Medical futility and life-sustaining treatment decisions.

By focusing our attention on the questions of "what are we trying to achieve" and "are we able to do it", the discussion of medical futility has contributed an important dimension to the ethics of treatment decision making near the end of life. It is not simply enough to ask and answer the question of what the patient wants. Healthcare professionals have a responsibility to offer only those life-sustaining efforts that have a reasonable chance of being beneficial. Futility policies should permit treatment-limiting decisions to be made without the agreement of the patient or surrogate at times, but such policies should also provide opportunities to challenge a judgement of futility. Above all, such policies should not be used as a reason to avoid communication. Patients or surrogates need to be informed about what treatments are options and what are not. The futility criterion for limiting treatment should be recognized as a means of contributing to communication and discussion regarding benefits, harms and medical goals. It should not be permitted to bypass such discussions. The recognition of the significance of the concept of futility means that discussion needs to continue at another level as well. The questions of "what are we trying to achieve" and "are we able to do it" are not easily answered. It is especially important, we think, that those who are experienced in working with patients with neurological impairments contribute to the on-going reflection on what constitutes benefit or what is the appropriate use of life-sustaining interventions for such patients.