Futility: a concept in evolution.

The debate about how to resolve cases in which patients and families demand interventions that clinicians regard as futile has been in evolution over the past 20 years. This debate can be divided into three generations. The first generation was characterized by attempts to define futility in terms of certain clinical criteria. These attempts failed because they proposed limitations to care based on value judgments for which there is no consensus among a significant segment of society. The second generation was a procedural approach that empowered hospitals, through their ethics committees, to decide whether interventions demanded by families were futile. Many hospitals adopted such policies, and some states incorporated this approach into legislation. This approach has also failed because it gives hospitals authority to decide whether or not to accede to demands that the clinicians regard as unreasonable, when any national consensus on what is a "beneficial treatment" remains under intense debate. Absent such a consensus, procedural mechanisms to resolve futility disputes inevitably confront the same insurmountable barriers as attempts to define futility. We therefore predict emergence of a third generation, focused on communication and negotiation at the bedside. We present a paradigm that has proven successful in business and law. In the small number of cases in which even the best efforts at communication and negotiation fail, we suggest that clinicians should find ways to better support each other in providing this care, rather than seeking to override the requests of these patients and families.