Case Study: Futile or Non-Beneficial Treatment
Victor’s story
Victor has hypertension, Type 2 Diabetes Mellitus and Coronary heart disease. He lives alone. Due to a recent fall he mobilises using a walking stick. Since his fall he has required assistance with some activities of daily living (showering, housework, meal preparation and shopping), and medication management. To assist his rehabilitation he receives a weekly visit from a Home Care provider team, and is transported once a week to appointments with a physiotherapist. He has capacity to make decisions about his healthcare, and does not have an Advance Care Directive.
One afternoon Victor experiences chest pain and presses the personal emergency alarm he wears around his neck. His son Patrick is alerted and rushes to Victor’s house where he discovers Victor on the floor, unconscious.
Victor is transferred by ambulance to hospital where he is diagnosed as having suffered a cardiac arrest, with several minutes of cerebral hypoxia. He remains comatose, and is placed on artificial ventilation in the Intensive Care Unit. Within a few days his condition stabilises, but due to the extent of Victor’s brain damage and his pre-existing chronic conditions, his specialists consider it is unlikely he will significantly improve, or be able to survive without artificial ventilation.
Hugh, an intensive care consultant, and Emma, Victor’s critical care nurse, meet with Patrick, and Patrick’s wife Claudia, to discuss Victor’s prognosis. Hugh explains that the clinical team’s unanimous opinion is that continuing to provide ventilation would not be in Victor’s best interests as it would be invasive, of little benefit in improving his condition, and may cause him pain and suffering. Patrick asks whether the doctors can continue Victor’s life support for a few more days to allow more time for him to show improvement. Hugh clarifies that in the unlikely event Victor did show improvement it would only be minimal, and that even if he could breathe independently he would most likely be immobile, with significant cognitive impairment and care needs. Hugh and Emma discuss with Victor’s family withdrawing ventilation and providing comfort care to Victor.
Points for reflection
- Is it lawful for the clinical team to withdraw Victor’s ventilation?
- If Patrick disagreed with the clinical team’s decision and insisted that Victor continue to be ventilated, does that request have to be followed?
1. Is it lawful for the clinical team to withdraw Victor’s ventilation?
Health professionals generally have no obligation to provide treatment that would not be in the person’s best interests, or is inconsistent with good medical practice. This type of treatment is known as futile or non-beneficial treatment.
Futile or non-beneficial treatment is not defined in law, but is generally used to refer to treatment that is of no benefit, cannot achieve its purpose, or is not in the person’s best interests.
Whether or not treatment is futile or non-beneficial is generally decided on a case-by-case basis by the person’s treating doctor. Factors that may be considered in making this decision include:
- the person’s treatment goals and the likelihood that they will be achieved by providing treatment;
- the risks, burdens and benefits of further treatment;
- treatment alternatives; and
- the person’s prognosis and quality of life.
Hugh, Emma and their colleagues consider that continuing Victor’s ventilation would be of no benefit, and unlikely to result in significant improvement due to the extent of his injuries and pre-existing conditions. They believe that continuing treatment would carry risks and burdens, including that it would be invasive, and could result in Victor enduring further pain and suffering. They conclude that even if Victor’s condition improved and he could breathe without ventilation, his quality of life would be impacted by significant cognitive impairment and immobility, with little prospect of further improvement.
These factors suggest that continuing Victor’s ventilation would be futile and non-beneficial. In these circumstances it would be lawful for the clinical team to withdraw Victor’s ventilation.
In Queensland however, the clinical team would need consent from Victor’s substitute decision-maker to lawfully withdraw the ventilation. The law on consent and futile and non-beneficial treatment is discussed in the next section.
2. If Patrick disagreed with the clinical team’s decision to withdraw treatment, and insisted that Victor continue to be ventilated, does that request have to be followed?
A health professional is not required to provide treatment they consider to be futile or non-beneficial, even if a person, their family member or substitute decision-maker requests that it be provided. A person also cannot require in their Advance Care Directive that futile treatment be given. Therefore, if Patrick requests that ventilation continue, the clinical team has no legal obligation to ventilate Victor if they believe it would be futile or non-beneficial, or not in his best interests to do so.
Similarly, a health professional does not need to obtain consent from a person or a substitute decision-maker to withhold or withdraw futile treatment. However, Queensland law is different when the person does not have capacity. There, a health professional must obtain consent from the person’s substitute decision-maker to withdraw or withhold treatment that is considered futile.
Though consent is not required (except for in Queensland if the person has impaired capacity), it is still good practice for health professionals to involve the person or, if the person does not have capacity, their substitute decision-maker in discussions about futile treatment, to reach a shared decision. Shared decision-making enables:
- the person’s values, preferences and goals of treatment, or the substitute decision-maker’s understanding of these, to be known,
- communication of the risks, benefits and burdens of continuing or commencing treatment,
- the clinical team to explain why they believe treatment is futile, and
- those involved to reach a shared view about the options.
If Patrick insisted Victor continue to be ventilated, the clinical team would most likely meet with him again later to try to reach consensus about Victor’s treatment, before engaging in other dispute resolution options.
Final legal observations
The clinical team are able to lawfully withdraw Victor’s ventilation on the basis that continuing to provide it would be non-beneficial and futile. They do not require consent to withdraw the ventilation (except in Queensland where a substitute decision-maker’s consent would be required), and may proceed to do so even if Patrick requested that it continue. However, it would be good practice for the clinical team to involve Patrick in discussions about Victor’s treatment, and to try to reach consensus. If there is disagreement between Patrick and the clinical team, dispute resolution, such as mediation, could be undertaken.