The concept of futility in health: A scoping review

Abstract

Introduction

Due to the constant scientific and technological development, health professionals are regularly confronted with situations in which there are always therapeutic options, regardless of the severity of the patient’s condition. However, regarding these therapeutic options as feasible in all situations can be harmful, since it is universally accepted that, despite all advances in health, there are inevitable limits and the promotion of some interventions may be useless or futile.

Objective

To characterize the use of the concept of futility in the health literature.

Method

Review of the literature following the Scoping Review protocol of the Joanna Briggs Institute. The research was performed in CINAHL, Cochrane, Pubmed, Scopus e Web of Science to identify studies published prior to 2020. Nineteen studies were selected.

Results

There is no universally accepted definition for the concept of futility. In the literature there are different conceptions for the concept of futility that point to qualitative and quantitative roots and that are associated with ethical dilemmas that make it difficult to conceptualize this concept and make it operational in clinical practice.

Conclusion

The central elements of the concept of futility include: the diagnosis of futility is closely related to clinical judgment; futility has both quantitative and qualitative roots; futility is always appreciated posteriori; futility is related to the lack of benefit. It is essential to promote a discussion that enables the definition of the concept and that makes it possible to promote ethical principles in care, especially when the inevitable limits of treatments are reached.

Keywords

Bioethics clinical ethics ethics medical futility professional ethics

Introduction

In health, due to the constant scientific and technological development, particularly in environments dedicated to providing care to people in complex and highly vulnerable situations, health professionals are faced, almost invariably, with situations in which there are always more interventions to perform, another device that can be used to replace one or more natural functions, an additional drug to be administered or one more technique that can be implemented.¹ Nevertheless, medicine has inevitable limits and, despite all the scientific and technological advances that arise and that can contribute to modify these limits, it is fallacious to act as if medicine could triumph in the face of all diseases or even in the face of death itself and there is no use in abstaining or promoting interventions that are useless or futile.²

From an etymological point of view, the word futility derives from the Latin “futilis”, an adjective that literally means a container that leaks easily or leaks and, consequently, is attributed a meaning of futile or useless, in reference to Greek mythology and the daughters of Danaus, king of Argos, who for murdering their husbands were condemned to the futile task of carrying water in perforated containers for eternity.^3,4

Within the scope of health care provision, it is accepted by most professionals that they should not implement futile interventions, for the fundamental principle that an intervention that is useless causes harm without benefit.⁵ Treatments that aim to save life or maintain life cannot be promoted when they are considered futile.⁶ However, despite all the negative consequences associated with futility, there is evidence that futile interventions continue to be implemented, especially in terminally ill patients and in intensive care units.⁷

Although several authors have made efforts to define futility, there is a lack of universal consensus on what constitutes this concept.⁵ The concept of futility is related to qualitative and quantitative assumptions^6,8 and is often associated with the promotion of inadequate treatments that do not improve the prognosis of the disease, alleviate physiological symptoms or prolong life.⁹ This interpretation of futility, which is based mainly on the objectives and results of procedures and interventions, is problematic⁹ and can lead to the invocation of this concept in ethically objectionable ways.⁶

In addition to the previous considerations, it is assumed that futility may be a factor that affects job satisfaction and may contribute to the experience of burnout¹⁰ and it is advocated that the use of resources associated with interventions that are futile may be the most conflict-generating situation among health professionals, namely among nurses.¹¹

Objective

To characterize the use of the concept of futility in the health literature.

Method

A literature review adhering to the Scoping Review protocol of the Joanna Briggs Institute,¹² including the development of the research question, research in scientific databases, identification of inclusion and exclusion criteria, selection of studies, analysis and interpretation of the selected studies, and synthesis and presentation of results.

In order to formulate the research question, the PCC mnemonic was used: (P) Population, (C) Concept, and (C) Context. The following question was asked to answer the outlined objective that served as the guiding principle for this literature review: What is the concept of futility (Concept) for health professionals (Population) who provide care to people admitted to a hospital (Context)?

The research strategy included a search for studies published in French, English, Spanish, and Portuguese carried out by the three authors, independently, to identify studies published before 2020, in CINAHL Complete, Cochrane, Pubmed, Scopus e Web of Science databases.

The search included the descriptors Medical Futility, Therapeutic Futility, Therapeutic Obstinacy, Futile Treatment, Futile Care, Concept and Definition. The descriptors were connected with the Boolean operators “AND” and “OR” in the following arrangement: “Medical Futility” OR “Therapeutic Futility” OR “Therapeutic Obstinacy” OR “Futile Treatment” OR “Futile Care” AND “Concept” OR “Definition”.

The privileged studies focused exclusively on articles that present concrete definitions for the concept of futility related to health care, academic journals with analysis by specialists and with available references. All articles in which no consistent definition is presented for the concept under study were excluded.

The initial search identified 1966 results, specifically, CINAHL (n = 152), Cochrane (n = 105), PUBMED (n = 596), Scopus (n = 565) and Web of Science (n = 545), from other sources (n = 3), ordered by the best match or relevance, with 897 duplications identified.

The evaluation of the remaining 1069 results, carried out by three authors independently, proceeded in two phases, namely: the phase of selecting the studies to be analyzed after reading the titles and the abstract, which allowed the identification of 48 studies with potential interest for the review; the phase of full reading of all studies, after which, once the inclusion criteria and analysis of the levels of evidence and methodological quality were applied, 19 studies were selected. Of these, 4 are primary studies and 15 are secondary studies (Figure 1).

Figure 1.

Literature search process (preferred items presented in the Joanna Briggs Institute Guidance).¹²

Results

It was decided to present the results obtained by analyzing the studies included in this review in table format (Table 1) in order to facilitate and simplify their reading and interpretation. The results are presented chronologically for a better perception of the evolution of the concept in the scientific literature, first presenting the results of the primary studies and then the results of the secondary studies. To carry out the content analysis, the authors relied on Bardin's content analysis method.¹³

Table 1.

Synopsis of the analyzed studies.

Authors	Title Drawing/population	Concept of futility
Aizawa et al.¹⁴	Defining futile life-prolonging treatments through Neo-Socratic Dialogue. Qualitative / 7 participants	Futility is associated with treatments carried out without a reason other than to prolong life, which is detrimental to the patient.
Huynh et al.¹⁵	The Frequency and Cost of Treatment Perceived to Be Futile in Critical Care. Qualitative / 13 participants	There are four reasons why a treatment should be considered futile: burdens grossly outweigh benefits, patient will never survive outside an ICU, patient is permanently unconscious, treatment cannot achieve the patient’s goals, or death is imminent.
Bahramnezhad et al.¹⁶	Futile Care; Concept Analysis Based on a Hybrid Model. Qualitative / 7 participants	Futile care consists of requesting irrelevant clinical care to the nurse's work and promoting care whereby the patient's return will be impossible, both physiologically and qualitatively.
White et al.¹⁷	What does “futility” mean? An empirical study of doctors’ perceptions.	The concept of futility focuses on quality and the perspective of benefit to the patient. The aspects associated with the benefit include the assessment of the physiological effects, which must include the assessment of the benefits and burdens, the duration and the quality of life.
Schneiderman et al.⁸	Medical Futility: Its Meaning and Ethical Implications. Theoretical	The notion of medical futility has quantitative and qualitative roots. Quantitative approach: a treatment should be regarded as futile when is concluded (either through personal experience, experiences shared with colleagues, or consideration of published empiric data) that in the last 100 cases has been useless. Qualitative approach: If a treatment merely preserves permanent unconsciousness or fails to end total dependence on intensive medical care should be regarded has nonbeneficial and, therefore, futile.
Smith¹⁸	Restructuring the Principle of Medical Futility. Theoretical	Four recognized clinical uses of futility are as follows: when a cure is physiologically impossible; when the treatment is nonbeneficial; when the treatment is unlikely to produce a desired benefit; when the treatment is plausible but not yet validated.
Low and Kaufman¹⁹	Medical futility and the critically ill patient. Theoretical	In the context of medicine, a futile action is one that is unable to achieve the desired objective or result. The concept of futility in the person in a critical situation, being difficult to define, is within the scope of what goes beyond the therapeutic plan designed between the person himself, his family and the health team. Anything that goes beyond this agreement is futile.
Ardagh⁴	Futility has no utility in resuscitation Medicine. Theoretical	Futility is a prospective appreciation of something which will be viewed as unsuccessful in retrospect.
Kasman²⁰	When Is Medical Treatment Futile? Theoretical	Futility is defined as a clinical action serving no useful purpose in attaining a specified goal for a given patient.
Bernat²¹	Medical Futility: Definition, Determination, and Disputes in Critical Care. Theoretical	Futility means that the proposed therapy should not be performed because available data show that it will not improve the patient’s medical condition. Medical futility remains ethically controversial for several reasons.
Pellegrino²²	Futility in Medical Decisions: The Word and the Concept. Theoretical	Futility can only be assessed in terms of an objective or a purpose. When in the course of a serious or fatal disease, a point is reached where medicine can no longer provide any recognizable good for the person, the doctor and the person / family must confront human finitude. it becomes unattainable and continuation of interventions becomes useless / futile.
Mohindra²³	Medical futility: a conceptual model. Theoretical	An intervention can only be meaningfully declared futile in relation to a defined purpose(s) of treatment. A declaration of futility made solely in relation to a medical intervention is inchoate. Value futility: the intervention obtains an effect but doesn’t produce any benefit. Goal futility: the intervention cannot alter the course of the events.
Ashby²⁴	The Futility of Futility: Death Causation is the ‘Elephant in the Room’ in Discussions about Limitation of Medical Treatment. Theoretical	The concept of futility is a mixture of clinical judgment about the results of the treatment and the quality or even the value of life, which has failed to contribute to the advancement of decision-making. With the exception of the principle of non-maleficence, there is no ethical or moral concept underlying futility.
Schneiderman²⁵	Defining Medical Futility and Improving Medical Care. Theoretical	Futility is the unacceptable likelihood of achieving an effect that the patient has the ability to appreciate as a benefit. Futility means that a treatment offers no therapeutic benefit to the patient.
Grant et al.²⁶	Futility and the Care of Surgical Patients: Ethical Dilemmas. Theoretical	Several definitions of therapeutic futility have been discussed, qualitative futility being the most controversial of all, as it describes a situation in which the treatment promoted is likely to result in an unacceptable quality of life.
Vincent³	When ICU Treatment Becomes Futile. Theoretical	Futile intensive care has been defined as the considerable use of resources without a reasonable expectation that the patient will recover to a situation of relative independence or be interactive with his environment. Futility consists of interventions that prolong life without achieving an effect that the patient can appreciate as a benefit.
Kon et al.²⁷	Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Theoretical	Intensive care interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment.
Brody²⁸	Futility: definition and goals. Theoretical	Futility can be readily defined as an intervention that will not work, and it is always an incomplete statement unless one specifies the goal one hopes to achieve.
Derse²⁹	The Brutal but Utile Truth of “Futile”. Theoretical	The term futile well describes the concept of the brutal reality, the hard stop of no medical benefit, or an extremely low likelihood of medical benefit in the face of limited resources.

Discussion

The analysis of the articles selected for this review allows the identification of different conceptions for the concept under study.

Aizawa, Asai and Bito (2013) associate futility with the culture of instituting treatments that aim only to prolong life.¹⁴ Huynh et al. (2013) present a definition aimed at the futility of a treatment and identify four reasons why it can be considered futile, namely, when the burdens outweigh the benefits, if it is predictable that the person will never survive outside the unit of treatment. intensive care, when the person is permanently unconscious, or when treatment does not allow reaching the person's goals or death is imminent.¹⁵ Bahramnezhad et al. (2014) mention that futility is associated with the promotion of care that does not offer physiological benefits or qualitative for the return of the person.¹⁶ White et al. (2016), proposes that the concept of futility focuses mainly on quality and the perspective of benefit to the patient and the aspects associated with the benefit include the assessment of the physiological effects, which must include the evaluation of the benefits and the burdens, of the duration and the quality of life.¹⁷

Schneiderman, Jecker and Jonsen (1990) present a clear and objective definition for the concept of futility, as they suggest that futility has both quantitative and qualitative roots. From a quantitative point of view, it is suggested that a treatment should be considered futile when it is recognized that in the last 100 identical situations the treatment was useless and did not bring benefits. The qualitative approach of this concept suggests that when treatment does not offer improvements to a permanent state of unconsciousness or failure to end up in total dependence on intensive care, it should be considered futile.⁸

Another way of conceptualizing futility, by Smith (1995), refers to the identification of four clinical uses, namely, when cure is physiologically impossible, when treatment is not beneficial, when treatment is unlikely to produce the desired benefit, or when the treatment is plausible, but it has not yet been validated.¹⁸

Some authors, such as Low and Kaufman (1999) point to the impossibility of defining futility in a safe or desirable way, but suggest that, in the context of medicine, a futile action is one that is unable to achieve an objective or the result desired.¹⁹

Ardagh (2000) states that futility consists of a prospective assessment of something that will be considered unsuccessful retrospectively, that is, it is a later assessment of interventions that were carried out, but that were considered posteriori, unsuccessful.⁴

Futility, for some authors, is associated with an intervention, or action, that does not serve an adequate purpose to reach a certain goal (Kasman, 2004),²⁰ or for which the available information is predictive of failure for clinical improvement of the person (Bernat, 2005).²¹

Pellegrino (2005), offers a definition in which he states that the clinical concept that futility incorporates, regardless of the verbal domain, cannot be eradicated, by the fundamental principle that the human being is mortal.²² However, Mohindra (2007) defines that the futility of an intervention can only be declared significantly in relation to the objective, or objectives, of the same intervention, since the futility associated only with the intervention is incipient. The same author identifies two components associated with the concept, value futility, which refers to the intervention that has an effect, but does not offer benefit, and objective futility, which points to the intervention that does not change the course of events.²³

Ashby (2011) alludes to the concept of futility being a mixture of clinical judgment about the results of a treatment and the quality and value of life that does not contribute to the decision-making process and that, with the exception of the ethical principle of not maleficence, has no other moral or ethical concept underlying it.²⁴

In the last decade, some authors have tried to conceptualize futility in a more objective way, such as Schneiderman (2011) who suggests that futility is the unacceptable probability of achieving an effect that the person can appreciate as a benefit, that is, futility is directly associated with the lack of a therapeutic benefit from a treatment.²⁵ However, some authors have presented definitions in which they include the ethical dilemmas associated with the concept. Grant, Modi and Singer (2014) refer that futility, be it seen as a question of the person's autonomy, of the physician's conscience, or as a guide of prudence, is a dilemma that will not be readily “resolved”²⁶ and Vincent (2014) adds that futility is incompatible with the three ethical principles of beneficence, non-maleficence and justice and that defining futility is a complex and sensitive task, which raises questions for which there are no simple answers.³

Kon et al. (2016) includes the term inappropriate in the definition of futility that he proposes, referring to the inadequacy of interventions when there is no reasonable expectation that the person will improve enough to survive outside the acute care environment or when there is no reasonable expectation that the person's neurological function improves enough to allow the person to realize the benefits of the treatment.²⁷ The concept proposed by Brody (2017) refers to the futility of an intervention that will not work but, unless the objectives are specified that are intended to be achieved with it, should be seen as an incomplete statement.²⁸ Derse (2018) presents a definition that is consistent with the previously proposed, with regard to the adequacy of available resources, as it refers to futility as the conception a brutal reality of medical benefit cessation, or an extremely low probability of medical benefit per in the face of limited resources.²⁹

Conclusion

There is no universally accepted definition for the concept of futility. The analysis of the studies included in this review allows the identification of some central elements for the concept of futility in a health context, namely: the diagnosis of futility is closely related to clinical judgment; futility has both quantitative and qualitative roots; futility is always appreciated a posteriori; futility is related to the lack of benefit.

In 2015, several international societies reached a consensus in which they advise that the term futility should be restricted to the rare situations in which legal substitutes call for the implementation of interventions that simply fail to achieve the intended physiological objective. Instead of the term futility, these societies suggest the use of the term potentially inappropriate to describe interventions or treatments that have some possibility of achieving the effects desired by the person, but professionals believe that current ethical considerations do not justify its implementation.³⁰

For the authors of this review, regardless of the terminology used, due to the lack of consensus, but above all due to the evident risk that some practices are based on a culture that favors the prolongation of life and the denial of death, regardless of the means used, it is urgent to promote a discussion that allows the identification of a concept for futility and that makes possible the promotion of ethical principles in care, especially when the inevitable limits of treatments are reached.

The complexity inherent to the concept under analysis and the small number of primary studies included in this review leads the authors to conclude that the results obtained cannot be generalized, which suggests carrying out more primary studies on the subject under study, with more significant samples.

Footnotes

Acknowledgements

The authors would like to thank the Institute of Health Sciences from the Portuguese Catholic University.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

João Vítor da Silva Vieira

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