The empirical basis for determinations of medical futility.
BACKGROUND
Decisions to limit treatment in critically ill patients often rely on publications that make claims of futility based on outcome data. Our objective was to systematically review the criteria for futility and the strength of empirical evidence across clinical studies that purport to support or refute claims of futility.


METHODS
The MEDLINE database was searched for relevant articles published between 1980 and 2008. Selected studies reported original outcome data in critically ill or cardiac arrest patients and claimed that these data can support or refute decisions to limit treatment in comparable patients. Two authors independently abstracted data on patient characteristics, intervention, outcomes, cost, and design.


RESULTS
Forty seven studies supporting a claim of futility and 45 refuting it were reviewed. Median point estimate for adverse outcome in studies supporting claims of futility was 100% (range 75% to 100%); median lower 95% confidence limit was 91% (range 48% to 99%). Explicit thresholds for futility were missing in 88% of articles. The original criteria for quantitative futility were fulfilled by only 28% of data, and almost exclusively in studies of cardiopulmonary resuscitation (CPR) for cardiac arrest. Substantial statistical overlap was observed between data brought in support of futility claims and data brought to refute them.


CONCLUSIONS
Most studies that purport to guide determinations of futility are based on insufficient data to provide statistical confidence for clinical decision-making. They usually lack explicit a priori thresholds for determination of futility. Many studies draw disparate conclusions based on statistically similar data. In most circumstances these problems preclude confident determinations of futility.
Gabbay
Ezra
E
Division of Nephrology, Tufts Medical Center, Boston, MA 02111, USA. Ezra.gabbay@tufts.edu
Calvo-Broce
Jose
J
Meyer
Klemens B
KB
Trikalinos
Thomas A
TA
Cohen
Joshua
J
Kent
David M
DM
D016638:Critical Illness / Q000628:therapy*; D036262:Empirical Research; D006801:Humans; D018447:Medical Futility; D016896:Treatment Outcome