Evaluating goals of therapy in critically ill patients

ICU: intensive care unit.

* Futile therapy is defined as a treatment that cannot accomplish the intended goals. Examples include administering cardiopulmonary resuscitation to a patient with myocardial rupture. Cases of futility are rare in the ICU.

¶ Potentially inappropriate therapy is defined as a treatment that has at least some chance of accomplishing the patient's intended goal, but the clinician judges that the treatment is outside the boundaries of acceptable practice due to other ethical considerations. This could include that the treatment is exceedingly unlikely to accomplish the patient's goals, represents an unfair allocation of scarce resources, or is intended to achieve a goal that is contrary to accepted medical goals. Examples may include long-term mechanical ventilation in a patient with widely metastatic cancer and progressive multiorgan failure. Cases of inappropriate therapy in the ICU are more common than cases of futility.

Δ Five North American and European professional societies have issued a 7-step process for conflict resolution for clinicians to use as guidance when disagreements arise between the clinician and the patient and/or surrogate(s). The process can stop at any step once a shared treatment decision is made. Refer to UpToDate text for additional details.

◊ If no willing provider can be located and the hospital review committee or independent appeals body concurs with the clinician's judgment, clinician can refuse to provide the requested treatment. If a willing provider is located or the review committee concurs with the patient and/or surrogate(s), the treatment in question should be initiated (or continued) or the patient transferred to a willing clinician.