Can physicians' judgments of futility be accepted by patients? A comparative survey of Japanese physicians and laypeople

Medical futility at the end of life: the first qualitative study of ethical decision-making methods among Turkish doctors

BACKGROUND

The swift advancement of intensive care medicine, coupled with technological possibilities, has prompted numerous ethical inquiries regarding decision-making processes concerning the withholding or withdrawal of treatment due to medical futility. This study seeks to delineate the decision-making approaches employed by intensive care physicians in Türkiye when faced with medical futility at the end of life, along with an ethical evaluation of these practices.

METHODS

Grounded theory, a qualitative analysis method was employed, conducting semi-structured, in-depth interviews with eleven intensive care physicians in Türkiye. The subsequent text analysis was carried out using MAXQDA software.

RESULTS

Participants assert that the decisions made by Turkish physicians determine whether treatment is futile, rely on medical consensus, and lack a standardized decision-making process. The decisions are influenced by legal and social pressures, resource constraints, and occasional conflicts of interest. The significance of professional hierarchy is notable, with limited consideration given to the opinions of nurses and other staff. The unstructured medical consensus processes are shaped by normative concepts such as benefit, age, justice, and conscience. Furthermore, it was observed that the conscientious opinions of physicians carry more weight than adherence to ethical principles and guidelines.

CONCLUSION

To create optimal conditions for doctors to make ethically justifiable decisions, the dynamics within the treatment team should be improved, emphasizing the minimization of hierarchy, and ensuring the active participation of all team members in the decision-making process. Additionally, efforts should be directed toward narrowing the gap between the conscience of the individual doctor and established ethical principles. A potential solution lies in the nationwide implementation of clinical ethics committees and the establishing of clinical ethics guidelines, aiming to address, and overcome the identified challenges.

Relationship Between Physician's and Nurses' Attitudes Towards Futile Treatment and Their Approach to Death and Terminally Ill Patients

We aimed to determine the relationship between the attitudes of healthcare professionals towards futile treatment and their approach to death and terminally ill patients. We collected the data from nurses-physicians working in the intensive care unit, using the Nurses' Attitudes towards Futile Treatment Scale (NAFTS) and Approach to Death and Dying Patients Attitude Scale (ADDPAS). Avoidant attitudes displayed towards death and terminally ill patients increase as futile treatment is administered more. Health workers who work in the intensive care unit and witness futile treatment more frequently in the clinic are of the opinion that futile treatment should not be performed.

A systematic review defining non-beneficial and inappropriate end-of-life treatment in patients with non-cancer diagnoses: theoretical development for multi-stakeholder intervention design in acute care settings

Background

Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.

Aim

To define and understand determinants of  non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.

Design

Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.

Data sources

Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.

Results

Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences.

Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to ‘Motivation to Address Conflict & Seek Agreement’ helped to lessen uncertainty around decision-making. Establishing agreement was reliant on ‘Valuing Clear Communication and Sharing of Information’. Reaching consensus was dependent on ‘Choices around Timing & Documenting of end-of-life Decisions’.

Conclusion

A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.

Trial registration

PROSPERO Protocol CRD42021214137.

Factors Influencing Potentially Futile Treatments at the End of Life in a Multiethnic Asian Cardiology Setting: A Qualitative Study

BACKGROUND

Modern medicine enables clinicians to save lives and prolong time to death, yet some treatments have little chance of conferring meaningful benefits for patients nearing the end-of-life. What clinicians perceive as driving futile treatment in the non-Western healthcare context is poorly understood.

AIM

This study aimed to explore clinicians' perceptions of the factors that influence futile treatment at the end of life within a tertiary hospital cardiac care setting.

DESIGN

We conducted semi-structured interviews with cardiologists, cardiac surgeons, and palliative care doctors from a large national cardiology center in Singapore. Interviews were transcribed verbatim and thematically analyzed.

RESULTS

A total of 32 clinicians were interviewed. We identified factors that contributed to the provision of potentially futile treatment in these theme areas: patient- and family-related, clinician-related, and institutional and societal factors. Family roles and cultural influences were most commonly cited by participants as affecting end-of-life decisions and altering the likelihood of futile treatment. Specialty-specific alignments within cardiology and availability of healthcare resources were also important factors underpinning futile treatment.

CONCLUSION

Family-related factors were a primary driver for futile treatment in a non-Western, multicultural setting. Future interventions should consider a targeted approach accounting for cultural and contextual factors to prevent and reduce futile treatment.

Is shared decision-making to blame for the provision of ethically inappropriate treatment? Results of a multi-site study exploring physician understanding of the "shared" model of decision making

Support for the concept of respect for first-person informed consent and patient autonomy, including the negative right of patients to refuse unwanted interventions has grown, but does not generally include a positive right of patients to receive whatever treatment they request or demand without constraint. Despite this, health-care providers in both Canada and the United States are guilty of providing, in their own opinions, futile or probably futile treatments at the request of patients or their substitute decision-makers. The purpose of this study was to examine whether physicians' understanding of the shared model of medical decision-making - shared decision-making, (SDM) - may be among the reasons why some patients receive treatment understood as ethically inappropriate, including those deemed futile, treatments that are not medically indicated, or those that are not in the patient's best interests to receive. A secondary question asked to study participants was whether they believed their professional college allowed, or further, required them to use shared decision-making in their practice. The initial hypothesis of the researcher in this study was that SDM is not well understood by physicians, and that this lack of understanding, combined with other factors to be discussed in the full text, may result in patients receiving ethically-inappropriate treatment. Results suggest support for this hypothesis, and that SDM should be more closely examined if it is to be pursued as a method of decision making.

A scale-development study: Exploration of intensive-care nurses' attitudes towards futile treatments

The study was conducted to determine the validity and reliability of the tool used to assess nurses' attitudes towards futility, and to explore intensive-care nurses' attitudes towards futility. Principal components analysis revealed that 18item scale was made up of four subdimensions that assess Identifying(beliefs), Decision-Making, Ethical Principles and Law, and Dilemma and Responsibilities related to futile treatments. The internal consistency of the scale was in the acceptable range, with a total Cronbach's alpha value of 0.72. Overall the results of study suggest that scale can be used as a valid and reliable assessment tool to assess nurses' attitudes towards futility.

Medical futility and its challenges: a review study

Concerns over limited medical equipment and resources, particularly in intensive care units (ICUs), have raised the issue of medical futility. Medical futility draws a contrast between physician's authority and patients' autonomy and it is one of the major issues of end-of-life ethical decision-making. The aim of this study was to review medical futility and its challenges. In this systematized review study, a comprehensive search of the existing literature was performed using an internet search with broad keywords to access related articles in both Persian and English databases. Finally, 89 articles were selected and surveyed. Medical futility is a complex, ambiguous, subjective, situation-specific, value-laden, and goal-dependent concept which is almost always surrounded by some degrees of uncertainty; hence, there is no objective and valid criterion for its determination. This concept is affected by many different factors such as physicians' and patients' value systems, medical goals, and sociocultural and religious context, and individuals' emotions and personal characteristics. It is difficult to achieve a clear consensus over the concept of medical futility; hence, it should be defined and determined at an individual level and based on the unique condition of each patient.

Reasons behind providing futile medical treatments in Iran

Background:

Despite their negative consequences, evidence shows that futile medical treatments are still being provided, particularly to terminally ill patients. Uncovering the reasons behind providing such treatments in different religious and sociocultural contexts can create a better understanding of medical futility and help manage it effectively.

Research objectives:

This study was undertaken to explore Iranian nurses’ and physicians’ perceptions of the reasons behind providing futile medical treatments.

Research design:

This was a qualitative exploratory study. Study data were gathered through conducting in-depth semi-structured personal interviews and analyzed using the conventional content analysis method.

Participants and research context:

Twenty-one nurses and nine medical specialists were recruited purposively from four teaching hospitals affiliated to Tehran University of Medical Sciences.

Ethical considerations:

This study was approved by the Nursing and Midwifery Research Center and the Research Ethics Committee of Tehran University of Medical Sciences. All participants gave informed consent for the research and that their anonymity was preserved.

Findings:

The main theme of the study was “having an obligation to provide medical treatments despite knowing their futility.” This theme consisted of three main categories including patients’ and family members’ request for continuing life-sustaining treatments, healthcare professionals’ personal motives, and organizational atmosphere and structure.

Discussion and conclusion:

Different personal and organizational factors contribute to providing futile medical treatments. Promoting the structure and the function of hospital ethics committees, establishing and developing home care facilities, increasing the number of palliative care centers and hospices, and educating healthcare professionals, patients, and family members about the services and the benefits of such centers can facilitate making wise decisions about continuing or discontinuing treatments which have been labeled as futile.

Reasons doctors provide futile treatment at the end of life: a qualitative study

OBJECTIVE

Futile treatment, which by definition cannot benefit a patient, is undesirable. This research investigated why doctors believe that treatment that they consider to be futile is sometimes provided at the end of a patient's life.

DESIGN

Semistructured in-depth interviews.

SETTING

Three large tertiary public hospitals in Brisbane, Australia.

PARTICIPANTS

96 doctors from emergency, intensive care, palliative care, oncology, renal medicine, internal medicine, respiratory medicine, surgery, cardiology, geriatric medicine and medical administration departments. Participants were recruited using purposive maximum variation sampling.

RESULTS

Doctors attributed the provision of futile treatment to a wide range of inter-related factors. One was the characteristics of treating doctors, including their orientation towards curative treatment, discomfort or inexperience with death and dying, concerns about legal risk and poor communication skills. Second, the attributes of the patient and family, including their requests or demands for further treatment, prognostic uncertainty and lack of information about patient wishes. Third, there were hospital factors including a high degree of specialisation, the availability of routine tests and interventions, and organisational barriers to diverting a patient from a curative to a palliative pathway. Doctors nominated family or patient request and doctors being locked into a curative role as the main reasons for futile care.

CONCLUSIONS

Doctors believe that a range of factors contribute to the provision of futile treatment. A combination of strategies is necessary to reduce futile treatment, including better training for doctors who treat patients at the end of life, educating the community about the limits of medicine and the need to plan for death and dying, and structural reform at the hospital level.

Nurses' Perceptions of Futile Care: A Qualitative Study

Health care professionals believe that futile care must not be provided; however, there is no clear agreement over the definition and the manifestations of futile care. The aim of this study was to explore Iranian nurses' perceptions of futile care. In this qualitative exploratory study, the conventional content analysis approach was used for collecting and analyzing the study data. Three main themes were extracted from the data: nonfutility of care: care tantamount with outcome; sense of burnout; and subjectivity and relativity of medical futility concept.

Comparison of timing and decision-makers of do-not-resuscitate orders between thoracic cancer and non-cancer respiratory disease patients dying in a Japanese acute care hospital

PURPOSE

The aim of the study was to compare timing and decision-makers of do-not-resuscitate (DNR) orders between patients with end-stage thoracic cancer and non-cancer respiratory diseases in a Japanese acute care hospital.

METHODS

This study retrospectively reviewed the medical records of patients who died between January 2008 and March 2013 in the Department of Respiratory Medicine of Osaka Police Hospital, a teaching and acute care hospital. We compared the decision-making process, especially timing and decision-maker, of DNR orders between patients with thoracic cancer and patients with non-cancer respiratory diseases.

RESULTS

There were 300 cancer patients and 147 non-cancer patients. Cancer patients were significantly younger, were hospitalized more frequently and for longer, were more likely to have a DNR order placed earlier and decided in advance of last admission, and were more likely to have normal cognitive function at the time of the DNR order than non-cancer patients. Spouses of cancer patients were more likely to participate in DNR discussion. Only approximately 6 % of patients participated in DNR discussion in both groups. Cancer patients less frequently received aggressive treatment at the end of life (EOL) and were more likely to die in general wards than in intensive care units.

CONCLUSIONS

Our study found that most Japanese patients, with or without cancer, who died in an acute care respiratory department, were not included in DNR discussions and that familial surrogates usually made the DNR decision at the EOL.

A comparative survey on potentially futile treatments between Japanese nurses and laypeople

In the issue of futile treatments, patients and healthcare professionals tend to disagree. We conducted an Internet questionnaire survey and explored the Japanese nurses' attitude toward this topic, comparing with that of laypeople. In total, 522 nurses and 1134 laypeople completed the questionnaire. Nurse respondents were significantly less in favor of providing potentially futile treatments in hypothetical vignettes and stressed quality of life of the patient for judging the futility of a certain treatment. Of them, 85.4% reported having experienced providing such treatments. Reasons for providing them included factors related to not only patients but also healthcare teams. Our results indicate that attitudes among Japanese nurses toward the issue of futile treatments are different from patients and that their actual practice is influenced by several situational factors.