family, or other clinical staff. We agree with the principles outlined by a policy statement from the American Thoracic Society on managing clinicians' conscientious objections .
Do-not-escalate-treatment orders — Some surrogate decision makers remain uncomfortable with being asked to withdraw or withhold treatments, but may understand that escalating therapy is unlikely to significantly impact the overall prognosis of their loved one (eg, additional inotropic support, hemodialysis). Thus, placing limits to escalating therapies can alleviate the burden of the decision to completely withhold or withdraw treatment. Further discussion of do-not-escalate-treatment (DNET) orders are discussed separately. (See "Palliative care: Medically futile and potentially inappropriate therapies of questionable benefit", section on 'Do-not-escalate-treatment orders'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Intensive care unit ethics".)
SUMMARY AND RECOMMENDATIONS
●The term "potentially inappropriate" should be used to describe treatments that clinicians believe go against their best understanding of their professional obligations. This includes treatment that is exceedingly unlikely to accomplish the patient's goals, represents an unfair allocation of scarce resources, and treatment intended to achieve a goal that is contrary to what the clinician believes is appropriate. The term "futile" treatment should be used to describe interventions that cannot accomplish the intended physiological goals (see 'Definitions' above). Requests for strictly futile interventions are very rare in intensive care units (ICUs).
●A clinician's initial response to a request for potentially inappropriate treatment should include intensive efforts to find a negotiated agreement, through both dialogue with the family and the involvement of expert consultants such as hospital ethics committees, palliative care consultants, or mediation experts (algorithm 1). If a mutually acceptable treatment plan cannot be found, there should be a fair process of dispute resolution, such as that recommended by a recent policy statement from five North American and European professional societies. (See 'Conflict resolution' above.)
●The recommended six-step process to conflict resolution entails: (1) Inform the surrogate about the conflict resolution process, (2) request review by a multidisciplinary hospital committee, (3) continue dialogue between the clinical team and surrogate, (4) attempt to transfer the patient to a willing provider, (5) inform surrogates of their right to seek legal intervention, and (6) implement a plan of care. (See 'Six-step process to conflict resolution' above.)
●In situations where a time-pressured decision is required, consensus should be reached by all involved clinicians around a specific decision prior to informing the patient and/or his or her surrogates and carrying out any action. (See 'Time pressured decisions' above.)
●Clinicians are not obligated to provide futile treatments. However, if a requested treatment is deemed futile, clinicians should carefully explain this to the patient and/or his or her surrogates and explain that the intervention will not be provided. In addition, they should seek input from other colleagues to aid in the conflict resolution process. (See 'Responding to requests for physiologically futile interventions' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges John Kellum, MD, who contributed to an earlier version of this topic review.
1 : Consensus statement of the Society of Critical Care Medicine's Ethics Committee regarding futile and other possibly inadvisable treatments.
6 : Perceptions of appropriateness of care among European and Israeli intensive care unit nurses and physicians.
8 : "Futile" care: do we provide it? Why? A semistructured, Canada-wide survey of intensive care unit doctors and nurses.
12 : A proactive approach to improve end-of-life care in a medical intensive care unit for patients with terminal dementia.
13 : Proactive palliative care in the medical intensive care unit: effects on length of stay for selected high-risk patients.
15 : Effect of ethics consultations on nonbeneficial life-sustaining treatments in the intensive care setting: a randomized controlled trial.
16 : Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected]of Critical Care Medicine.
18 : An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units.
19 : Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee.
20 : A history of resolving conflicts over end-of-life care in intensive care units in the United States.
24 : Best interests at end of life: a review of decisions made by the Consent and Capacity Board of Ontario.
26 : Counterpoint: The Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process.
27 : Counterpoint: The Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process.