title: Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians.
abstract: OBJECTIVE
  Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile.
  
  
  METHODS
  The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis.
  
  
  RESULTS
  Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families.
  
  
  CONCLUSIONS
  Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.
authors.affiliation: Institute of Ethics, History and Theory of Medicine, University of Munich, Lessingstrasse 2, 80336 Muenchen, Germany. ralf.jox@med.lmu.de
authors.forename: Ralf J
authors.initials: RJ
authors.lastname: Jox
authors.forename: Andreas
authors.initials: A
authors.lastname: Schaider
authors.forename: Georg
authors.initials: G
authors.lastname: Marckmann
authors.forename: Gian Domenico
authors.initials: GD
authors.lastname: Borasio
mesh_terms: D000328:Adult; D000465:Algorithms; D001291:Attitude of Health Personnel; D003142:Communication; D003422:Critical Care / Q000941:ethics*; D003657:Decision Making; D005858:Germany; D006801:Humans; D007362:Intensive Care Units; D018447:Medical Futility / Q000941:ethics*; D010166:Palliative Care / Q000941:ethics*; D011788:Quality of Life; D013727:Terminal Care / Q000941:ethics*; D062606:Tertiary Care Centers