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Medical Futility in End-of-Life Care, WSMA Opinion on

When further intervention to prolong the life of a patient becomes futile, physicians have an obligation to shift the intent of care toward comfort and closure. However, there are necessary value judgments involved in coming to the assessment of futility. These judgments must give consideration to patient or proxy assessments of worthwhile outcome. They should also take into account the physician or other provider's perception of intent in treatment, which should not be to prolong the dying process without benefit to the patient or to others with legitimate interests. They may also take into account community and institutional standards, which in turn may have used physiological or functional outcome measures. Nevertheless, conflicts between the parties may persist in determining what futility means in the particular instance. This may interrupt satisfactory decision-making and adversely affect patient care, family satisfaction, and physician-clinical team functioning. To assist in fair and satisfactory decision-making about what constitutes futile intervention: (1) All health care institutions, whether large or small, should adopt a policy on medical futility; and (2) Policies on medical futility should follow a due process approach. The following seven steps should be included in such a due process approach to declaring futility in specific cases. (a) Earnest attempts should be made in advance to deliberate over and negotiate prior understandings between patient, proxy, and physician on what constitutes futile care for the patient, and what falls within acceptable limits for the physician, family, and possibly also the institution. (b) Joint decision-making should occur between patient or proxy and physician to the maximum extent possible. (c) Attempts should be made to negotiate disagreements if they arise, and to reach resolution within all parties' acceptable limits, with the assistance of consultants as appropriate. (d) Involvement of an institutional committee such as the ethics committee should be requested if disagreements are irresolvable. Due process shall include allowing the patient or the patient's representative to have an advocate or legal counsel present at the ethics or other relevant institutional committee hearing. (e) If the institutional review supports the patient's position and the physician remains unpersuaded, transfer of care to another physician within the institution may be arranged. (f) If the process supports the physician's position and the patient/proxy remains unpersuaded, and transfer to another physician within the institution is not possible, transfer to another institution may be sought and, if done, should be supported by the transferring and receiving institution. Treatment should be continued while efforts are being made to locate and transfer to a receiving institution. (g) If transfer is not possible, the intervention need not be offered. (Res A-2, A-10)

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Abbreviations for House of Delegates report origination:

EC – Executive Committee; BT – Board of Trustees; CPA – Council on Professional Affairs; JC – Judicial Council; CHS – Community and Health Services

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