A Canadian study looking into the perceptions of and reasons for futile medical care in intensive care units (ICUs) found that medical staff made consistent decisions about it, had a clear idea of what it was, and how to focus future efforts to limit the impact of futile care in the ICU.
The study is published in the 6th November issue of the CMAJ (Canadian Medical Association Journal) and is the work of Dr Robert Sibbald from the Department of Ethics, London Health Sciences Centre, London, Ontario, and Drs James Downar and Laura Hawryluck of the Division of Critical Care, Department of Medicine at the University of Toronto, Toronto, Ontario.
There is no universally accepted definition of “futile care” although many ICU frontline staff have expressed concern that they may sometimes be providing excessive or inappropriate care. Also, little research exists on “futile care”, why it happens, and why ICU staff would provide it.
Sibbald and colleagues interviewed 44 senior health care providers (14 physician directors, 16 nurse managers and 14 respiratory therapists) in 16 ICUs across Ontario and talked with them around a set of prepared questions about futile care.
From their narrative responses, using a method called modified grounded theory, the researchers formed a working definition of medically futile care:
“The use of considerable resources without a reasonable hope that the patient would recover to a state of relative independence or be interactive with his or her environment.”
Further analysis of the responses, which the authors said were broadly consistent, revealed a number of reasons for providing futile care, including:
- Pressure from family members.
- Lack of timely or skilled communication.
- Lack of consensus among the treating team members.
Sibbald and colleagues also found that most of the respondents said they wanted better ethical and legal support to help deal with futile care cases.
The Canadian Critical Care Society does support withholding of life support in futile care cases, but the law is insufficient to help make decisions in instances when patients and their substitute decision makers are opposed to the opinions of the medical team.
The researchers wrote that:
“The best solution is always to achieve consensus, and ethical consultation may be helpful in resolving cases of seemingly intractable conflict.”
Respondents also said there should be more education for the public and health care professionals about the role of ICU and other options such as: palliative care, mandating early and skilled discussion of resuscitation status, and establishing guidelines for admission to the ICU.
Sibbald and colleagues said there was an increasing need for frontline ICU doctors, nurses and respiratory therapists to make decisions on the best use of scarce clinical resources as the need for critical care beds is rising.
The study concluded that:
“Frontline ICU physicians, nurses and respiratory therapists in Ontario have similar and well-formed opinions about how to define and resolve medically futile care and where to focus future efforts to limit the impact of futile care in the ICU.”
“Perceptions of “futile care” among caregivers in intensive care units.”
Sibbald, Robert, Downar, James, Hawryluck, Laura.
Written by: Catharine Paddock