MMHA 6205 Week 8 Futility Dispute Analysis Example

CPR Cannot Do What It Is For, Ventilation Can Only Continue: Separating Two Kinds of Futility in a Wife's Request for Full Treatment, and the Process That Resolves What Definitions Cannot

Student Name

Walden University

MMHA 6205: Health Law and Ethics

Instructor Name

Month Day, Year

CPR Cannot Do What It Is For, Ventilation Can Only Continue: Separating Two Kinds of Futility in a Wife's Request for Full Treatment, and the Process That Resolves What Definitions Cannot

The Case

A 79-year-old man has been in a medical intensive care unit for 24 days after septic shock from a perforated bowel. He has had two operations. He remains on a ventilator, receives continuous dialysis and needs medication to maintain his blood pressure. He has not been awake since admission, and imaging shows extensive brain injury from a period of low blood pressure. The team believes he will not survive to leave the hospital. His wife, his surrogate, asks that everything be done, including CPR if his heart stops. She says that her faith teaches that life is a gift only God may end and that she is praying for a miracle. The attending physician believes CPR would be futile and continued ventilation inappropriate. The unit and family are invented.

What Futility Means Here

The word futility hides two different judgments. Physiologic futility describes an intervention that cannot achieve its immediate physiological aim. Other claims of futility are judgments that an intervention may work but is not worth doing, because the life it sustains has a quality the clinician considers too poor, or because the chance of benefit is low. A policy statement from five critical care societies recommended reserving the word futile for the first, narrow sense, and calling the second category potentially inappropriate treatment, to be handled through a fair process rather than by a clinician's unilateral decision (Bosslet et al., 2015).

Applied to this patient, the distinction gives different answers for different interventions. CPR falls close to physiologic futility. In a man with multiorgan failure already on maximal support, cardiac arrest would most likely reflect the failure of support itself, and chest compressions could not restore what the ventilator, dialysis and medications are already failing to sustain. Continued ventilation is different. It is achieving its physiological aim: it is keeping him oxygenated. The team's objection is that it sustains a life without awareness and without prospect of recovery. That is a judgment about value and probability, and under the policy statement it belongs in the second category.

What the Law Offers Each Side

A surrogate's authority to refuse treatment on a patient's behalf is well established. Her authority to compel treatment clinicians consider nonbeneficial is far less settled. Courts have rarely ordered clinicians to provide specific treatments over their objection. In one well-known case, the Fourth Circuit held that a hospital's obligations under the federal emergency treatment law required it to provide stabilizing ventilation to an infant with anencephaly when she arrived in respiratory distress, despite the physicians' view that it was inappropriate (In re Baby K, 1994). That decision rested on the specific requirements of the emergency treatment statute, not on a general right to demand treatment, and its reach beyond emergency presentations is limited.

A few states have statutory procedures for these disputes. The best known is Texas, whose law provides for ethics committee review, written notice to the family and a waiting period in which the hospital assists in finding another facility before it may stop treatment over the surrogate's objection (Texas Advance Directives Act, 2023). Most states have no such procedure, which leaves hospitals to rely on their own policies, with uncertain legal protection if they act unilaterally.

Ethics

The wife's faith deserves respect, not management. Her request comes from a belief that life is sacred and that it is not hers or the doctors' to end, and that belief is held by many patients and families. A chaplain from her tradition, or one familiar with it, may help her consider what her faith teaches about burdensome treatment, since many traditions do not require every possible intervention. Her hope for a miracle can be acknowledged without being argued against.

It also helps to ask what she means by everything. Families who ask for everything are often asking not to be abandoned, or for assurance that no one has given up on the person they love. The team can promise that it will keep caring for her husband in every way that helps him, including relief of pain and distress, regular updates and time with him, whatever is decided about specific machines. Separating care, which never stops, from particular treatments, which may, often changes the conversation more than any argument about probabilities.

The team's moral distress is also real. Nurses who turn, suction and bathe a patient they believe is suffering without benefit carry a burden that physicians may not fully see. Continuing treatment they believe is wrong, without any process for review, wears down staff and erodes trust between the unit and families. A fair process protects them as well.

Process

The policy statement recommends a process when a surrogate requests treatment clinicians consider potentially inappropriate (Bosslet et al., 2015). Adapted to this case, it has five steps.

Table 1

Process for Resolving the Dispute Over Continued Ventilation

CPR is treated separately: the attending may write a do-not-resuscitate order on grounds of physiologic futility, with notice to the wife and the chance for a second opinion.

CPR and ventilation therefore follow different paths. Because CPR cannot achieve its aim, the attending can decline to provide it, as clinicians are not required to perform interventions that cannot work, though the wife should be told and offered a second opinion. Ventilation goes through the full process. This avoids an all-or-nothing standoff in which agreement on one intervention is held hostage to disagreement on the other. Throughout, the team should document each meeting, what was offered and what the wife said, so that the process can be reviewed later by the committee or a court.

References

Bosslet, G. T., Pope, T. M., Rubenfeld, G. D., Lo, B., Truog, R. D., Rushton, C. H., Curtis, J. R., Ford, D. W., Osborne, M., Misak, C., Au, D. H., Azoulay, E., Brody, B., Fahy, B. G., Hall, J. B., Kesecioglu, J., Kon, A. A., Lindell, K. O., & White, D. B. (2015). An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. American Journal of Respiratory and Critical Care Medicine, 191(11), 1318-1330. https://doi.org/10.1164/rccm.201505-0924ST

In re Baby K, 16 F.3d 590 (1994).

Texas Advance Directives Act, Tex. Health & Safety Code § 166.046 (2023).