Evaluating a patient's request for life-prolonging treatment: an ethical framework

Contrary to the widespread concern about over-treatment at the end
of life, today, patient preferences for palliative care at the end
of life are frequently respected. However, ethically challenging
situations in the current healthcare climate are, instead,
situations in which a competent patient requests active treatment
with the goal of life-prolongation while the physician suggests
best supportive care only. The argument of futility has often been
used to justify unilateral decisions made by physicians to withhold
or withdraw life-sustaining treatment. However, we argue that
neither the concept of futility nor that of patient autonomy alone
is apt for resolving situations in which physicians are confronted
with patients' requests for active treatment. Instead, we integrate
the relevant arguments that have been put forward in the academic
discussion about 'futile' treatment into an ethical algorithm with
five guiding questions: (1) Is there a chance that medical
intervention will be effective in achieving the patient's treatment
goal? (2) How does the physician evaluate the expected benefit and
the potential harm of the treatment? (3) Does the patient
understand his or her medical situation? (4) Does the patient
prefer receiving treatment after evaluating the benefit-harm ratio
and the costs? (5) Does the treatment require many resources? This
algorithm shall facilitate approaching patients' requests for
treatments deemed futile by the physician in a systematic way, and
responding to these requests in an ethically appropriate manner. It
thereby adds substantive considerations to the current procedural
approaches of conflict resolution in order to improve decision
making among physicians, patients and families.