The use of the term ‘futility’ in cancer care has been prompted, in part, by increasing requests from patients for treatments thought to be ineffective as well as costly.[1] The appropriate role of chemotherapy near the end of life is a complex issue.[2] As chemotherapy is increasingly available and better tolerated, its use at life's end involves sophisticated oncologic assessment, a focus on the patient's goals of care, and a balancing of perspectives of the patient and treating oncologist.
| THE ISSUES |
| What is 'futile care' and what drives it? |
A number of factors play a role in the delivery of chemotherapy to patients who are unlikely to benefit. Incentives ranging from the expectation of prolonged survival, symptom improvement, the preservation of hope, or simply not "wanting to give up" all contribute to some degree. In this review we hope to investigate these issues and expand on the role that physicians, patients, and even popular media may play.
What Is 'Futile Care'?
There is no generally accepted medical definition of futile care.[3] If one considers that the goal of medical care is to achieve a benefit above a certain minimal threshold, then futile care could be defined as care that fails to achieve that benefit.[4] The sticking point, then, is not one's definition of futility, but one's definition of benefit. That is why the application of the word "futility" in discussions of medical care is considered ethically hazardous, especially when the values of the physician are incongruous with those of his or her patient.[5]
In addition, the inexact and somewhat unpredictable nature of medicine makes it a precarious endeavor to call a therapy futile unless, as Schneiderman narrowly defines it, "in the last 100 cases a medical treatment has been useless." He goes on to say that "physicians should distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which the patient has the capacity to appreciate."[4] Finally, one of the main reasons the word "futility" became unpopular is that it was perceived to be invoked when a therapy became too costly.
The moral implications of how futility is viewed are equally important as we deal with the emotionally charged issues surrounding the patient for whom further treatment will provide questionable benefit. Notably, the right to refuse a proposed treatment is considered a negative right. This means that if deemed to have decision-making capacity, a patient may refuse any medical care offered.[6] However, a patient is not entitled to any intervention he or she requests that is not deemed medically indicated.[7] In other words, a physician is not obligated to provide futile therapies.[8] This does not mean that a physician should decline to provide requested therapy without a thorough, considered discussion with the patient and his or her family. The specter of futility may signal a turning point in the patient's trajectory at which it is most important to discuss and clarify benefits and burdens as well as goals of care.[9]
Table 1 | |
| Barriers to Hospice Utilization | |
Barriers | Examples |
Patient | Lack of knowledge about hospice, denial of terminal status, belief that hospice means giving up |
Hospice structure | Complicated admission criteria, drug restrictions, prognosis of 6 months or less |
| Physician | |
Negative perceptions | Perception that hospice is inflexible or a last resort, lack of knowledge and experience with hospice |
Discomfort communicating | Reluctance to give a terminal diagnosis and prognosis, fear of being blamed for giving up, discomfort talking about death |
Instrumentalist perspective | Fear of losing control of patient, preference for active treatment, fear of pressure from a cure-oriented profession |
Timing of discussion | Overestimate of life expectancy, waiting until patient has no other options or is too fragile to transfer |
Adapted from McGorty and Bornstein.[24] | |
