Medical Futility and Nonbeneficial Interventions
2014; Elsevier BV; Volume: 89; Issue: 12 Linguagem: Inglês
10.1016/j.mayocp.2014.08.017
ISSN1942-5546
AutoresM Armstrong, Joseph Ken Adu Poku, Christopher M. Burkle,
Tópico(s)Childhood Cancer Survivors' Quality of Life
ResumoMedical futility is a clinically relevant and controversial issue. In 2005, 87% of Canadian intensivists surveyed1Palda V.A. Bowman K.W. McLean R.F. Chapman M.G. "Futile" care: do we provide it? why? a semistructured, Canada-wide survey of intensive care unit doctors and nurses.J Crit Care. 2005; 20: 207-213Abstract Full Text Full Text PDF PubMed Scopus (114) Google Scholar believed that they had provided futile medical interventions during the past year. A 2013 study2Huynh T.N. Kleerup E.C. Wiley J.F. et al.The frequency and cost of treatment perceived to be futile in critical care.JAMA Intern Med. 2013; 173: 1887-1894Crossref PubMed Scopus (173) Google Scholar of 5 academic intensive care units found that physicians considered nearly 20% of all interventions provided over a 3-month period to be futile. The duration of futile interventions ranged from 1 to 58 days, with an estimated cost of $2.6 million during the 3-month study. More than half of the cases were considered futile because even with intervention the physician believed that the patient's goals were unreachable. In 31% of the futile intervention cases, the physicians believed that the patient would never survive outside of the intensive care unit.2Huynh T.N. Kleerup E.C. Wiley J.F. et al.The frequency and cost of treatment perceived to be futile in critical care.JAMA Intern Med. 2013; 173: 1887-1894Crossref PubMed Scopus (173) Google Scholar, 3Healy M. Intensive care treatment is often futile and costly, study finds. Los Angeles Times. September 9, 2013:Science Now.Google Scholar Despite some authors describing the "rise and fall of the futility movement," the challenge of intervening in these scenarios remains difficult and clinically prevalent.4Helft P.R. Siegler M. Lantos J. The rise and fall of the futility movement.N Engl J Med. 2000; 343: 293-296Crossref PubMed Scopus (273) Google Scholar The term medical futility has been widely discussed in the literature and in the clinical setting. Despite evading definition, it has become integral to the modern medical lexicon. Any scenario involving a potentially nonbeneficial intervention (NBI) is dynamic, variable, and value laden. Family members and clinicians, however, often lack the skills to comfortably navigate these very difficult issues. The associated discomfort may stem from treatments or scenarios that transgress the family's or physician's ethical limits, and both groups need to be apprised of their rights to withdraw from, in the case of providers, or open a discussion, in the case of families, regarding the particular interventions they perceive as nonbeneficial. Multiple sources have independently offered techniques intended to assist during NBI scenarios. We first briefly review the legal and clinical history of the futility literature, noting the difficulty surrounding its precise definition and use in clinical arenas. We argue that incorporating the concept of NBIs offers several advantages when discussing futility disputes. Given this reframed perspective, a novel algorithm is advanced, synthesized from previously published techniques that have been shown to assist clinicians struggling with potentially NBIs. The words futile and medical futility are not present in Stedman's Medical Dictionary.5Stedman T. Stedman's Medical Dictionary for the Health Professions and Nursing, Illustrated, Fifth Edition. Lippincott Williams & Wilkins, Baltimore, MD2005Google Scholar Merriam-Webster Dictionary defines futile as having "no result or effect, pointless or useless."6Futile. http://www.merriam-webster.com/dictionary/futile. Accessed April 26, 2014.Google Scholar Clinically, interventions labeled as medically futile refer to the unfortunate situation in which continued therapy will not benefit the patient and, therefore, ought not be used. Expanding this definition is difficult, particularly when applied to complex patient situations. Some classifications use the term strictly to refer only to the absence of physiologic effect—a situation rarely encountered in clinical medicine. The second, loose classification acknowledges that interventions may have some physiologic action but do not promote the patient's goals. Individual goals, inaccurate statements regarding prognosis, or a miscalculation of the burden to benefit ratio can cause nearly any therapy to seem futile in the loose sense. Because the definition is relative to the goals of each stakeholder, the patient prognosis, the burden to benefit ratio perceived by each stakeholder (patient, family, physician, hospital), and the limits of medical technology, clarity among involved parties is paramount. Because what is considered futile is relative to many factors, a universal definition has been elusive, keeping futility at the forefront of ethical medical practice for centuries. The Edwin Smith surgical teaching papyrus references ancient Egyptian notions of futility regarding high spinal cord injuries.7Sigerist H.E. A History of Medicine. Oxford University Press, New York, NY1950Google Scholar Without ventilators or vasopressors, treatment was largely ineffective, and attempts would have been futile in both the strict and looser senses. Identifying futile interventions in the Hippocratic tradition meant finding patients whose prognosis was so poor that they were "overmastered" by their disease. Identification of these patients was central to the physician's duty to do no harm by incurring the risk of intervention only when there was reasonable certainty that the benefit of the intervention could be realized.8Jecker N. Knowing when to stop: the limits of medicine.Hastings Cent Rep. 1991; 21: 5-8Crossref PubMed Scopus (49) Google Scholar"It appears to me a most excellent thing for the physician to cultivate Prognosis … [so] he will be the more readily believed to be acquainted with the circumstances of the sick; so that men will have confidence to intrust themselves to such a physician …. For it is impossible to make all the sick well; this, indeed, would have been better than to be able to foretell what is going to happen; … [It] therefore becomes necessary to know the nature of such affections, [and] how far they are above the powers of the constitution."9Hippocrates The Genuine Works of Hippocrates. Williams & Wilkins Co, Baltimore, MD1939Google Scholar Hippocrates understood well the physician's duty to benefit his or her patients (beneficence) by selecting interventions that would truly help. He does not recognize in this particular passage that benefit is more than physiologic improvement or that patients deserve input into which benefits are sought. More recently, the ethical principle of autonomy, which protects patients' personal values from infringement by others, was underscored in the medical sphere by Justice Cardozo in 1914 when he wrote that "[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body."10Schloendorff v Society of New York Hospital, 211 N.Y. 125, 105 N.E. 92 (1914).Google Scholar This entrenched protection of personal goals and values has clearly and consistently been interpreted to show that the desirability of any given intervention is also relative to the goals of the individual who it is intended to benefit. The 1976 case of Karen Ann Quinlan is a prominent example of a request (by the patient's family) that noncurative interventions be withheld because according to Ms Quinlan's value system there was little benefit to the patient from prolonging her physiologic life without significant mental recovery.11Lo B. Jonsen A.R. Clinical decisions to limit treatment.Ann Intern Med. 1980; 93: 764-768Crossref PubMed Scopus (73) Google Scholar, 12Cruzan v Director, Mo. Dept. of Health, 497 US 261 (1990).Google Scholar, 13In re Quinlan, 355 A.2d 647 (NJ: Supreme Court 1976).Google Scholar In re Cruzan,12Cruzan v Director, Mo. Dept. of Health, 497 US 261 (1990).Google Scholar the US Supreme Court underscored a patient's right to refuse treatment, a decision that later helped ground legislation promoting patient autonomy.14Patient Self-determination Act §4206-4751, Pub L No. 101-508 (1990).Google Scholar Although the Quinlan and Cruzan cases do not speak directly to the matter of what futile medical care is, they provide legal insight and guidance regarding patient autonomy and solidify the preeminent place of patient values in determining the benefit or burden imposed by medical interventions. Early clinical efforts to define medically futile interventions were based on the empirical success rate of a given intervention and quickly fell victim to the omission of the patient's value system. Some ethicists and clinicians proposed success rates between 0% and 13% as a threshold for the definition of medically futile interventions.15Lantos J.D. Singer P.A. Walker R.M. et al.The illusion of futility in clinical practice.Am J Med. 1989; 87: 81-84Abstract Full Text PDF PubMed Scopus (215) Google Scholar Others thought that "when physicians conclude (either through personal experience, experiences shared with colleagues, or consideration of reported empiric data) that in the last 100 cases, a medical treatment has been useless, they should also regard the treatment as futile."16Schneiderman L.J. Jecker N.S. Jonsen A.R. Medical futility: its meaning and ethical implications.Ann Intern Med. 1990; 112: 949-954Crossref PubMed Scopus (922) Google Scholar The procedural details and difficulty associated with personal recollection, case matching, and ascertainment of accurate prognosis, along with challenges in defining the term useless, made these absolute approaches clinically untenable. Youngner17Youngner S.J. Who defines futility?.JAMA. 1988; 260: 2094-2095Crossref PubMed Scopus (264) Google Scholar and Schneiderman16Schneiderman L.J. Jecker N.S. Jonsen A.R. Medical futility: its meaning and ethical implications.Ann Intern Med. 1990; 112: 949-954Crossref PubMed Scopus (922) Google Scholar separated the quantitative (percentage success rate), qualitative (can any treatment goals be met), and physiologic aspects of futility. Increasing the fidelity with which futility could be defined brought the debate out of the statistical trenches and helped create a less paternalistic concept by placing subjective individual value alongside physiologic effect and medical success rate. The 1986 case of Elizabeth Bouvia18Bouvia v Superior Court, 179 Cal. App. 3d 1127 (Cal: Court of Appeal, 2nd Appellate Dist., 2nd Div. 1986).Google Scholar underscored the importance of qualitative metrics in autonomous decision making, holding that the quality of a patient's life was of equal if not superior import relative to quantity when considering various interventions. Although this approach moved clinical and ethical practice forward, a precise definition and consistent application remained elusive, leaving clinicians and researchers only slightly better equipped to battle the seemingly indefinable yet readily identifiable foe.19Truog R.D. Brett A.S. Frader J. The problem with futility.N Engl J Med. 1992; 326: 1560-1564Crossref PubMed Scopus (362) Google Scholar The difficulty of finding a precise definition to easily encompass the broad scope of the concept, and a general disease facilitating these difficult clinical discussions, seem to have led to a clinical preference for procedural solutions. These methods involved a period of conflict resolution, followed by involvement of an institution's ethics committee. The process could be initiated by a patient, the family, or the medical staff (any stakeholder) in response to any treatment they felt was of greater burden than benefit to the patient. A contingency pathway for physician withdrawal in deference to a colleague willing to perform the disputed intervention, transferring the patient to another facility, or withdrawing the disputed intervention was created for unfortunate cases of intractable conflict. This type of procedural resolution was useful in a broad range of circumstances and offered a means to resolve difficult situations without precisely defining futility. As such, procedural solutions were rapidly assimilated into societal guidelines and hospital policies.20AMA Council on Ethical and Judicial AffairsMedical futility in end-of-life care: report of the Council on Ethical and Judicial Affairs.JAMA. 1999; 281: 937-941Crossref PubMed Scopus (287) Google Scholar, 21Bay Area Network of Ethics Committees (BANEC) Nonbeneficial Treatment Working GroupNonbeneficial or futile medical treatment: conflict resolution guidelines for the San Francisco Bay area.West J Med. 1999; 170: 287-290PubMed Google Scholar, 22Swig L. Cooke M. Osmond D. et al.Physician responses to a hospital policy allowing them to not offer cardiopulmonary resuscitation.J Am Geriatr Soc. 1996; 44: 1215-1219PubMed Google Scholar One frequently referenced policy used at Boston Children's Hospital (BCH) is exemplary of the procedural nature of futility resolution. The BCH policy, although formally unproven and never tested in court, focuses on exhaustive dispute resolution.23Truog R.D. Medical futility.Georgia State University Law Rev. 2009; 25 (Article 13)Google Scholar, 24Truog R.D. Counterpoint: the Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process.Chest. 2009; 136: 968-971Crossref PubMed Google Scholar, 25Fine R.L. Point: the Texas advance directives act effectively and ethically resolves disputes about medical futility.Chest. 2009; 136: 963-967Crossref PubMed Scopus (33) Google Scholar Any stakeholder (patient, family, nurse, or physician) who perceives that the burdens of therapy may outweigh the benefits or that the active intervention is not moving toward the goals of care can initiate this policy. Discussion between medical staff and patients (or their surrogates) attempts to address any misunderstanding or miscommunication of a patient's values, prognosis, options, and wishes. This discussion is intended to clarify the values of the care team and patient so that the manner in which a given intervention may align or conflict with those values and goals can be discussed and a decision about how to manage the questioned intervention can be made. The style with which this exhaustive resolution is performed is left to the attending physician. Strategies to aid clinicians in this effort are not directly offered under the BCH policy. If agreement cannot be reached after these initial efforts, institutional or legal recourse may follow (Table).24Truog R.D. Counterpoint: the Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process.Chest. 2009; 136: 968-971Crossref PubMed Google Scholar, 25Fine R.L. Point: the Texas advance directives act effectively and ethically resolves disputes about medical futility.Chest. 2009; 136: 963-967Crossref PubMed Scopus (33) Google ScholarTableBoston Children's Hospital and Texas Advance Directives Act Medical Futility PoliciesBoston Children's Hospital Futility PolicyTexas Advance Directives ActRequest for help: any party (clinicians or family).Request for help: any party (clinicians or family).Exhaustive dispute resolution involving ethics, pastoral care, social work, palliative care, etc.Exhaustive dispute resolution involving ethics, pastoral care, social work, palliative care, etc.Case is referred to ethics committee.Case is referred to medical review committee or ethics committee.Verbal notification of surrogates.Written or verbal notification of surrogates with information regarding other rights under the policy or law. Included is written notification of the potential for withdrawal of medically inappropriate treatment if no alternative provider is found during a 10-d search and the family does not seek court intervention.If futility is endorsed by the ethics committee, the surrogates are informed in writing. Hospital leadership must endorse the decision.If futility is endorsed by the appropriate institutional committee, the surrogates are informed in writing.Attempts must be made to transfer treatment to another physician and facility willing to provide the disputed medical intervention. The length of this period is not specified.Attempts to transfer treatment to another physician and facility willing to provide the disputed medical intervention can be made for 10 d.Hospital may consider judicial challenge to the decisions of the surrogate decision maker.Notify the family of the intention to unilaterally withdraw futile therapy.Inform the family of their option to seek a court order to continue treatment.Surrogates have been previously notified of their option to ask a judge to extend the time frame for the search for an alternative provider of the disputed medical intervention, which should be granted only if transfer is "reasonably likely."Withdraw medically inappropriate or futile interventions.Withdraw medically inappropriate or futile interventions.Clinicians are not legally immune, but their decisions are endorsed by the hospital leadership.Clinicians are legally immune from civil and criminal prosecutions. Open table in a new tab The state of Texas has taken the procedural resolution of futility disputes further by adopting the Texas Advance Directives Act (TADA) into legislation.26Texas Advance Directives Act, Vol TEX HS. CODE ANN. §166.046: Texas Statutes - §166.046(e) (1999).Google Scholar The law stipulates that if physicians or surrogate decision makers decide that an intervention cannot reach a reasonable physiologic or qualitative goal, the hospital's ethics committee can be asked to help facilitate a process of discussion and deliberation. Ultimately, if the committee agrees that a treatment will not benefit the patient, the patient's surrogates must be informed in writing and provided 10 days to secure another physician or facility willing to offer the disputed intervention. Although the patient's surrogates may seek a court-granted extension of the transfer period, withdrawal of the futile intervention is legally protected if no physician or facility is found. The hallmark of TADA is that the ethics committee's decision protects the involved clinicians from future civil and criminal prosecution as well as medical license review. Unlike the policies at BCH, disputes involving TADA have been brought before the courts. Sun Hudson was born with a fatal congenital dwarfism at Texas Children's Hospital in 2005. His condition required that he be placed on a ventilator while physicians determined his final diagnoses. The hospital's ethics committee agreed with clinicians that continued ventilator support was futile in the loose sense of the definition discussed previously, yet his mother requested that the ventilator support be continued. After no other medical facility was willing to accept the transfer of the child, the breathing tube was removed, and the child died shortly after. The probate court and an appellate court later upheld the process and the ethics committee's decision. This case marked the first time a US judge allowed a hospital to discontinue an infant's life-sustaining care against a parent's wishes.23Truog R.D. Medical futility.Georgia State University Law Rev. 2009; 25 (Article 13)Google Scholar, 27Hudson v Texas Children's Hosp, 177 SW 3d 232(Tex: Court of Appeals, 1st Dist. 2005).Google Scholar Fine and Mayo28Fine R.L. Mayo T.W. Resolution of futility by due process: early experience with the Texas advance directives.Ann Intern Med. 2003; 138: 743-746Crossref PubMed Scopus (104) Google Scholar published a description of the Baylor Medical Center experience 12 months before and 24 months after the passage of TADA. They reported that under the new law, 37 of 47 futility cases were resolved with ethics committee counseling alone. Of the remaining 10 cases, the committee affirmed the clinical decision in 6 and disagreed in 4. A report to the Texas state legislature25Fine R.L. Point: the Texas advance directives act effectively and ethically resolves disputes about medical futility.Chest. 2009; 136: 963-967Crossref PubMed Scopus (33) Google Scholar regarding 2922 ethics consultations performed in 2005 showed that only 974 (33%) were judged to involve futile interventions. Of those 974 consultations, 65 "10-day letters" were issued. Eleven of 65 patients were transferred within 10 days, 22 died while waiting for transfer, 27 had interventions withdrawn, and 5 were granted judicial extension pending transfer. Proponents of TADA argue that this rate of resolution before an ethics committee's formal affirmation of futility is excellent. Also, when the mechanism of adjudication is contained in the health system, the decision process moves at the pace of clinical medicine, not bureaucracy. These policies are intended to help protect the rights and values of both physicians and patients, but each has their detractors. Those who advocate BCH-like policies have argued that TADA creates an inherent conflict of interest by placing too much authority in the hands of the hospital's ethics committee, an intra-institutional body. To avoid this potential bias, Truog24Truog R.D. Counterpoint: the Texas advance directives act is ethically flawed: medical futility disputes must be resolved by a fair process.Chest. 2009; 136: 968-971Crossref PubMed Google Scholar argues that the final authority ought to reside with the judiciary. He notes that futility policies rarely deny or question treatments requested by patients themselves; the issue surfaces much more commonly when surrogate decision makers are involved. The judiciary was created to balance the rights and obligations of conflicted stakeholders, and being divorced from the institution makes conflicts of interest less apparent. Most important, a judicial route allows institutions to challenge the root of the problem—dysfunctional surrogate decision making—rather than skirting the central issue by attacking its end result—inappropriate intervention. Other potential advantages of directing disputed cases to the judiciary exist. Decisions made by clinical ethics committees are not routinely published, which arguably fails to promote conceptual review or the sharing of ideas and arguments outside institutional walls. Directing medical futility cases to the judiciary could create a repository of decisions from which clinicians and ethicists could draw clinical guidance and information regarding the legal limits of medical liability. Most clinicians, however, believe that these decisions belong in a clinical sphere. With guidance from ethics committees, clinicians and families can discuss the goals of care, and the adequacy of surrogate decisions can be gently addressed. Shapiro29Shapiro R.S. In re Edna MF: case law confusion in surrogate decision making.Theor Med Bioeth. 1999; 20: 45-54Crossref PubMed Scopus (6) Google Scholar argued that the court may be misinterpreting surrogate decision-making standards and "threatening individual's decision making rights by creating serious roadblocks"29Shapiro R.S. In re Edna MF: case law confusion in surrogate decision making.Theor Med Bioeth. 1999; 20: 45-54Crossref PubMed Scopus (6) Google Scholar to appropriate care. Furthermore, creating a repository of cases in the academic literature may be the responsibility of the professional ethicist, not the barrister. Finally, some courts have made it clear that these decisions are best handled at the bedside, among patients, surrogates, and health care providers.13In re Quinlan, 355 A.2d 647 (NJ: Supreme Court 1976).Google Scholar, 30Matter of Conservatorship of Torres, 357 N.W. 2d. 332 (Minn: Supreme Court 1984).Google Scholar We assume that all stakeholders intervene with beneficent intentions at all times. Even in this idealistic scenario, individuals may choose to support certain values in different hierarchies. This ability to choose actions that align with a patient's value system deserves ethical protection. It follows, however, that there will be instances in which 2 teams working to protect the same person will choose different interventions to achieve their beneficent aims. When discussion and resolution of the differences is possible, interventions respecting both value systems may be identified and performed. There are practices that can facilitate this understanding. Unfortunately, there will always be situations in which this mutual understanding is not possible and recourse to arbitrated judgment is necessary (BCH Futility Policy, TADA, etc). End-of-life conflicts often stem from inadequate communication among stakeholders; therefore, most effective resolution strategies aim to improve communication, clarify values, and align goals, values, and prognosis.31Hanson L.C. Danis M. Garrett J. What is wrong with end-of-life care? opinions of bereaved family members.J Am Geriatr Soc. 1997; 45: 1339-1344Crossref PubMed Scopus (418) Google Scholar Avoiding these conflicts with proactive, open, honest, and sensitive communication about the values of the patient and the family, the prognosis of the patient, and the way in which these entities interact is ideal.17Youngner S.J. Who defines futility?.JAMA. 1988; 260: 2094-2095Crossref PubMed Scopus (264) Google Scholar, 32Murphy D.J. Do-not-resuscitate orders: time for reappraisal in long-term-care institutions.JAMA. 1988; 260: 2098-2101Crossref PubMed Scopus (117) Google Scholar, 33Brennan T.A. Ethics committees and decisions to limit care: the experience at the Massachusetts General Hospital.JAMA. 1988; 260: 803-807Crossref PubMed Scopus (75) Google Scholar, 34La Puma J. Consultations in clinical ethics: issues and questions in 27 cases.West J Med. 1987; 146: 633-637PubMed Google Scholar However, open and clear communication at the end of life can be difficult, and clinicians often lack the training for these types of discussions.35Shanawani H. Wenrich M.D. Tonelli M.R. Curtis J.R. Meeting physicians' responsibilities in providing end-of-life care.Chest. 2008; 133: 775-786Crossref PubMed Scopus (41) Google Scholar We believe that a combination of preventive communication strategies, early detection and discussion of potentially inappropriate treatment, and conflict resolution skills must be used to help minimize the number of cases that require difficult procedural and legal resolution. Previous attempts to aid clinicians confronted with potentially futile interventions—defining the concept, analysis of qualitative vs quantitative futility, exhaustive dispute resolution, or procedurally protected withdrawal—have been largely reactive strategies. Regardless of the procedure followed, a preventive approach is best, and any policy (or law) should promote this from the outset.36Burns J.P. Truog R.D. Futility: a concept in evolution.Chest. 2007; 132: 1987-1993Crossref PubMed Scopus (116) Google Scholar, 37Truog R.D. Campbell M.L. Curtis J.R. et al.Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine.Crit Care Med. 2008; 36: 953-963Crossref PubMed Scopus (738) Google Scholar We propose an algorithm (Figure)38Curtis J.R. Communicating about end-of-life care with patients and families in the intensive care unit.Crit Care Clin. 2004; 20: 363-380Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar to help clinicians conceptualize the intricate concept of NBIs and understand the role that excellent and proactive communication, early identification, and conflict resolution can play in minimizing the need for reactive interventions. One strategy advocated for promoting communication is represented by the mnemonic VALUE (value comments made by the family, acknowledge family emotions, listen, understand the patient as a person, elicit family questions).39Lautrette A. Darmon M. Megarbane B. et al.A communication strategy and brochure for relatives of patients dying in the ICU.N Engl J Med. 2007; 356: 469-478Crossref PubMed Scopus (887) Google Scholar If agreement on prognosis, values, and treatment goals can be reached in discussion, there is a higher likelihood that surrogate decisions will fulfill the criteria for substituted judgment and autonomous decisions.40Miller B.L. Autonomy & the refusal of lifesaving treatment.Hastings Cent Rep. 1981; 11: 22-28Crossref PubMed Scopus (81) Google Scholar If a family's values are understood when communication comes to an impasse around a particular issue, discussing the source of conflict as part of the patient's or surrogate's value system can be effective and compassionate, allowing for tailored intervention and mutual understanding. For example, conflict of a religious nature may be more readily resolved by requesting help from a clergy member rather than from the institution's ethics committee. Likewise, a second opinion from a physician chosen by the family may help resolve issues surrounding a difficult prognosis.41Siegel M.D. Rosenbaum S.H. Withholding and withdrawing life support in the intensive care unit.in: Van Norman G.A. Clinical Ethics in Anesthesiology: A Case-Based Textbook. Cambridge University Press, New York, NY2011: 97-102Google Scholar These strategies all facilitate meaningful communication with the intent to prevent disputes going forward. Huynh et al2Huynh T.N. Kleerup E.C. Wiley J.F. et al.The frequency and cost of treatment perceived to be futile in critical care.JAMA Intern Med. 2013; 173: 1887-1894Crossref PubMed Scopus (173) Google Scholar suggested that early detection and discussion of potentially futile interventions or NBIs is a valuable way to minimize the time the intervention is used, thereby minimizing the time a patient is subjected to the harms of an intervention without any
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