Decision making

Futile measures are requested

The paramedic says
"Can't you do more?"(3:22)

Don't let him die. - Family member

Sometimes patients and families simply can’t absorb information at the time; or, although on some level they are aware of the gravity of the situation, they may be in shock and have trouble accepting what’s happening. Remember that denial is a normal way to deal with stress and is a common psychological response at the end of life.

You may be confronted with requests for futile measures that go against your judgement and may impact the patient’s quality of life. In some cases, the patient may request that “everything possible” be done to keep them alive. A more likely scenario is that when death is imminent, some families will panic even when there has been consensus about prognosis and allowing death to occur. In those final moments, they may want life-sustaining interventions the patient had earlier declined. They may demand unnecessary assessments and treatments that may in fact cause discomfort or be worse for the patient and won’t change the outcome.

It can be very difficult for a patient, family or substitute decision-maker to accept the idea of “futility” so you will need great patience and skill when having these delicate conversations. Be clear that you are not saying, “Nothing more can be done” and that your goal is to keep the patient as comfortable as possible. 

In these situations, provide information slowly and respectfully. Expect frustration and anger, some of which may be directed at you as the messenger. Anger is a natural response when someone is forced to take in unwanted information and realities. Some people may take longer to process the information, become silent and withdrawn, and even shut down. Be prepared for the possibility that your recommendations will not be followed.

When possible, take time to be with the individual and family. If they wish, access supports such as friends and members of faith and other communities. 

Considerations

  • Will the treatment cause discomfort, distress, or further complications for the patient?
  • Will the intervention provide useful information that will contribute to the patient’s comfort and care?
  • Will the intervention produce the result the family expects?
  • What were the patient’s wishes and how can they best be carried out now?
  • Are there other health care professionals you can involve according to your community guidelines?
  • How will these decisions impact:

o   The patient’s quality of life?

o    The dying process?

o    The family’s experience of the death?

o    Your satisfaction with the call?

o    Your ethics and values?

Examples of futile measures: 

  • CPR.
  • Feeding the patient when it may result in choking and other medical issues.
  • Transport when not medically necessary and the family can support a home death with or without support. 
For additional information about situations where a family insists on transport that is contraindicated, see Module 5, Challenging situations - Chapter 3, Transport.  

Conversation Prompts

I know that you’re worried that your daughter hasn’t eaten any food in some time and that this is hard for you to see. But if we give her food there’s a very good chance that she will be unable to swallow and will choke on it.

Let’s take a moment to think about what your husband would want in this situation. He is in a very fragile state and his heart may soon stop beating. If we attempt resuscitation, it won’t save his life and will almost certainly cause broken ribs or distress as he dies. Can we instead work together to make him as pain-free and peaceful as possible? 

PAUSE 

We can give him medication to help him feel more comfortable, and you can take this time to be with him, to touch and reassure him, and tell him anything that you feel is important. 

PAUSE 

Do you have any questions? Perhaps there are things you’re wondering or worrying about that I can help with?