SURGICAL ETHICS CHALLENGES

Futility and surgical interventionJames W. Jones, MD, PhD,a and Laurence B. McCullough, PhDb

An 86-year-old man presents with a history of multipleendarterectomies, coronary grafting, and an infrarenalabdominal aneurysmectomy. He is now diagnosed withan 8-cm symptomatic thoracoabdominal aneurysm andemphysema with an FEV1 of 0.5 L. Patient and familyinsist on urgent surgical intervention. What is the bestresponse?

A. Refer the request to the hospital’s ethics committee.B. Refuse the request as inappropriate.C. Refer them to another surgeon because you are uncom-

fortable operating in this case.D. Explain why surgery is likely to be futile in this case, and

recommend palliative care.E. Involve Risk Management in subsequent discussions

with the patient and his family.The best response is D. Limits on the obligation to

preserve life have been understood in medicine throughouthistory. The dramatic success of high-technology surgeryand critical care since World War II has sometimes mademedicine’s ability to extend life seem boundless, but ofcourse it is not. Cardiopulmonary resuscitation and ad-vanced surgical procedures have often been implementedwith insufficient attention to associated morbidity and lostfunctional status, as many patients, families, and somephysicians have refused to acknowledge limits to medicine’sobligation to preserve life.

Despite recent skepticism,1 clinical assessments of futil-ity can be made and reliably implemented. “Futility” meansthat the therapeutic goal of a clinical intervention is unlikelyto be achieved. The key clinical issues in assessing futilitytherefore become the specified goal and the evidence that itis unlikely to be reached. Four senses of futility are relevantto the specification of goals2:

1. “Physiologic futility” is recognized when the interventionis reliably expected not to produce its desired physiologiceffect. Cardiopulmonary resuscitation is routinely discon-tinued when it can no longer be expected to restorespontaneous circulation and respiration.

2. “Overall futility” reflects a reliable expectation that theintervention will not restore the patient’s capacity tointeract with the environment and continue humandevelopment. Antibiotics for management of opportu-nistic infections can justifiably be withheld from patientsin a persistent vegetative state.

3. “Imminent demise futility” characterizes a reliable ex-pectation that the patient will die before discharge andnot recover interactive capacity before death.

4. “Quality of life futility” applies when the patient’s cur-rent or projected condition will result in an intolerableinability to engage in or derive pleasure from life.In this case, there are two likely outcomes of surgical

intervention; first, that the patient will die during or shortlyafter surgery, and, second, the patient will survive but notbe weanable from ventilation, thereby losing any remaininginteractive capacity. Blackhall3 set the standard for physio-logic futility at a 98% to 100% expectation of failure toachieve the desired outcome. This case may not meet thatstandard, but it can be seen as exemplifying either immi-nent demise futility or overall futility.

The surgeon should meet with the patient and hisfamily to discuss the prognosis of overall or imminentdemise futility. The surgeon should explain that surgerywould not be in the patient’s best interest and that acomfortable and dignified death is the most appropriateavailable goal. The surgeon should make a referral to hos-pice care. If the patient continues to insist on surgery, thesurgeon should consider referral to the hospital ethicscommittee (choice A).

The problem with refusing to perform inappropriatesurgery (choice B) resides in the term’s vagueness whenclinically applied. The four concepts of futility can help toclarify the surgeon’s reluctance to operate when the out-come will be poor. “Uncomfortable” is an even fuzzierterm in clinical discourse and so, until an attempt has beenmade to reason with this patient and his family, option C ispremature. Finally, surgeons should not rely upon riskmanagers for clinical guidance in potentially conflictualsituations (choice E). Rather, surgeons should form clinicalethical judgments carefully as patient fiduciaries and guidethemselves and their patients accordingly.

REFERENCES1. Helft PR, Siegler M, Lantos J. The rise and fall of the futility movement.

N Engl J Med 343;2000:293-6.2. McCullough LB, Jones JW. Postoperative futility: a clinical algorithm.

Brit J Surg 2001;88:1-2.3. Blackhall L. Must we always use CPR? N Engl J Med 317;1987:1281-5.

From the Department of Surgery, University of Missouri,a and the Centerfor Medical Ethics and Health Policy, Baylor College of Medicineb.

Correspondence: James W. Jones, MD, PhD, University of Missouri, De-partment of Surgery (M580), One Hospital Dr, Columbia MO 65212(e-mail: jonesjw@health.missouri.edu).

J Vasc Surg 2002;35:1305.Copyright © 2002 by The Society for Vascular Surgery and The American

Association for Vascular Surgery.0741-5214/2002/$35.00 � 0 24/1/124492doi:10.1067/mva.2002.124492

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