Use of the medical futility rationale in do-not-attempt-resuscitation orders

J. R. Curtis, D. R. Park, M. R. Krone and R. A. Pearlman
Robert Wood Johnson Clinical Scholars Program, University of Washington, Seattle.

OBJECTIVE. To describe the use of the medical futility rationale in do-not-attempt-resuscitation (DNAR) orders written for medical inpatients. DESIGN. Structured interviews with medical residents. METHODS. Second- and third-year internal medicine residents (n = 44) were telephoned weekly and briefly interviewed about each patient who received a DNAR order in the preceding week. SETTING. Two university-affiliated hospitals: a veterans affairs medical center and a municipal hospital. PATIENTS. One hundred forty-five medical inpatients for whom DNAR orders were written during their hospitalization. RESULTS. Residents stated that the medical futility rationale applied for 91 patients (63%), but this rationale was invoked independent of patient or surrogate choice for only 17 patients (12%). Of the 91 patients for whom futility applied, both quantitative futility (low probability of success) and qualitative futility (poor quality of life if cardiopulmonary resuscitation [CPR] were performed) applied to 45 (49%), quantitative futility alone to 30 (33%), and qualitative futility alone to 16 (18%). Residents report that they discussed resuscitation issues with all communicative patients for whom the medical futility rationale was invoked. Among patients for whom quantitative futility applied, residents' predictions of the probability that patients would survive to hospital discharge after CPR varied from 0% (for 60% of patients) to 75%. For 32% of these patients, residents predicted survival at 5% or more. Logistic regression modeling showed that the presence of organ failure (odds ratio [OR], 8.9; 95% confidence interval [CI], 3.3 to 23.9), the residents' estimates of the probability of surviving CPR (OR, 0.94; 95% CI, 0.88 to 0.99), and nonwhite race (OR, 2.7; 95% CI, 1.1 to 6.3) were associated with the determination of quantitative futility. In one third of the cases where qualitative futility applied, residents made the judgment of qualitative futility without discussing quality of life with communicative patients. Logistic regression modeling showed immobility (OR, 3.2; 95% CI, 1.1 to 9.0) and age > or = 75 years (OR, 0.3; 95% CI, 0.1 to 0.8) to be associated with the determination of qualitative futility. CONCLUSIONS. While residents did not appear to use the medical futility rationale to avoid discussing DNAR issues with patients, we found evidence of important misunderstandings of the concepts of both quantitative and qualitative futility. If the futility rationale is to be applied to withholding or withdrawing medical interventions, practice guidelines for its use should be developed, and education about medical futility must be incorporated into medical school, residency training, and continuing medical education programs.

THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES

Meeting Physicians' Responsibilities in Providing End-of-Life Care
Shanawani et al.
Chest 2008;133:775-786.
ABSTRACT | FULL TEXT  

Perceptions of "futile care" among caregivers in intensive care units
Sibbald et al.
CMAJ 2007;177:1201-1208.
ABSTRACT | FULL TEXT  

Point: The Ethics of Unilateral "Do Not Resuscitate" Orders: The Role of "Informed Assent"
Curtis and Burt
Chest 2007;132:748-751.
FULL TEXT  

Do-Not-Resuscitate Orders and Medical Futility
Cantor et al.
Arch Intern Med 2003;163:2689-2694.
ABSTRACT | FULL TEXT  

Determining resuscitation preferences of elderly inpatients: a review of the literature
Frank et al.
CMAJ 2003;169:795-799.
ABSTRACT | FULL TEXT  

Futility-of-care decisions in the treatment of moribund intensive care patients in a developing country: [L'acharnement therapeutique pour des moribonds a l'unite des soins intensifs dans un pays en developpement]
Hariharan et al.
Canadian J. Anesthesia 2003;50:847-852.
ABSTRACT | FULL TEXT  

Answers and Questions About Ethics Consultations
Lo
JAMA 2003;290:1208-1210.
FULL TEXT  

Withdrawing life support and resolution of conflict with families
Way et al.
BMJ 2002;325:1342-1345.
FULL TEXT  

Is There a Lingua Franca for Bioethics at the End of Life?
Derse
J Law Med Ethics 2000;28:279-284.
 

The Rise and Fall of the Futility Movement
Helft et al.
NEJM 2000;343:293-296.
FULL TEXT  

The Attitudes of Patients With Advanced AIDS Toward Use of the Medical Futility Rationale in Decisions to Forgo Mechanical Ventilation
Curtis et al.
Arch Intern Med 2000;160:1597-1601.
ABSTRACT | FULL TEXT  

Factors Associated With Use of Cardiopulmonary Resuscitation in Seriously Ill Hospitalized Adults
Goodlin et al.
JAMA 1999;282:2333-2339.
ABSTRACT | FULL TEXT  

Mechanical Ventilation in a Cohort of Elderly Patients Admitted to an Intensive Care Unit
Ely et al.
ANN INTERN MED 1999;131:96-104.
ABSTRACT | FULL TEXT  

Making decisions about the forgoing of life-sustaining therapy
Luce
Am. J. Respir. Crit. Care Med. 1997;156:1715-1718.
ABSTRACT | FULL TEXT  

Overriding a Patient's Refusal of Treatment after an Iatrogenic Complication
Casarett and Ross
NEJM 1997;336:1908-1910.
FULL TEXT  

Recommended Guidelines for Reviewing, Reporting, and Conducting Research on In-Hospital Resuscitation: The In-Hospital `Utstein Style' : A Statement for Healthcare Professionals From the American Heart Association, the European Resuscitation Council, the Heart and Stroke Foundation of Canada, the Australian Resuscitation Council, and the Resuscitation Councils of Southern Africa
Cummins et al.
Circulation 1997;95:2213-2239.
FULL TEXT  

Agreement on Disease-Specific Criteria for Do-Not-Resuscitate Orders in Acute Stroke
Alexandrov et al.
Stroke 1996;27:232-237.
ABSTRACT | FULL TEXT