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.
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