CURRENT OPINION

Futility and the acute care surgeon Linda L. Maerz, MD, Anne C. Mosenthal, MD, Richard S. Miller, MD, Bryan A. Cotton, MD, MPH, and Orlando C. Kirton, MD, New Haven, Connecticut THE PROBLEM Managing medical and surgical futility is a challenging aspect of the practice of the acute care surgeon. Analysis of futility and application of multidisciplinary and interprofessional patient care have the potential to optimize clinical management of patients at the end of life. Review of the vast literature on the topic reveals evolving practices for the management of futility. The Critical Care Committee of the American Association for the Surgery of Trauma (AAST) was charged with addressing this topic in a luncheon session at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery on September 12, 2014, in Philadelphia, Pennsylvania. We surmised that querying surgeons engaged in the management of trauma and emergency general surgery patients nationally would provide a practical context and framework useful for the individual acute care surgeon. To this end, we created a survey defining the attitudes and practices of acute care surgeons related to medical and surgical futility and end-of-life care in the trauma and emergency general surgery patient populations. The survey was distributed to the membership of the AAST on June 10, 2014, and again on June 30, 2014. Responses were not linked to individuals, and participation was anonymous and confidential. The results of the survey were the focal point of discussion for the aforementioned luncheon session entitled, ‘‘Death, Dying and Futile Care in the ICU, ED and ORVWhat Have We Learned?’’

DEFINING FUTILITY The word ‘‘futility’’ comes from the Latin ‘‘futilis,’’ translated as ‘‘leaky.’’ In Greek mythology, the daughters of Danaus were condemned in Hades to draw water in leaky sieves, an apt analogy to the way we sometimes perceive the care we render to

From the Department of Surgery (L.L.M.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (A.C.M.), Rutgers New Jersey Medical School, Newark, New Jersey; Department of Surgery (R.S.M.), Vanderbilt University Medical Center, Nashville, Tennessee; Department of Surgery (B.A.C.), University of Texas Health Science Center, Houston, Texas; and Department of Surgery (O.C.K.), Hartford Hospital and the University of Connecticut School of Medicine, Hartford, Connecticut. This material was presented in a luncheon session entitled, ‘‘Death, Dying and Futile Care in the ICU, ED and ORVWhat Have We Learned?’’ at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery on September 12, 2014, in Philadelphia, PA. Address for reprints: Linda L. Maerz, MD, FACS, Associate Professor of Surgery and Anesthesiology, Department of Surgery, Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale School of Medicine, 330 Cedar St., BB 310 PO Box 208062, New Haven, CT 06520-8062; email: [email protected]. DOI: 10.1097/TA.0000000000000622

our patients at the end of life. The Oxford English Dictionary defines a ‘‘futile action’’ as ‘‘leaky, hence untrustworthy, vain, failing of the desired end through intrinsic defect,’’ and MerriamWebster defines the ‘‘quality or state of being futile’’ as ‘‘uselessness’’ and ‘‘futility’’ as ‘‘a useless act or gesture.’’ In medical and surgical practice, interventions that are unlikely to produce any significant benefit for the patient are defined as futile. Of note, futility does not apply to treatments globally, to a patient, or to a general medical situation. Rather, ‘‘futility’’ refers to a particular intervention at a particular time for a specific patient. Although this seems simple on the surface, defining futility is complex because there is no consensus on ethical or operational definitions; futility means different things to different people (physicians vs. patients and their surrogates), there are no absolute professional guidelines to determine futility and what to do when futility has been established, and there is a great deal of regional and international variability. The literature devoted to this topic is vast. Indeed, a PubMed advanced search using the text word ‘‘futility’’ on December 15, 2014, yielded 3,554 publications from 1910 to the present. One useful construct to provide a framework for the futility concept is the effect-benefit principle. An effect of an intervention is limited to some part of the patient’s body, whereas benefit improves the person as a whole. Futile care defines treatment that fails to provide the latter whether or not it achieves the former. Another way to define this is quantitative versus qualitative futility. Quantitative futility occurs when the likelihood that an intervention will benefit the patient is exceedingly poor. Qualitative futility occurs when the likelihood that the quality of benefit an intervention will produce is exceedingly poor.1 Medical goal futility is quantitative. Can surgery or treatment meet the accepted therapeutic goal of the procedure? If the answer is no, the intervention is deemed to be futile. The assessment is physician directed and based on clinical evidence if such evidence exists. The problem that arises is uncertainty of prognosis. Alternatively, value futility is qualitative. Can surgery or treatment meet the patient’s goals of care? If the answer is no, the intervention is deemed to be futile, but on a different basis. The assessment is patient directed and requires knowledge of patient values and preferences. The problem that frequently arises in this construct is uncertainty of the individual patient’s values particularly when the patient is unable to communicate and when surrogates are not readily available or when they are unsure of the patient’s wishes.2 An assessment of futility can also be approached in an algorithmic manner, as described by McCullough. The most basic question to be answered in this schema is, ‘‘Will the clinical intervention produce its usually intended physiological effect?’’ If the answer is no, criteria for physiologic futility are met. The J Trauma Acute Care Surg Volume 78, Number 6

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next question to be answered is, ‘‘Will the clinical intervention produce clinical benefit, enabling the patient to interact with the environment and develop as a human being?’’ If the answer is no, criteria for clinical futility are met. This harkens back to the basic effect-benefit principle. The next question to be answered is, ‘‘Will the patient die without regaining consciousness before discharge?’’ Again, this is a basic concept, and if the answer is no, the criteria for imminent demise futility are met. Finally, ‘‘Will the intervention be physiologically and clinically effective but with significant risk of disease-related or iatrogenic morbidity, loss of function, and unacceptable quality of life?’’ This is perhaps the most complex question, but if the answer is no, the criteria for qualitative futility are met.3 Definitions of futility are useful to provide a framework for decision making, but, in the end, it is the responsibility of the individual surgeon to bridge the gap from futility to providing acceptable care for the individual patient. In the words of Schneiderman, it is ‘‘. . . the ethical duty of the physician to redirect efforts from lifesaving treatments toward the conscientious pursuit of treatments that maximize comfort and dignity for the patient and the grieving family.’’4 In certain circumstances, efforts should be redirected from ‘‘rescue’’ to ‘‘care,’’ and the question should always be asked, ‘‘Does the patient benefit in the context of their world?’’

THE AAST FUTILITY SURVEY To better understand the attitudes and practices of acute care surgeons related to medical and surgical futility and endof-life care in the trauma and emergency general surgery patient populations, we surveyed the membership of the AAST in June 2014. The first query was sent via email on June 10, 2014, to the total membership, approximately 1,200 individuals. The second query was sent via email on June 30, 2014, only to those members opting in for surveys, approximately 833 individuals. Two hundred five individuals responded, for a response rate of approximately 17.1%. The survey consisted of 27 questions. The first 13 questions defined the demographics of the respondents and their institutions, and the last 14 questions defined the attitudes and practices of the individual respondents. With respect to the demographics of the respondents, most are mid-to-late career, approximately 83% are male, and most practice trauma (84%), surgical critical care (80%), and/or emergency general surgery (71%). Eighty-one percent of the institutions represented are university-affiliated hospitals, and most have a 250- to 1,000-bed capacity (35% of the hospitals have 501Y750 beds). Eighty percent of the institutions are level I trauma centers, 90% have general surgery residency programs, 70% have surgical critical care fellowship programs, and 26% have acute care surgery fellowship programs. Ninety-nine percent of the hospitals represented have an ethics committee, and 93% have a palliative care service. Ninety-four percent of respondents answered yes to the question, ‘‘Can medical futility be determined?’’ The most frequently cited parameters used to define medical futility included degree of neurologic disability (85.37%), comorbidities (82.93%), acute organ failure(s) (82.93%), when the prescribed

care cannot achieve the desired goals (79.02%), and advanced age (65.37%). When asked the question, ‘‘In the past year, how many times have you declined to offer surgical intervention or aggressive critical care to an emergency department (ED) patient on the basis of medical futility?’’ the majority of respondents chose one to five times for both trauma (56.50%) and emergency general surgery (55.39%) patients. The same trend proved to be true when the same question was asked regarding intensive care unit (ICU) patients; the majority of respondents chose one to five times for both trauma (53.20%) and emergency general surgery (56.10%) patients. When asked the question, ‘‘In the past year, how many times have you aborted an operation prior the patient’s physiologic death because you determined that continuing the operation would be futile?’’ the majority of respondents were split between choosing zero times (57.14% for trauma patients; 47.78% for emergency general surgery patients) and one to five times (41.87% for trauma patients; 49.26% for emergency general surgery patients). The most frequently cited circumstances used to determine that an operation already underway is futile included extensively infarcted bowel (89.66%), diffuse carcinomatosis (75.86%), uncontrollable hemorrhage (55.67%), unresectable malignancy (54.19%), and a ‘‘frozen abdomen’’ causing inability to proceed with dissection (42.36%). Sixty-two percent of respondents discuss code status with their ICU patients or their surrogates within 24 hours of admission to the ICU. Ninety-four percent of respondents institute comfort measures in the ICU or step-down units, as opposed to elsewhere in the hospital. When asked the question, ‘‘In the past year, on how many patients have you instituted comfort measures?’’ the majority of respondents were split choosing between one to five times (24.39% for trauma patients; 38.05% for emergency general surgery patients) and 6 to 10 times (32.20% for trauma patients; 35.61% for emergency general surgery patients). Disagreement among family members was cited as the most common barrier to limitation in goals of care when treatment has been determined to be futile (59.02% of respondents); disagreement between the medical team and the patient or surrogate was cited as the next most common barrier (27.80%). Eighty-four percent of the respondents answered no when asked, ‘‘Does the palliative care team round with the ICU team?’’ The most common reasons to consult the palliative care team are when the patient or family asks for the consultation (53.77%), when disagreement in goals of care is anticipated (53.27%), when it is believed that the patient has a significant chance of dying (40.70%), whenever comfort measures are instituted (38.19%), and whenever goals of care are otherwise limited (38.19%). In summary, the typical survey respondent consults palliative care when he or she thinks that there will be disagreement regarding goals of care or when the patient or family requests it; believes that medical futility can be determined; determines medical futility and declines aggressive management in the ED and ICU one to five times per year equally for trauma and emergency general surgery patients; is most likely to determine ‘‘surgical futility’’ when dead bowel or diffuse carcinomatosis is encountered; is unlikely to abort an operation; discusses code

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status within 24 hours of admission to the ICU; institutes comfort measures 1 to 10 times per year equally for trauma and emergency general surgery patients, usually in the ICU or step-down unit; and perceives disagreement among family members as the major barrier to limitation in goals of care. The survey results are limited by the response rate, as is the case for many survey-initiated queries. In addition, it is apparent that our respondents tended to self-select likely because the topic was of particular interest to them: the ‘‘majority’’ respondent is a middle-aged male trauma surgeon, practices in a large academic level I trauma center, and has access to an ethics committee and a palliative care service.

THE AAST FUTILITY PANEL The AAST Critical Care Committee, chaired by Orlando Kirton (University of Connecticut), assembled a panel to present the survey results and lead the discussion for the luncheon session entitled, ‘‘Death, Dying and Futile Care in the ICU, ED and ORVWhat Have We Learned?’’ Linda Maerz (Yale) moderated, and Anne Mosenthal (Rutgers, New Jersey), Richard Miller (Vanderbilt), and Bryan Cotton (University of Texas, Houston) served as panelists.

GEOGRAPHIC DOMAINS To provide a framework for the luncheon session, the geographic domains in which futility is encountered by the acute care surgeon were discussed by the panelists. Dr. Mosenthal addressed futility encountered in the ED. Particular challenges observed in this domain include a compressed time frame for high-stakes decision making and frequent uncertainty of diagnosis, prognosis, and long-term outcome. Determining qualitative futility by answering the question, ‘‘Will the resultant quality of life be acceptable?’’ can be challenging under these circumstances. When the patient or the patient’s surrogate is able to communicate, shared decision making may be used to come to the best possible treatment plan for the individual patient. This construct balances beneficence and autonomy. The surgeon communicates likely prognosis for therapeutic options, and the patient or surrogate communicates goals of care and values. The objective is to determine whether the intervention accomplishes benefit in the context of the patient’s goals. When communication with the patient or surrogate is not feasible because of the condition of the patient and/or the absence of an appropriate surrogate, shared decision making is not possible. Under these circumstances, decisions to limit interventions fall under the purview of the physician responsible for the care of the patient. The emergency medicine literature discusses balancing concerns for litigation and criticism with professional judgment.5 More recently, a body of literature is emerging that addresses the institution of palliative care and even comfort measures in the ED. Although a relatively new paradigm in modern medicine, the concept is ancient, as Hippocrates counseled against medical futility when he advised, ‘‘ . . . refuse to treat those who are overmastered by their disease, realizing that in such cases medicine is powerless.’’6 In the end, physicians are under no ethical obligation to render treatments that they judge have no realistic likelihood of 1218

medical benefit to the patient. These judgments should be unbiased, based on available scientific evidence and societal and professional standards when they exist, and sensitive to differences of opinion regarding the value of medical intervention in various situations.7 An example of a high-stakes minimal-data scenario encountered by trauma surgeons in the ED is the trauma patient who arrives receiving cardiopulmonary resuscitation or who loses signs of life soon after arrival in the ED. Criteria for decision making regarding resuscitative ED thoracotomy and the definition of futility in this circumstance have been in evolution for many years.8,9 Dr. Miller addressed futility encountered in the ICU. In general, decision making in the ICU may have the benefits of enhanced information regarding the patient’s comorbidities and current illness and the advantage of the opportunity to develop a relationship with the patient and/or surrogate. This is also the ideal environment in which to use a multidisciplinary and interprofessional approach to decision making with respect to end-of-life care, particularly as it pertains to incorporating palliative care services into the treatment armamentarium. It has been postulated that knowledge of a patient’s premorbid condition greatly influences postinjury trajectory. For example, substantive recovery is highly unlikely in elderly patients who sustain a significant injury as a result of a fall if they have progressive or severe disability before the fall.10 Injury pattern and short-term trajectory can also portend long-term prognosis, as in the elderly patient who presents with a severe traumatic brain injury and a Glasgow Coma Scale score that remains low after 72 hours. These patients have a greater than 80% mortality or long-term placement disposition.11 Finally, well established is the observation that mortality increases with worsening multiple organ failure and multiple organ dysfunction.12Y14 These are examples of clinical circumstances in which goals of care may be expanded to include palliative care in addition to, or in lieu of, the more traditional treatment paradigms of aggressive medical and surgical interventions. In general, palliative care consultations improve communication with respect to goals of care in relation to prognosis and patient preferences. Early involvement encourages collaboration and shared decision making, so that all parties work toward achieving the best outcome for the patient in the framework of the patient’s overreaching goals of care and life philosophy. If palliative care services are consulted proactively, rather than reactively, endof-life management, grief counseling, transitional planning, and family and spiritual support can be optimized. Literature is emerging to develop guidelines to identify patients who would benefit from palliative care services in the surgical ICU.15 To this end, incorporating a palliative care needs assessment into daily work rounds to identify the specific patient populations that may benefit from the integration of palliative care and surgical intensive care may be considered.16 Finally, Dr. Cotton addressed futility in the operating room (OR), perhaps the most challenging domain in which we encounter the difficulties of decision making, because there are little absolute data and frequently conflicting opinion regarding determination of futility in this venue.17Y20 In addition, as our survey suggests, once we begin an operation, we are reluctant to stop before the patient’s physiologic death. This investment adds yet another layer of complexity to our ability to make a * 2015 Wolters Kluwer Health, Inc. All rights reserved.

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reasonable determination of futility in the context of rendering operative surgical care. Perhaps one means of mitigating this dilemma is to make a measured assessment of futility before proceeding to the operating room. This is addressed in the article by Cooper et al.,21 published in the December 2014 issue of Annals of Surgery, which provides a thoughtful analysis of nonbeneficial emergency surgery in elderly patients with serious illness. Shared decision making can match patient preferences with an educated prediction of long-term outcome of treatment and requires optimal communication strategies.

CONCLUSIONS Futility is an elusive but real phenomenon. The effectbenefit principle provides a useful construct for analysis to answer the question, ‘‘Will the outcome of an intervention be what the patient wants?’’ A multidisciplinary approach ranging from aggressive surgical and critical care to palliative care may benefit our patients by enhancing honest and compassionate communication and expanding the armamentarium of potential appropriate interventions. Optimizing desired outcomes will benefit the individual patient and better allocate valuable resources. AUTHORSHIP L.L.M. wrote the survey. A.C.M., R.S.M., B.A.C., and O.C.K. reviewed and revised the survey. L.L.M. moderated the panel discussion. A.C.M., R.S.M., and B.A.C. were panelists. O.C.K. oversaw the organization of the panel discussion. L.L.M. wrote the manuscript. A.C.M., R.S.M, B.A.C, and O.C.K. reviewed the manuscript.

ACKNOWLEDGMENT We thank the Critical Care Committee of the AAST for their support of the Futility Survey and luncheon session at the 73rd Annual Meeting of the American Association for the Surgery of Trauma and Clinical Congress of Acute Care Surgery.

DISCLOSURE The authors declare no conflicts of interest. There are no funding disclosures.

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6. O’Connor AE, Winch S, Lukin W, Parker M. Emergency medicine and futile care: taking the road less travelled. Emerg Med Australas. 2011; 23:640Y643. 7. American College of Emergency Physicians. Code of ethics for emergency physicians. Ann Emerg Med. 2008;52:581Y590. 8. Powell DW, Moore EE, Cothren CC, Ciesla DJ, Burch JM, Moore JB, Johnson JL. Is emergency department resuscitative thoracotomy futile care for the critically injured patient requiring prehospital cardiopulmonary resuscitation? J Am Coll Surg. 2004;199:211Y215. 9. Moore EE, Knudson MM, Burlew CC, Inaba K, Dicker RA, Biffl WL, Malhotra AK, Schreiber MA, Browder TD, Coimbra R, et al., and the WTA Study Group. Defining the limits of resuscitative emergency department thoracotomy: a contemporary Western Trauma Association perspective. J Trauma. 2011;70:334Y339. 10. Gill TM, Murphy TE, Gahbauer EA, Allore HG. The course of disability before and after a serious fall injury. JAMA Intern Med. 2013;173: 1780Y1786. 11. Calland JF, Ingraham AM, Martin N, Marshall GT, Schulman CI, Stapleton T, Barraco RD, Eastern Association for the Surgery of Trauma. Evaluation and management of geriatric trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S345YS350. 12. DeCamp MM, Demling RH. Posttraumatic multisystem organ failure. JAMA. 1988;260:530Y534. 13. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. 1995;23:1638Y1652. 14. Vincent J-L, Moreno R, Takala J, Willatts S, De Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707Y710. 15. Bradley CT, Brasel KJ. Developing guidelines that identify patients who would benefit from palliative care services in the surgical intensive care unit. Crit Care Med. 2009;37:946Y950. 16. Mosenthal AC, Weissman DE, Curtis JR, Hays RM, Lustbader DR, Mulkerin C, Puntillo KA, Ray DE, Bassett R, Boss RD, et al. Integrating palliative care in the surgical and trauma intensive care unit: a report from the Improving Palliative Care in the Intensive Care Unit (IPAL-ICU) Project Advisory Board and the Center to Advance Palliative Care. Crit Care Med. 2012;40:1199Y1206. 17. Do¨pp-Zemel D, Groeneveld ABJ. High-dose norepinephrine treatment: determinants of mortality and futility in critically ill patients. Am J Crit Care. 2013;22:22Y32. 18. Barbosa RR, Rowell SE, Diggs BS, Schreiber MA, and the Trauma Outcomes Group. Profoundly abnormal initial physiologic and biochemical data cannot be used to determine futility in massively transfused trauma patients. J Trauma. 2011;71:S364YS369. 19. Mitra B, Tullio F, Cameron PA, Fitzgerald M. Trauma patients with the ‘triad of death.’ Emerg Med J. 2012;29:622Y625. 20. Velmahos GC, Chan L, Chan M, Tatevossian R, Cornwell EE 3rd, Asensio JA, Berne TV, Demetriades D. Is there a limit to massive blood transfusion after severe trauma? Arch Surg. 1998;133:947Y952. 21. Cooper Z, Courtwright A, Karlage A, Gawande A, Block S. Pitfalls in communication that lead to nonbeneficial emergency surgery in elderly patients with serious illness: description of the problem and elements of a solution. Ann Surg. 2014;260:949Y957.

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