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Patient benefit at heart of end-of-life treatment

When determining whether or not treatment is futile, the overall benefit to patients is at the centre of a doctor’s decision, according to research published in Medical Journal of Australia.

Professor Ben White and colleagues from Australian Centre for Health Law Research and Institute of Health and Biomedical Information at the Queensland University of Technology, the University of Queensland and the Royal Brisbane and Women’s Hospital found that determining futility of treatment at end of life was deeply subjective.

The researchers interviewed 96 Brisbane doctors from a range of specialities who treat adults at the end of life.

“Doctors’ conceptions of futility focused on the quality and prospect of patient benefit. Aspects of benefit included physiological effect, weighing benefits and burdens, and quantity and quality of life,” the authors wrote.

The doctors also discussed treatments that were considered medically futile but were justified for other reasons, including treatment that enables a patient to fulfil significant social roles (such as attending a wedding) or giving relatives the opportunity to gather and say goodbye to the patient.

Although futility is a familiar term, doctors commented that there was a high degree of variability as to how this term could be applied in a clinical setting.

As a result, the authors recommend that doctors be aware of the subjectivity of its definition when making end-oflife care decisions.

“Because doctors place patient benefit at the heart of futility, engaging with patients and their families about their values and goals is a critical part of decisions about limiting or stopping treatment,” they wrote. In a linked editorial, Professor Ian Maddocks from Flinders University said doctors should focus on what can be done for patients, not what can’t be done.

“I suggest that, when assessing further management in such situations, “utility” is a more appropriate term than ‘futility’. Futility carries a sense of finality; you stop. Utility is not an absolute; it assesses usefulness over a range of applications and opportunities,” he wrote.

By re-directing efforts to treatments that have ‘utility’, Professor Maddocks says the comfort and dignity of the patient and their grieving family will be maximised, which could benefit them by extending their days and easing the therapeutic relationship between patient and doctor.

Palliative care is an important component of utility in difficult medical situations, says Professor Maddocks. “From 25 years of experience, I judge most palliative care to be just good medicine and within every doctor’s capability. It calls for kindness, attentiveness, comprehensive assessment of realities, awareness that specialist palliative care resources are available for difficult cases, and a personal confidence in the delivery of comfort care,” he concluded.

Article: What does “futility” mean? An empirical study of doctors’ perceptions, Ben White, Lindy Willmott, Eliana Close, Nicole Shepherd, Cindy Gallois, Malcolm H Parker, Sarah Winch, Nicholas Graves, Leonie K Callawa, Medical Journal of Australia, doi: 10.5694/mja15.01103, published 2 May 2016.

Editorial: Futility and utility, Ian Maddocks, Medical Journal of Australia, doi: 10.5694/mja16.00006, published 2 May 2016.