Futility: Lack of Benefit

1. Futility: lack of benefit, which means lack of improvement of a person as a whole
2. Medical futility means that the proposed therapy should not be performed because available data show that it will not improve the patient’s medical condition.
   1. (Pro) It is ethically controversial: the claim that treatment is futile by a physician can come without them knowing relevant outcome data (Medscape Nurses, 2022).
3. (Pro) There is no consensus regarding the statistical threshold for a treatment to be considered futile (Medscape Nurses, 2022).
4. (Pro) There is often disagreement between physicians and families regarding the benefits to the patient of continued treatment  (Bernart, 2005).
5. (Pro) There are minimally invasive approaches to doing aortic valve replacement including partial upper sternotomy, right parasternal thoracotomy or transverse sternotomy. These procedures are done to help decrease invasiveness and reduce surgical trauma (Luciani & Lucchese, 2013).
6. (Pro) The average survival for patients 85 and older after surgery was 6 years (NIRH, 2022).
   1. (Pro) Fewer than 1 in 100 developed a stroke each year (NIRH, 2022). People who undergo the surgery have only a slightly lower life expectancy than someone who does not have the disease at all.
   2. (Pro) One year survival is higher in those who elect for the procedure than those who are denied the procedure (Lung et al., 2005).
7. Autonomy:
   1. (Pro) The doctor’s may choose not to operate due to advanced age, survival time, and neurological dysfunction, however this is preventing the patient to choose for themselves (Iung et al, 2005).
   2. (Pro) The patient does not have cognitive impairment and should be able to make decisions for herself, even at 94 years of age (Samaritini &Candido, 2021).
   3. (Pro) The patient may be experiencing symptoms such as shortness of breath, dizziness, tiredness, and fainting (NIRH, 2022). Surgical intervention may decrease these symptoms and make it worthwhile, in the patient’s eyes.

Panel Discussion Scenarios:

A 94-year-old woman with critical aortic stenosis is hospitalized with symptoms of heart failure.  Until her hospitalization, she was living alone independently.  She showed no signs of any cognitive or memory impairment.  Based on the echocardiogram and other diagnostic results, it is determined that her heart failure symptoms are the result of her progressing aortic stenosis.  Until now medical therapy (diuretics, beta-blockers, and ace inhibitors) have been effective in managing the condition and her symptoms have been mild.  Now the only option left is aortic valve replacement.  She has a history of PAD and therefore is not a candidate for TAVR.  The cardiologist consults the cardiothoracic surgeon for possible AVR via sternotomy.  The surgeon documents that the patient is at such high risk for complications, including major stroke and death, from surgery that he strongly recommends palliative care and symptom management rather than surgery.  The patient and family seek a second opinion, and this time the surgeon says that the surgery is certainly high risk, but is willing to try as long as the patient and family understand the risks and want to proceed.  Is there an ethical problem here? (Some points to consider: medical futility-How is futility determined?  If a procedure is futile, but the patient “wants to try,” should the procedure be done?)

Identify all relevant ethical principles and explain how they guide decision-making in this scenario. Supported the positions with relevant facts, statistics, and examples.

● Please follow the example outline above, but as the “CON” side. Why should the patient not have surgery. Please include one research article as a reference.