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Contents lists available at SciVerse ScienceDirect

Australian Critical Care

journal homepage: www.elsevier.com/locate/aucc

Medical futility in the care of non-competent terminally ill patient:

Nursing perspectives and responsibilities
Andrew Scanlon DNP, MNS, RN, NP, FACN a,b, ,
Maria Murphy Phd, Grad Dip Crit Care, BN, RN a
a
La Trobe University/Austin Health Clinical School of Nursing, Faculty of Health Sciences, La Trobe University, Melbourne, Australia
b
Department of Neurosurgery, Austin Health, Heidelberg, Australia

article information a b s t r a c t

Article history: Background: Debate continues on the use of medical technology to prolong life independent of the quality
Received 23 August 2011 of the outcomes. As a consequence, acute care nurses often nd themselves in situations where they are
Received in revised form 22 October 2012 asked to carry out physicians orders, in the context of a patients deteriorating condition, which may
Accepted 25 October 2012
be at odds with professional and personal ethical standards. This can cause nurses to become distressed
Available online xxx
when struggling with the ethical dilemmas involved with medical futility.
Purpose: This paper is a perspective on nursing considerations of our Code of Ethics and the concept of
Keywords:
medical futility in acute nursing care. The utility of the Code is examined through a clinical vignette.
Acute care
Decision making
Method: A database search using the keywords medical futility and acute care limited to 2008 to 2012
Clinical and a secondary hand search of these references identied thirty journal publications. The Code of Ethics
Medical futility was examined via a clinical scenario pertinent to an acute environment.
Nursing ethics Findings: This paper examines the ethical principles that underpin nursing and illustrates how the code
Nursepatient relations of ethics may serve as sign posts when faced with caring for a terminally ill patient that is inappropriately
Palliative care managed.
Conclusion: Understanding how individual nurses may address ethical dilemmas when faced with medical
futility can better enable the nurse to full their role as patient advocate, health promoter and alleviator
of suffering. Ongoing education and communication to decrease any ambiguity or anguish associated
with a patients impending death optimises apt outcomes.
2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of
Reed International Books Australia Pty Ltd). All rights reserved.

Introduction setting. In doing so, we demonstrate the application of ethical

Advances in medical science over recent decades have allowed
healthcare providers to prolong human life through extraordinary
means fostering debate regarding what is considered medically
appropriate as opposed to that which is considered medically futile.
Nurses are expected to practice in an ethical manner1 and, when
working in acute care settings, may experience ethical distress
when implementing high tech measures they believe are merely
postponing or causing undue suffering prior to death.2
The purpose of this paper is to rst present a discussion
of the concepts of medical futility and then to examine these
concepts using a clinical vignette taken from an acute care
Corresponding author at: La Trobe University/Austin Health Clinical School of
Nursing, Division of Nursing and Midwifery, La Trobe University, Level 4 Austin
Tower, PO Box 5555, Heidelberg, VIC 3084, Australia. Tel.: +61 3 94964457;
fax: +61 3 9496 4450.
E-mail address: a.scanlon@latrobe.edu.au (A. Scanlon).
principles to clinical practice and propose recommendations for
practice.
Medical futility
The word futility stems from the 16th century Latin term mean-
ing leaky and describes an action that produces no useful result
or is pointless. Medical futility, therefore, could simply be dened
as a course of medical treatment that does not produce a worth-
while result. The difculty with medical futility is determining who
is best to decide whether the patient might benet from treatment,
or on what grounds and, with what evidence, should decisions
for treatment be implemented. The difculty in determining what
constitutes medically futile care is well described in the literature,
although consensus on denitions is lacking.36 Terms that attempt
to dene medical futility are summarised in Table 1.
The various terms used to describe medical futility can cre-
ate confusion. Table 1 lists seven different terms for medical
futility, many with overlapping denitions.69 For example, both

1036-7314/$ see front matter 2012 Australian College of Critical Care Nurses Ltd. Published by Elsevier Australia (a division of Reed International Books Australia Pty Ltd). All rights reserved.
http://dx.doi.org/10.1016/j.aucc.2012.10.003

Please cite this article in press as: Scanlon A, Murphy M. Medical futility in the care of non-competent terminally ill patient: Nursing
perspectives and responsibilities. Aust Crit Care (2012), http://dx.doi.org/10.1016/j.aucc.2012.10.003
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2 A. Scanlon, M. Murphy / Australian Critical Care xxx (2012) xxxxxx

Table 1
Terms related to medical futility.

Term Description

Physiological futility Medical treatment is unable to produce a specic benecial physiological outcome.41

Imminent demise futility The patient will die regardless of the intervention.41

Lethal condition futility An underlying disease that is not compatible with long-term survival, regardless of the intervention, even if the patient could
survive to be discharged from their current hospitalization.41

Quantitative futility The clinician through personal experience, the shared experiences of their colleagues or, consideration of reported empiric
data, determines that further medical treatment will be useless.42,43

Qualitative futility Circumstances where medical treatment merely preserves permanent unconsciousness or there is a persistent dependence on
medical care.44

Goal futility When treatment cannot alter the likelihood of the dened goal emerging into reality.44

Value futility When treatment can alter the probability of the dened goal but, the dened goal is deemed a goal not worth achieving.44

Qualitative futility and value futility describe a health outcome that
may leave the patient in a severely debilitated state which may be
an unacceptable situation for the individual. Likewise, quantitative
futility, physiological futility, imminent demise futility, lethal con-
dition futility and goal futility all suggest that despite evidence to
support the intervention, it fails on a physiological level (i.e. the
antibiotics do not work for this patient). Having multiple terms
with shared meaning can make communicating concepts around
medical futility challenging.
Despite the multiple denitions for medical futility, many which
dene similar concepts, the key issue is often the lack of agree-
ment on whether a situation is considered medically futile (or not).
In such cases, especially where disagreement exists between the
health care practitioner(s) and the patient and/or their family, deci-
sions may be made to continue with treatments as a means to
prevent legal action or avoid media scrutiny.10,11
Ethics in nursing
Ethics are described as being the standards that govern
behaviour or conduct.12 The underlying universal principles of
ethics important for nursing practice are based on the obligation
to do good (Benecence); do no harm (Nonmalecence); provide
equal and fair care for all without judgement (Justice); uphold
individual determination (Autonomy), tell the truth (Veracity) and
remain faithful to ones commitments (Fidelity).12 These tenets
are the basis for all Codes of Ethics for all professional groups in
healthcare.
Codes of Ethics are guidelines for practice, underpinned by the
universal principles of ethics and are determined by an author-
ity or representative group in light of what is considered right.13
Furthermore, ethical principles are implicit in all major Codes of
Ethics for nursing internationally, in Australia,14 the United States
of America,15 the United Kingdom,16 Canada17 and in European
models.18 All Nursing Codes of Ethics reects those of the interna-
tional nursing body: the International Council of Nurses (ICN). The
ICN Code of Ethics reports that the nurses responsibilities are: to
promote health, to prevent illness, to restore health and to allevi-
ate suffering.19 The ICN also acknowledges that there are differing
aspects of nurses work and has applied ethical principles to four
main areas as outlined in Table 2. The ICN Codes of Ethics are meant
to provide nurses with a moral compass to point us in the right
direction for professional and patient centred outcomes.20
Judgement in nursing ethics
The application of the Code of Ethics is dependent on individual
judgement and experience and therefore subject to variability.21
Judgments are inuenced by religious beliefs, education, training,
advanced medical knowledge, clinical experience and the utili-
sation of evidence-based practice, all which can affect the way
individuals interpret and apply the Code of Ethics. Furthermore,
the frequent interaction nurses have with the patient and family22
allows for the development of unique insight into patient care
and how treatment should be implemented to obtain optimal out-
comes. Nurses, thus apply the Code of Ethics and use their personal
and professional judgement when caring and treating for patients.
In addition, we must be considerate of how these judgments may
in turn inuences the care we perceive to be appropriate.
Medical futility and ethical dilemmas for nurses
Ethical dilemmas are problems which require a decision in
which there are only unsatisfactory solutions and thus contribute
to the development of tension and conict.23 Ethical dilemmas
usually occurs when, in clinical practice, there is conict between
ethical principles. For example, in acute care settings preventing
death, as opposed to facilitating end of life care, appears on face

Table 2
The four elements in the ICN Code of Ethics.27

Element Description

1. Nurses and people Advocacy for individual and society.

Through the provision of care, nurses should advocate for the basic principles of autonomy and justice when interacting with
individuals and society as a whole.

2. Nurses and practice Nurses are responsible and accountable and are required to be competent in the use of technology and scientic knowledge in clinical
practice

3. Nurses and profession Standards of clinical nursing practice, management, research and education.
How nurses should advocate for their own standards through participation in professional bodies and through scholarly work to
advance our profession

4. Nurses and co-workers Maintains a co-operative relationship with co-workers not only in nursing but other disciplines. However, it is the nurses
responsibility to take appropriate action to safeguard the health of an individual or society in general if a co-worker or any other
person endangers it. Interdependency on others within and outside nursing to achieve the best outcomes for our patients

Please cite this article in press as: Scanlon A, Murphy M. Medical futility in the care of non-competent terminally ill patient: Nursing
perspectives and responsibilities. Aust Crit Care (2012), http://dx.doi.org/10.1016/j.aucc.2012.10.003
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value, to be a clear and logical ethical decision, but at what cost
or outcome? There are some situations, such as persistent uncon-
sciousness or lifetime dependence on invasive and painful medical
treatment, which may be considered worse than death by some
(qualitative futility or value futility). In such situations nurses
have a duty to care to achieve the best possible outcome for the
patient.14,20
Nurses are guided through professional relationships with
patients and signicant others by our Code of Ethics. The Code
supports nurses to advocate for the needs of our patients. Unfortu-
nately in acute practice, it is not always simple. Nurses can become
distressed when participating in treatment plans that prolong the
dying process without any perceived or tangible benet to the
patient.2427 Nurses are required to act responsibly and be account-
able for measures we implement in clinical practice28 whilst
safeguarding patients and ensuring they are provided with appro-
priate treatment. However, nurses work in a multi-disciplinary
environment and are often not in a position to make treatment-
related decisions. In situations where the treatment goal is shared
by all stakeholders then there is no conict. However if the treat-
ment goal is at odds with the nurses judgement, then the nurse
has the right to not participate in care and can opt-out of care. If
the treatment goal does not align with the wishes of the patient
and/or their family, then the nurse must advocate for the patients
interests as their judgement informs them. This is not an easy task.
Additional distress for nurses occurs when the multi-
disciplinary team is not involved in making the decision2 and when
the nurse must implement the treatment plan and/or explain this to
the patient and their family.29 This phenomena has been described
as being in the middle.30 This professional conict can ultimately
affect the relationships with the treating team and has the potential
to adversely affect patient care. The following vignette illustrates
the application of these ethical principles to clinical practice.
Clinical vignette
Irene is a 72 year-old female who is three weeks post-biopsy of
a left temporal glioblastoma (high-grade malignant brain tumour).
Her post-procedure recovery was complicated by a large intra-
cerebral bleed. Since that time, Irene has had a Glasgow Come Score
of 57/15 which is consistent with severe disability.31 Her current
treatment consists of broad-spectrum antibiotics for an iatrogenic
lung infection, multiple intravenous medications for malignant
hypertension, enteral feeding via a nasogastric tube, two hourly
full neurological assessments and general nursing care. Prior to this
procedure, Irene did not have advanced medical directives docu-
mented and does not have a Do Not Resuscitate order.
It is anticipated that Irene will be discharged from the inten-
sive care unit (ICU) in the next few days. Due to her age, current
condition and poor prognosis, it is documented in her medical
record that she is not a candidate for readmission to the ICU. There
are no medical orders for palliative care and full active treatment
continues.
Prior to this hospital admission, Irene was living independently.
Although not documented, you have learnt from her family that she
has previously stated she would not choose to be an ongoing burden
if she became incapacitated. Her family has asked you, as her nurse,
for advice on what can and should be done? These questions sug-
gest to you that the family is questioning whether the continuation
of active treatment is appropriate.
Our Code of Ethics requires that our care is premised on princi-
ples of benecence (to do good) and nonmalecence (do no harm).
In Irenes case, if she were to survive this period of acute of illness,
she would not recover to her pre morbid state and is expected to die.
Her current clinical condition is consistent with what the family has
Please cite this article in press as: Scanlon A, Murphy M. Medical futility in the care of non-competent terminally ill patient: Nursing
perspectives and responsibilities. Aust Crit Care (2012), http://dx.doi.org/10.1016/j.aucc.2012.10.003
3
described as being unacceptable to her. Given her neurological sta-
tus and diagnosis with a malignant brain tumour, it is unlikely that
she will recover and be able to resume independence. As such, con-
ict between the current treatment plan and the patients wishes is
present. It is likely that Irene will require full general nursing care
until her death and consequently is likely to experience complica-
tions associated with her debilitated state. The question that would
need to be answered in this clinical scenario and any other similar
case would be Would Irene choose this health state over death?
This is an individual choice and unfortunately Irene cannot convey
her wishes at this time. However, her family is well placed to advo-
cate for what they consider Irenes wishes and should be consulted
by the team.32
Irene is a critically ill, older patient with multiple complications
and a poor prognosis. Irenes family has asked you, as her nurse, for
advice on what can and should be done? Irenes family require the
opportunity to meet with representatives of her management team
so that her projected health outcomes complicated by confounders
of age and co morbidities enable her family the opportunity to con-
sider a probable trajectory based on the professional assessments
of her treating team. This enables the family the time to consider
why a return admission to ICU would be futile to restoring Irenes
health, time to consider Irenes interests as the people who know
her best and the opportunity for an open and honest dialogue with
her management team and each other. All members of this conver-
sation remain faithful to their commitment of just and benecial
care whilst respecting the individuals needs. As our patient Irene is
unconsciousness and, unable to make decisions for herself, verac-
ity is a critical aspect of care. To best assist Irene and her family
the nurse should be aware of the ethical principles underpinning
decisions relevant to Irenes ongoing care.
Discussion: nursing practice implications
This clinical vignette that has been examined here is complex
and there are no clear cut solutions. The judgement you might form
as a nurse are inuenced by a number of variables. These vari-
ables include our individual understanding and interpreting the
code of ethics, of the patients condition, the patients and their
families perceived wishes as well as the clinicians own judgement.
All act as lters and explain the variability in how different mem-
bers of the health care team conceptualise the appropriateness of
treatment goals. Fundamental to nursing, is the alleviation of any
patients discomfort28 which can result from physical and/or emo-
tional causes associated with an altered health state. Difculties for
family members arise when they are placed in the position to decide
whether or not to continue treatment for their loved one. Distress
is a common reaction for the terminally ill, their loved ones, and
members of the healthcare team. As a nurse caring for Irene, you
should advocate for the patients dignity and respect whilst insur-
ing continuation of reasonable care irrespective of the prognosis.33
It is the role of the nurse to advocate for their patients particu-
larly when the patients wishes are at odds with current treatment
goals. In the case of Irene, nurses must help the family to decide
what is best for Irene and, this can be very difcult and a source of
tension.
The rst task of ethical decision making in nursing is to consider
both your own and the patient values12 as these will ultimately
effect personal judgement. Firstly consider your own values and
judgement as the nurse in providing care for Irene. Does the current
ongoing care of Irene cause you some ethical conict and if so, think
carefully about why this might be the case. If the distress is your
own then, you have the right as an autonomous clinician to opt out
of care of this patient.
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Secondly, is the ethical dilemma caused by discord when per-
spectives on the goals of care differ within the healthcare team or
between the healthcare team and the family. If so, nurses need to be
aware of their own interpretation of their hospital policy on futility
and advocate for its correct interpretation and implementation by
other health team members.34
To assist with making these decisions a medical ethicist could be
engaged. Most tertiary health care centres have access to a medical
ethicist whose role includes assisting the patient and their fam-
ily with complex decision making processes during this difcult
time and to encourage open discussions with all involved.35 Whilst
this discussion would usually be facilitated by medical staff, at
times it may be necessary to have other clinicians engaged in this
process.36,37 There currently exist independently trained groups
of clinicians within the hospital networks to assist in this process.
Examples would be the Respecting Patient Choices Teams35 or Hos-
pital Ethics Committees within some larger healthcare facilities.38
In addition, tertiary centres frequently include the appointment
of a medical ethicist to assist with this complex decision making
process.
Finally, consider whether it is the patient or their surrogates
decision to continue care and ensure that all avenues been explored
with them. There are numerous reasons why a patients family
may demand treatment considered medically futile. The familys
feelings of helplessness, belief in the possibility of an incorrect
diagnosis and prognosis, an attitude of not giving up and not aban-
doning the patient, placing trust in God, and belief that medicine
can work miracles.34 The nurses unique position of both under-
standing the physicians treatment goals and, the patient and their
loved ones perspective enables us to facilitate and broker a
resolution.30 Through a nurses rapport, support, knowledge and
empathy, a patients and/or their loved ones coping strategies can
be strengthened and assist them in making clearer choices of treat-
ment goals.10,39
When considering your actions or even the response you may
give to Irenes family, it is important to not only to understand the
truth as you perceive it but, any alternative that may be pertinent.
By exploring all possible scenarios with her surrogates veracity can
be met. In doing so, the clinician should be wary of personal judge-
ment and how this may affect the delivery of what is communicated
to the family.
Conclusion
Acute clinical nursing will always be faced with medical futil-
ity, particularly when advances in medical treatment continue to
prevent death beyond limits not previously considered possible.
However, we also must understand that the sheer absence of death
does not equate to quality of life. When faced with medically futile
situations, patients, their loved ones and the clinicians who care for
them can become distressed. Through understanding the underly-
ing ethical principles, our own regional and international Codes of
Ethics together with our own judgments, nurses can alleviate not
only their own distress but also those of the family and patient.
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