P0535 - Determining Futility - One Free-standing Children's Hospital's Experience with a Policy

Treatment which is unable to achieve the desired goal or will do no more than temporarily prolong dying is generally considered futile. The process of determining futility can be unclear and variable, presenting legal and ethical dilemmas. These dilemmas become exponentially greater if the patient and family disagree with the medical team and are requesting continued treatments and interventions. To assist with this process, some hospitals have developed futility policies. This presentation reviews the outcomes of a futility policy developed and implemented by a large children’s hospital.
This policy was developed by the Ethics Committee, which includes representation from the Palliative Care team. Specific road maps and process were developed and outlined for both the treatment team and Ethics team to follow in determining and communicating futility (see attachments).
Ethics consults for futility were reviewed over an eight year period (since policy implementation). Seventeen consults were completed. The majority of consults were from the pediatric (7) and neonatal (6) ICUs. The remaining consults originated from the cardiac ICU, Oncology floor, and outpatient settings. Patients ranged in age from 2 days old to 18 years old, with the majority being age 3 years or younger. The largest single etiology of consults was neurologic diagnoses due to injury (submersion, spinal cord transection, non-accidental trauma).
In 12/17 cases the Ethics consultation supported futility. In five cases futility was not supported. Outcomes for these cases included additional surgery and chemotherapy. Two of these patients died in the weeks subsequent to the consult.
In 10/17 consults, the consult was placed because the treatment team felt futility had been reached and the family did not agree, requesting ongoing interventions. In 9/10 of these consultations, the patient was nearing end of life and discussions centered on code status and withdraw of life support. Of these nine consults, no patients received resuscitation at end of life and six families went on to withdraw life support measures. Only one case had court involvement, with the court granting change of code status to DNR and transition to hospice care. This child was in custody of child protective services, although parental rights had not been terminated.
It is notable that following ethics consultation supporting futility, no child nearing end of life underwent resuscitative measures, and several families chose to withdraw interventions. Given that the policy has a strong emphasis on communication, both within the team and with the family, the process in and of itself may have helped resolve disagreements between the team and families.