Defining Futile and Potentially Inappropriate Interventions

Publication Date: September 1, 2016

Recommendations

  1. Appropriate goals of ICU care include:
    • Treatment that provides a reasonable expectation for survival outside the acute care setting with sufficient cognitive ability to perceive the benefits of treatment.
    • Palliative care that provides comfort to patients through the dying process may be an appropriate goal of care in some ICUs.
  2. ICU interventions should generally be considered inappropriate when there is no reasonable expectation that the patient will improve sufficiently to survive outside the acute care setting, or when there is no reasonable expectation that the patient’s neurologic function will improve sufficiently to allow the patient to perceive the benefits of treatment.
  3. The above definition should not be considered exhaustive. There will be cases in which life-prolonging interventions may reasonably be considered inappropriate even when the above definition is not met.
  4. Decisions regarding whether specific interventions are inappropriate should be made on a case-by-case basis.
  5. The term “futile” should be used only in the rare circumstance that an intervention simply cannot accomplish the intended physiologic goal. Clinicians should not provide futile interventions and should carefully explain the rationale for the refusal.
  6. As detailed in the ATS/AACN/ACCP/ESICM/SCCM Policy Statement on Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units, a processbased approach should be used whenever an intervention is considered potentially inappropriate yet the patient or surrogate decision maker(s) requests the intervention.
  7. When time pressures make it infeasible to complete all seven steps and the above definition is met, clinicians should refuse to provide the requested treatment and endeavor to complete as much of the seven-step process as the clinical situation allows. Such a decision is consistent with professional standards and good medical practice.
  8. At times, it may be appropriate to provide time-limited ICU interventions to a patient even when the above definition is met if doing so furthers the patient’s reasonable goals of care.
  9. If the patient is experiencing pain or suffering, treatment to relieve pain and suffering is always appropriate.

Recommendation Grading

Disclaimer

Overview

Title

Defining Futile and Potentially Inappropriate Interventions

Authoring Organization

Publication Month/Year

September 1, 2016

Document Type

Consensus

Country of Publication

US

Document Objectives

The Society of Critical Care Medicine and four other major critical care organizations have endorsed a seven-step process to resolve disagreements about potentially inappropriate treatments. The multiorganization statement (entitled: An official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units) provides examples of potentially inappropriate treatments; however, no clear definition is provided. This statement was developed to provide a clear definition of inappropriate interventions in the ICU environment.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospice, Hospital

Intended Users

Healthcare business administration, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Management

Diseases/Conditions (MeSH)

D011050 - Policy Making, D006291 - Health Policy, D057970 - Inappropriate Prescribing, D032781 - Codes of Ethics, D004989 - Ethics, D017041 - Ethics Committees

Keywords

ICD decisions, ethics, futility, decision making, end of life

Source Citation

Kon AA, Shepard EK, Sederstrom NO, Swoboda SM, Marshall MF, Birriel B, Rincon F. Defining Futile and Potentially Inappropriate Interventions: A Policy Statement From the Society of Critical Care Medicine Ethics Committee. Crit Care Med. 2016 Sep;44(9):1769-74. doi: 10.1097/CCM.0000000000001965. PMID: 27525995.