Institute of Ethics, History and Theory of Medicine, University of Munich, Lessingstrasse 2, 80336 Muenchen, Germany.
J Med Ethics. 2012 Sep;38(9):540-5. doi: 10.1136/medethics-2011-100479. Epub 2012 May 5.
Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile.
The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital in Germany. The transcripts were subjected to qualitative content analysis.
Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families.
Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment.
生命终末期的医疗无效性是医学面临的一个日益严峻的挑战。作者的目的是阐明临床医生如何定义无效性，何时他们认为生命支持治疗（LST）无效，他们如何沟通这种情况，以及为什么尽管被认为无效，但有时仍会继续进行 LST。
作者回顾了伦理案例咨询协议，并对德国一家三级医院成人重症监护和姑息治疗病房的 18 名医生和 11 名护士进行了半结构化访谈。对转录本进行了定性内容分析。
在大多数案例咨询中都确定了无效性。受访者将无效性与未能实现对患者生活质量有好处且与风险、危害和成本成比例的护理目标联系起来。提到的典型例子是患者完全依赖 LST、晚期转移性恶性肿瘤和广泛脑损伤的情况。参与者一致认为，应在与护理团队协商后由医生评估无效性。重症监护医生赞成间接和逐步透露预后。姑息治疗临床医生专注于坦诚和富有同理心的信息策略。继续进行无效 LST 的主要原因是情感上的，例如内疚、悲伤、对法律后果的恐惧以及对家庭反应的担忧。其他障碍包括组织常规、法律和姑息治疗知识不足以及患者或家属的治疗请求。
通过沟通培训、知识转移、组织改进以及情感和伦理支持系统，可以改善无效性的管理。作者提出了一种关注治疗目标的终末期决策算法。
