'Futile Care': What To Do When Your Patient Insists On Chemotherapy That Likely Won't Help

Main Category: Cancer / Oncology
Article Date: 07 Jan 2009 - 3:00 PDT

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While there is no generally accepted medical definition of "futile care," many factors may play a role in the delivery of chemotherapy to patients who are unlikely to benefit. In this review, we consider the roles of both the patient and the physician in driving the provision of "futile care" and offer practical steps the oncologist can take to avoid it.

The use of the term 'futility' in cancer care has been prompted, in part, by increasing requests from patients for treatments thought to be ineffective as well as costly. The appropriate role of chemotherapy near the end of life is a complex issue. As chemotherapy is increasingly available and better tolerated, its use at life's end involves sophisticated oncologic assessment, a focus on the patient's goals of care, and a balancing of perspectives of the patient and treating oncologist.

A number of factors play a role in the delivery of chemotherapy to patients who are unlikely to benefit. Incentives ranging from the expectation of prolonged survival, symptom improvement, the preservation of hope, or simply not "wanting to give up" all contribute to some degree. In this review we hope to investigate these issues and expand on the role that physicians, patients, and even popular media may play.

What Is 'Futile Care'?

There is no generally accepted medical definition of futile care. If one considers that the goal of medical care is to achieve a benefit above a certain minimal threshold, then futile care could be defined as care that fails to achieve that benefit. The sticking point, then, is not one's definition of futility, but one's definition of benefit. That is why the application of the word "futility" in discussions of medical care is considered ethically hazardous, especially when the values of the physician are incongruous with those of his or her patient.

In addition, the inexact and somewhat unpredictable nature of medicine makes it a precarious endeavor to call a therapy futile unless, as Schneiderman narrowly defines it, "in the last 100 cases a medical treatment has been useless." He goes on to say that "physicians should distinguish between an effect, which is limited to some part of the patient's body, and a benefit, which the patient has the capacity to appreciate." Finally, one of the main reasons the word "futility" became unpopular is that it was perceived to be invoked when a therapy became too costly.

James Khatcheressian, MD, Sara Beth Harrington, MD, Laurel J. Lyckholm, MD, Thomas J. Smith, MD

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