Originally Posted - January 23, 2007

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Medical Futility Policies are dictated by bioethicists and end-of-life advocates who push for policy changes within medicine and public policy changes via legislation. Additionally, Ethics Committee protocols within healthcare facilities are developed to support these policy changes. The degree of influence these euthanasia proponents have in medical futility care policy development and protocol is uncertain. One thing is certain; when you find "futile care" in healthcare facilities, you know euthanasia proponents, also known as End of Life (EOL) and Right to Die (RTD) proponents have made inroads in promoting their concept through their seminars at healthcare facilities, and by changing legislative policy, as in Oregon and Texas. The language often used is "burden," "quality," "suffering," "dignity", and "quality adjusted life year (QALY)." You also hear people claim, "Who would want to live like that?"

EOL/RTD proponents unsuccessfully tried to define end of life and recently removed the word death and suicide from their programs and literature. Similarly, they are now calling for a new definition of not only futility, but Physician Assisted Suicide (PAS) as well. Miriam Webster defines futility as uselessness as a consequence of having no practical result. Uselessness is not an aesthetic term, especially in the world of medicine, hospice and end of life. We simply did not use these words, nor were they in medical textbooks. The rationale for redefining the word among EOL advocates is simply because they need a new buzz word that generates and promotes acceptance of the futile care concept. Futility correlated with burden, quality, suffering, and dignity are no longer winning the public over.

Many hospitals across this country have "futility" protocols in place. Futile care was the rage from 1996 to 2003, but the policies were surreptitiously devised and implemented, and this unbeknownst to the public. Most healthcare facility employees were not aware or informed of futility policy implementation at their place of employ either.

Today, if a physician or ethics committee members think you are not a candidate for rehabilitation or are not a candidate for treatment or "life sustaining treatment," they can invoke their "futile care policy," declare you a futile case, and refuse treatment based on their opinion and policies which is often subjective; you will not receive standard medical treatment, or worse yet, you will receive no treatment, because it is considered unnecessary treatment. You will only be provided with comfort care or palliative care, and if the treatment is a lethal dose of opioids to keep you pain free, you die.

The prime concern with medical futility laws in a healthcare setting is that whoever sits on the ethics committees, along with the attending physicians, have the ability to subjectively determine whether you receive treatment, and ultimately, whether you live or die. In other words, is the treatment "futile," or is the patient receiving treatment a "futile case?" If there is any hope of rehabilitation or improvement from a serious injury, you are never given the chance to heal or recover enough to determine that factor under these circumstances. Medications, treatments, and testing may all be discontinued. You lay in a bed with only basic care provided, and this does not always include food and fluids. You are sedated to the point that you are unable to eat. You die of dehydration, lack of needed medications and/or medical treatments, and the effects of immobility by sedation.

You say you have an Advance Directive (AD)? An AD is not followed with any regularity, particularly in Texas. Futile care policies override your AD, and not just in the state of Texas. The media provides us with accounts of people who are killed, because Advance Directives are not followed in Texas, and they make no secret that George Bush signed the bill into law that create these situations and allow these deaths to occur. Healthcare facilities in other states condone this same practice of futile care, yet go unreported.

Ironically, there is nothing in medicine that defines medical care or patients as futile. This was changed by bioethicists who pose as EOL/RTD proponents and provide curriculum and medical policies directed toward the field of medicine, and legislative policy. Make no mistake; EOL has deep ties and the ability to make these changes.

There are several versions of medical futility, all defined differently, depending on who is asked; those for or those against euthanasia and assisted suicide. There are also those who deny futile care exists, but it does.

Medical futility is defined as treatment that has no benefit or is outside accepted medical practice where the clinician may be justified in withholding or withdrawing treatment. Example: discontinuing a ventilator or other life support measures, such as CPR in a dying patient.

If there is such a thing as medical futility, this is my idea of what it means----"discontinuing a ventilator or CPR in dying patients." CPR did not revive the patient after several minutes; halt CPR. Ventilator patient's condition is rapidly deteriorating with aggressive treatment; shut off the ventilator.

Yanking a feeding tube to purposely dehydrate and starve a person to death is not justifiable medical care. It is refusing care, and not just medical care. It is neglect when animals are not fed and hydrated, and it should be neglect when a human being is not fed and hydrated.

What goes unchallenged and is not debated is what constitutes and defines the "dying" patient. For EOL advocates, the "dying" or "terminal" includes those with mental impairments and those with chronic diseases, such as diabetes, heart diseases, those with mental illnesses, and even drug addicts. The person does not have to be actively dying, but at some point they will die, so EOL labels them all as terminal. Since we all die, EOL could define all persons as "terminal" and thus, subject all to their "futile care policies." http://www.northcountrygazette.org/articles/092606ChronicToTerminal.html

Some state legislatures defined life sustaining treatment to include feeding tubes, IV fluids, oxygen administration and respiratory treatments, and even antibiotics in some areas. Is there a difference between life support and life sustaining treatment? Yes, but state governments do not understand it, and EOL radicals do not want the discrepancies pointed out. They want both terms to define the same types of treatment and to be used interchangeably. Since life sustaining treatment was not used in medical texts in the past, we can presume the term was introduced by EOL proponents or state governments, as those are the only areas we find that specific terminology and usage. What defines life sustaining treatment? It varies in today's climate. Since state laws change frequently, make sure your AD specifies whether you want "life sustaining treatment" and "life support," or not.

Gee, I feel better already just knowing the government is defining medical terminology and has the ability to limit and decide my medical care, don't you?

How do you know what life sustaining treatments to choose? You cannot know in advance with specificity. You can broadly choose options, but not the specifics. This is one of the major flaws with Advance Directives and the POLST forms initiated in many states that were developed by the EOL movement.

Myra Christopher's Center for Practical Bioethics first introduced the concept of POLST to the public in the Robert Wood Johnson Foundation's (RWJF) Community State Partnership initiative #3. That initiative specifically states POLST prevents unwanted, aggressive life sustaining treatment by Emergency Medical Service personnel. But does it? POLST was developed by Oregon EOL proponents with the claim there was no legislative inclusion; however, we now know POLST has been created by statutes, regulations and guidelines; but mostly by state statutes.
http://www.northcountrygazette.org/articles/050206MyraChristopher3.html

Another definition of medical futility is defined as an institutional policy that supports the withholding or withdrawal of treatment and that has been determined to be non-beneficial. Non-beneficial by whose standards; mine, my family, the physician, an ethics committee, a hospital policy, end of life advocates, the government, the insurance provider, the medical institution administrator, or other? This definition is deeply flawed, is too broad, subject to frequent changes, and begs for revision and clarification. This is what occurs when a concept is applied to medicine. As such, medical treatment and care has been changed by these definitions and terminology.

Still another author defines futile care as medical care that prolongs suffering, does not improve the quality of life, or fails to achieve a good outcome for the patient.

To avoid prolonged suffering, the excuse for terminal sedation and hastening death, along with assisted suicide arises. If "quality of life" (a subjective term) does not improve by medical measures, patients with Alzheimer's and other chronic progressive diseases will then suffer the consequences of passive assisted suicide. These diseases do not improve, they worsen over time. What constitutes a "good outcome" for these patients? How can a good outcome (another subjective term) be clarified and defined, then further applied to medical care? A good outcome in an Alzheimer's patient is to remain free of respiratory infections and skin breakdown. We know respiratory aspiration and infections can go untreated by hospice, hospitals, and long term care facilities in some patients. POLST tells us this. Do these facilities and caregivers perceive a good outcome in an Alzheimer's patient as free from "suffering," even though suffering cannot be ascertained in these patients?

Patients with amputated legs do not always feel they have a good outcome. Do we assist all leg amputees to die or just those who are depressed over the loss of a limb? A good outcome must be measurable, and not solely the product of an opinion, a treatment outcome alone, or an illness, such as depression that develops as a symptomatic result of an injury or disease.

It is worth noting that while the American Nurses Association (ANA) rejects active euthanasia, passive euthanasia, defined as deliberately ending a person's life, exists when death results from willful omission; withdrawing or withholding treatment as cited in Cawsey, 1996. Justifying self determination and patients' rights, and defining euthanasia as a painless, peaceful death does not make the practice medically sound or morally acceptable. Simply stated, the ANA supports physician assisted suicide in their position statement.

Another author goes on to clarify the three conceptual types of futility as physiologic futility, imminent demise futility, and lethal condition futility. Imminent demise and lethal condition is self explanatory, but there is a high degree of probability in exploiting physiologic futility. Leg amputees with resultant depression as a common complication and the mentally impaired are two classic examples.

Futile care may also be defined as quantitative: "When physicians conclude through personal experience, experiences shared with colleagues, or reported empiric data that a medical treatment has been useless." Qualitative futility describes treatment that "merely preserves permanent unconsciousness or cannot end dependence on intensive medical care." Intensive medical care would be a ventilator. A feeding tube is not intensive medical treatment or care.

The problems we face with futile care policies involve opinions and judgments that are harmful, loss of patient autonomy, abuse, neglect and exploitation by surrogates and physicians, and can cause premature death for patients. While futile care policies may save resources, there is no compassion or dignity involved in the practice, and medical care becomes non-existent. We are left with the provision of simple custodial care for basic needs and the plan to hasten patients' death, while calling it medical treatment.

What role should futility judgments play in clinical decision making? According to Dr. Bradley Wilson, a physician might rely on a judgment of futility to justify not offering a particular treatment as an option to a patient or their surrogate. A physician might override the expressed wishes of a patient or their surrogate for treatment, on the grounds that the desired treatment is futile. Dr. Wilson goes on to explain that "……determination of when treatment or care is judged futile cannot be answered, as the specific goals of futility treatment must first be identified, such as whether the goal of CPR for an elderly patient is eventual discharge or just maintaining life long enough to allow distant family members the chance to visit." Since the specific goals of futile care or treatment are variable among patients, futile care or treatment is variable, and cannot be defined, not even by broad parameters.

EOL and RTD radicals link futility to the use of massive resources during the final days or years of life. An EOL proponent stated, "Some feel that futile care is an appropriate place to start rationing health care dollars. Although this may seem unjust, care deemed as futile may be a more acceptable alternative to limiting resource consumption than rationing on the basis of social worth or ability to pay."

Healthcare rationing is their excuse for following futile care policy! Somehow, we are to believe that limiting care versus rationing care is not the same, but is a solution when treating certain classes of society. If the term futile is utilized, medical care is then justifiably limited or rationed. Where is public discourse on this issue? There is none, because the public is not aware. Rationed healthcare is not a solution to the problems we face with the elderly, brain injured, and disabled, or the uninsured in this country.

There are many interpretations of health care rationing via futility policies that leave families with uncertainty and guilt. Example: Andrea Clark, a Texas case where the attending physician and hospital refused to follow the patient's advance directive. Only after national media attention and public outcry did the facility change their stance and provide medical treatment.

Another example is Terri Schiavo when Florida legislators defined feeding tubes as medical treatment "supplanting or supporting a spontaneous vital function" that could be discontinued with their redefined terminal disease of PVS, even though the specific outcome is death to the patient, also known as passive euthanasia, and noted in the ANA position statement. As Florida law now states, and Dr. Ronald Cranford and other right to die activists declared, PVS is a terminal condition, but not all of medicine agrees with this premise, nor does medical science support it. Treating PVS is "futile" and a waste of resources, according to EOL proponents.

A confused elderly patient with a medical history of heart disease or diabetes who falls and breaks a hip could subjectively be labeled by the physician and hospital ethics committee as "futile" and then over sedated due to futile care policies in our healthcare facilities. There are state laws currently in place that supports futility policies and condones this practice.

If you assume that self determination or ownership of your medical decisions and rights are absolute, they are not. It is not about self determination. That was used as a means to an end by EOL. At some point, autonomy will become a hindrance to EOL proponents and will no longer apply; as unnecessary medical treatment, limiting medical care and healthcare rationing cannot co-exist with autonomy and self determination.

As we saw in the Terri Schiavo case, other interests can override your rights. A hospital ethics committee, a hospice protocol, a physician, a judge, and a guardian can override your rights. A member of the clergy, the media, and all of the above can sway your opinion, or that of your guardian, thereby overriding your rights.

Physicians do not agree as to what constitutes futile care or treatment. So, bioethicists are stepping in and dictating medicine, once again. If patients are labeled as "futile" they can then be easily euthanized by hospitals and hospice facilities as in the cases of Terri Schiavo, Nancy Cruzan, Brianne Rideout, Marjorie Nighbert, Hugh Finn, and many others.

Michael Brannigan, vice president of the Center for Practical Bioethics, claims that physicians evaluate a treatment's effectiveness, while patients weigh medical benefits and burdens. The patient ultimately has the choice to receive or forego treatment; at least they did at one time. Brannigan espouses a biomedical and physiological model of medicine with guidelines that establish definitions of "medical futility," "standard-of-care," "autonomy," "beneficence," "palliative care," and other medical and end of life terms in these guidelines.

But, not everyone will fit into the guidelines of that model, as patients do not respond to illness and treatment exactly the same. Patient autonomy is only applicable if we are guaranteed the ability to make our medical decisions and only if we are competent enough to voice our preferences. Everyone's moral values will not agree with Brannigan and the Center for Practical Bioethics. Classifying patients into a model will simply never benefit the public. It may be an aid to government, the insurance companies, EOL movement, and hospice, but it will not aid patients or the public. http://www.practicalbioethics.org/FileUploads/MO%20Medicine.Medical%20Futility.MarchApril06.pdf

End of life proponents and bioethicists want futility evaluated on a case by case analysis using disease categories. Healthcare rationing on the basis of social worth or the ability to pay are factors in who ultimately receives treatment. EOL also wants not just patient decisions, but family, the healthcare interdisciplinary team with institutional futility policies in place given a voice, and guidance from ethics committees included in deciding whether to provide treatment or not. This is the end of patient autonomy and self determination, but ironically, exactly what EOL has fought for over the past 2 decades to advance their agenda of legalizing euthanasia.

Since the public is not often equipped to make informed decisions concerning life and death treatments, this leaves decisions made largely by the unilateral ethics committees and their institutional futile care policies. The standard medical care guidelines currently followed will not exist when this is enacted. Standard medical care will erode to less than acceptable levels.

Futile care and futility are elusive terms in medicine, not applicable to all patients, and should never become a standard. Yet, our medical care is often predicated on these half baked terms. Futility and futile care does nothing except provide ethical justification, an excuse, for specific types of medical decisions that condone death by active and passive euthanasia.

Futile care is healthcare rationing. Futile care is weighing burdens over benefits, not necessarily of the patient, but of the family and society. Futile care is one step closer to euthanasia in this country.

The concept of futile care is difficult to define, is subjective, encourages and condones abuse and neglect, and encourages euthanasia. Equating "futile care" with efforts to prolong life is now viewed as prolongation of suffering and as harmful acts. Too many Americans believe this fallacy. If this is true, why do we treat infections and market antibiotics; why do we treat high blood pressure and perform heart surgeries; why treat chronic diseases; why have nursing homes and long term care facilities; why bother with research and technology?

Someone recently commented that the concept of futile care was disputed because the legal system forced medicine to examine the theoretical boundaries in depth. Maybe this is true. We do know futile care was implemented at the behest of EOL advocates and bioethicists with help from the legal field. EOL simply used the legal field to set case law, they used the medical field to enact medical policies, and they used state governments to enact policy changes. http://www.managedcaremag.com/archives/0404/0404.ethics.html

Bioethicists pushing assisted suicide and euthanasia policies need to stand down. The EOL and RTD movement is about due to wither and die, as their goals are nearly accomplished. The medical field needs to regain their integrity and set their own ethical standards. Let us practice medicine the way we were taught. We do not have goals or an agenda to accomplish. This is the only guarantee any of us have of receiving adequate medical treatment in our elder years and in the future. 1-23-07

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