Medical futility is commonly encountered in small animal clinical practice

Nathan W. Peterson Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
Center for Bioethics, Harvard Medical School, Boston, MA

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 DVM, DACVECC
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J. Wesley Boyd Center for Bioethics, Harvard Medical School, Boston, MA
Psychiatry and Medical Ethics, Baylor College of Medicine, Houston, TX

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 MD, PhD
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Lisa Moses Center for Bioethics, Harvard Medical School, Boston, MA
Faculty of Medicine, Case Western Reserve University, Cleveland, OH
Interdisciplinary Center for Bioethics, Yale University, New Haven, CT

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 VMD, DACVIM (SAIM)

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Abstract

OBJECTIVE

To document veterinarians’ perceptions and understanding of medical futility and determine the frequency with which medical futility occurs in small animal practice.

SAMPLE

477 veterinarians in small animal general and specialty veterinary practice.

PROCEDURES

A cross-sectional study was performed with a 25-question, web-based, confidential, anonymous survey distributed through various professional veterinary specialty associations.

RESULTS

Nearly all respondents (469/474 [99.0%]) believed that futile care occurs in veterinary medicine, and 42.4% (201/474) felt it occurred commonly (> 6 times/y). A similar percentage (471/475 [99.2%]) reported encountering futile care within their careers, and 85.0% (402/476) reported encountering it within the past year. A majority (293/477 [61.4%]) reported witnessing futile care occurring in both inpatient and outpatient settings. Most respondents disagreed or strongly disagreed (320/463 [69.1%]) with a statement that providing futile care is always wrong, and only 38 (8.2%) agreed or strongly agreed. Over 70% (329/464 [70.9%]) of respondents agreed that there are situations in which provision of futile care is appropriate.

CLINICAL RELEVANCE

The importance of reaching a consensus definition for medical futility in veterinary medicine is evident given the frequency with which such care is being provided. Most small animal specialist veterinarians will encounter futile care, and the establishment of an ethical framework to navigate questions surrounding medical futility may help reduce moral distress.

Abstract

OBJECTIVE

To document veterinarians’ perceptions and understanding of medical futility and determine the frequency with which medical futility occurs in small animal practice.

SAMPLE

477 veterinarians in small animal general and specialty veterinary practice.

PROCEDURES

A cross-sectional study was performed with a 25-question, web-based, confidential, anonymous survey distributed through various professional veterinary specialty associations.

RESULTS

Nearly all respondents (469/474 [99.0%]) believed that futile care occurs in veterinary medicine, and 42.4% (201/474) felt it occurred commonly (> 6 times/y). A similar percentage (471/475 [99.2%]) reported encountering futile care within their careers, and 85.0% (402/476) reported encountering it within the past year. A majority (293/477 [61.4%]) reported witnessing futile care occurring in both inpatient and outpatient settings. Most respondents disagreed or strongly disagreed (320/463 [69.1%]) with a statement that providing futile care is always wrong, and only 38 (8.2%) agreed or strongly agreed. Over 70% (329/464 [70.9%]) of respondents agreed that there are situations in which provision of futile care is appropriate.

CLINICAL RELEVANCE

The importance of reaching a consensus definition for medical futility in veterinary medicine is evident given the frequency with which such care is being provided. Most small animal specialist veterinarians will encounter futile care, and the establishment of an ethical framework to navigate questions surrounding medical futility may help reduce moral distress.

Introduction

In the authors’ experience, providing care that may be deemed futile or nonbeneficial to patients can take an extraordinary toll on members of the veterinary care team. This type of care drains resources, both physical and emotional, and may contribute to moral distress experienced by members of the veterinary care team.1 Anecdotally, the authors have witnessed coworkers become distraught at the prospect of continuing to care for animals they judge to be suffering unnecessarily. Observing the impact this type of care has had on members of the veterinary care staff coupled with the lack of empirical information on the provision of futile care in veterinary medicine prompted this investigation.

Through nearly 50 years of combined clinical experience in specialty veterinary medicine, the authors have observed that concerns about futility of care can occur in multiple situations, including, but not limited to, when a veterinarian and pet owner disagree about whether further treatment would impose burdens that are disproportionate to the possible benefits, when there is disagreement about whether life-sustaining treatment itself is appropriate, and when an owner’s overall or specific goals are discordant with the veterinarian’s treatment recommendations. With increasing availability of advanced treatment modalities and specialized care, it is likely that veterinarians will encounter requests for nonbeneficial care at higher and higher rates. Despite the advances in care that are possible and the expectations of clients, published literature on veterinary clinical ethics related to nonbeneficial care is virtually nonexistent.

The idea of medical futility dates back to Hippocrates, when he conceived of medicine as doing “away with the sufferings of the sick, to lessen the violence of their diseases, and to refuse to treat those who are overmastered by their diseases, realizing that in such cases medicine is powerless.”2 Since that time, a large amount of research has been done to examine the ethics and costs of medical futility in human medicine.312 The concept of futile or nonbeneficial care as it relates to veterinary medicine has been lightly explored in recent years.1316 However, there currently is no accepted definition for futile or nonbeneficial care in veterinary or human medicine. The authors consider the essential concept of futility to entail continuing treatment for a patient when relevant goals can no longer be reached. Importantly, this includes the idea that futile care might be harmful to patients in some instances. Still, the exact nature of these goals and whose goals matter the most is poorly defined. A strict definition of futile and nonbeneficial care would be based on physiologic goals. When there is no possibility that treatment can achieve those goals, then treatment would be deemed nonbeneficial or futile. However, this fails to consider the values and nonmedical goals of various stakeholders. For instance, mechanical ventilation for a dog with advanced metastatic lung cancer will not achieve an intended physiologic goal (eg, spontaneous breathing without hypoxemia), but it may provide time for an owner to be present during euthanasia. The truism that “futility is in the eye of the beholder” reminds us that every stakeholder has their own definition of what is beneficial and what is not.

Moral distress occurs when a clinician believes they know the right thing to do but are prevented from doing it by institutional or other constraints.17 Ethical dilemmas arise when there is no clear correct course of action and no readily apparent way to determine one.18 The definition of moral distress used by Montoya et al18 as “the psychological disequilibrium experienced from being constrained from following the perceived correct moral path” encompasses the affective component and neatly separates the 2 terms. Some work has been done documenting the occurrence of moral distress as it relates to ethical dilemmas in veterinary medicine, with some indication that medical futility contributes to moral distress,1,13,14 and some has been done to provide veterinarians with ethical frameworks for navigating ethical conflicts.19 While providing insight into the consequences of these ethical dilemmas, these studies do not attempt to determine how frequently medical futility is encountered in veterinary medicine.

The current state of mental health in the veterinary profession is poor, with 31% of veterinarians having experienced depressive episodes, and ethical challenges contribute to veterinarian stress.20 The authors undertook the present study to help elucidate how medical futility contributes to ethical challenges faced by veterinarians. Specifically, we wanted to know how veterinarians conceptualize medical futility, how often veterinarians encounter futile or nonbeneficial care, how veterinarians feel about the provision of futile or nonbeneficial care for veterinary patients in general, and how veterinarians feel personally about being asked to provide this type of care. We also wanted to identify the main factors involved in deciding whether to provide futile or nonbeneficial care for animals.

Materials and Methods

A web-based survey consisting of 25 questions was developed to assess the occurrence and frequency with which futile or nonbeneficial care was encountered by veterinarians. The questions include demographic questions, yes-no questions, multiple-choice questions with some free text options, and Likert-type questions. The survey was distributed via an online survey service (SurveyMonkey Inc; San Mateo) to members of the American College of Veterinary Emergency and Critical Care and the American College of Veterinary Internal Medicine (Small Animal Internal Medicine and Cardiology). Additionally, respondents were encouraged to share the survey instrument with members of the veterinary care teams at their places of employment, providing all participants were > 18 years of age. Respondents were informed that completing the survey was deemed as consent and that participation was voluntary and could be terminated at any time. Responses were collected between March 12, 2020, and October 8, 2020. Owing to the impact of the COVID-19 pandemic on the veterinary profession, a reminder email was distributed on September 14, 2020. Results were tabulated by SurveyMonkey survey software. The research project was reviewed by the Cambridge Health Alliance of Harvard Medical School Institutional Review Board.

Results

Respondent characteristics, demographics, and training

A total of 508 individuals responded to the survey. Owing to the small number of non-veterinarians who responded, responses from nonveterinarians were excluded, leaving 477 respondents who were included in analyses (Table 1). Small percentages of respondents reported working only in a general practice setting (7 [1.5%]) or did not specify their practice setting (28 [5.9%]), whereas the remaining respondents were split among specialty practice, hybrid (general and specialty) practice, and academia. Most respondents (280 [58.7%]) indicated that their primary role in the practice was something other than emergency or critical care, and most (251 [52.6%]) reported that emergency and critical care made up 0% to 25% of their daily work. The overwhelming majority of respondents were associate veterinarians (353 [74.0%]) or medical directors (62 [13.0%]). Most respondents (447/477 [93.7%]) were board certified by at least 1 recognized veterinary specialty organization.

Table 1

Demographic characteristics of 477 respondents to a survey on medical futility in small animal practice.

Variable No. (%)
Age (y) 476 (99.8)
 25–34 76 (16.0)
 35–44 205 (43.1)
 45–54 129 (27.1)
 55–64 51 (10.7)
 65–74 14 (2.9)
 ≥ 75 1 (0.2)
Gender 474 (99.3)
 Female 352 (74.3)
 Male 120 (25.3)
 Prefer not to answer 2 (0.4)
Practice setting 477 (100)
 General practice 7 (1.5)
 Specialty practice 279 (58.5)
 Hybrid (general and specialty) practice 60 (12.6)
 Academia 103 (21.6)
 Other or not specified 28 (5.9)
 Primary role 477 (100)
 Emergency and critical care 152 (31.9)
 Critical care only 32 (6.7)
 Emergency only 13 (2.7)
 Other 280 (58.7)
Percentage of time spent on emergency and critical care 477 (100)
 0%–25% 251 (52.6)
 26%–50% 67 (14.1)
 51%–75% 25 (5.2)
 76%–100% 134 (28.1)
Current position 477 (100)
 Intern 3 (0.6)
 Resident 11 (2.3)
 Associate 353 (74.0)
 Medical director 62 (13.0)
 Other 48 (10.1)

Beliefs about medical futility

When asked to choose which of 3 options most closely matched their definition of medical futility, most respondents (273/474 [57.6%]) selected “Providing interventions that are unlikely to offer a reasonable expectation of recovery or achieve a desired therapeutic goal,” and 194 of 474 respondents (40.9%) selected an option describing uncontrolled suffering, permanent suffering, pain, distress, or disability. Few respondents (7/474 [1.5%]) choose the option that suggested that owners determined futility and were entitled to receive any treatment or seek any outcome they desired.

Of 464 respondents who indicated whether they agreed that all treatment options should be presented to owners, 73 (15.7%) strongly agreed and 206 (44.4%) agreed that all treatment options should be provided. However, 50 (10.8%) neither agreed nor disagreed, 111 (23.9%) disagreed, and 24 (5.2%) strongly disagreed. A large majority of respondents agreed (311/463 [67.2%]) or strongly agreed (42/463 [9.1%]) that providing futile care benefited the owners in some way, whereas 71 (15.3%) neither agreed nor disagreed, 35 (7.6%) disagreed, and 4 (0.9%) strongly disagreed. Most respondents strongly agreed (24/463 [5.2%]) or agreed (238/463 [51.4%]) that they were sympathetic to owners’ feelings and wishes, with 105 (22.7%) neither agreeing nor disagreeing, 80 (17.3%) disagreeing, and 16 (3.5%) strongly disagreeing.

Most respondents disagreed (256/463 [55.3%]) or strongly disagreed (64/463 [13.8%) with the statement that providing futile care is always wrong. However, 105 (22.7%) neither agreed nor disagreed, 33 (7.1%) agreed, and 5 (1.1%) strongly agreed with this statement. Over 70% of respondents agreed (294/464 [63.4%]) or strongly agreed (35/464 [7.5%]) that there are situations during which providing futile care is appropriate; few respondents disagreed (40 [8.6%]) or strongly disagreed (5 [1.1%]) with this statement, with the remainder (90 [19.4%]) neither agreeing nor disagreeing.

Over 60% of respondents did not believe (disagree, 148/464 [31.9%]; strongly disagree, 146/464 [31.5%]) that they could envision a scenario in which they might ask for futile care to be provided to their own pet, with 114 (24.6%) respondents agreeing and 11 (2.4%) respondents strongly agreeing that they could; the remaining 45 (9.7%) neither agreed nor disagreed. Approximately equal numbers of respondents agreed (agree, 130/465 [28.0%]; strongly agreed, 12 [2.6%]) and disagreed (disagree, 132 [28.4%]; strongly disagree, 29 [6.2%]) that they would be comfortable providing futile care in the future, with 162 (34.8%) neither agreeing nor disagreeing.

Experience with medical futility

Nearly all respondents (99.0%) believed that futile care occurs in veterinary medicine (Table 2), and 201 of 474 (42.4%) respondents felt that it occurred commonly in their practice (> 6 times/y). A similarly large percentage of respondents (99.2%) reported encountering futile care at some point in their career, with many (85.0%) having encountered it within the past year. Most participants (98.5%) indicated that they had been asked to provide futile care at some point in their career, and most (89%) indicated that they had provided care they believed to be futile. When respondents who had provided futile care were asked what factors influenced their decision, the most common responses were to allow time for an owner or agent of the owner to arrive and be present for euthanasia, to satisfy an owner’s request that all treatment options be exhausted, and to respond to the fact that the owners failed to understand the severity of the pet’s condition. Responses were similar when respondents were asked about reasons for futile care provided by their colleagues. Most respondents witnessed futile care being provided in both inpatient and outpatient settings, with a lower percentage witnessing it only in inpatient settings.

Table 2

Experience with medical futility for respondents in Table 1.

Variable No. (%)
Believe futile care occurs in veterinary medicine 474 (99.4)
 Yes 469 (99.0)
 No 5 (1.0)
Have encountered futile care during career 475 (99.6)
 Yes 471 (99.2)
 No 4 (0.8)
Encountered within past year 473 (99.2)
 Yes 402 (85.0)
 No 71 (15.0)
Frequency with which futile care occurs at your hospital 474 (99.4)
 Rarely (0–1 times/y) 30 (6.3)
 Infrequently (2–4 times/y) 127 (26.8)
 Frequently (4–6 times/y) 116 (24.5)
 Commonly (> 6 times/y) 201 (42.4)
Have provided futile care 474 (99.4)
 Yes 422 (89.0)
 No 52 (11.0)
Asked to provide futile care at same time during career 476 (99.8)
 Yes 469 (98.5)
 No 7 (1.5)
If provided, what influenced decision? 457 (95.8)
 Satisfy owners request for all options to be exhausted 371 (81.2)
 Allow time for owner to be present for euthanasia 397 (86.9)
 Satisfy personal belief that all options were exhausted 88 (19.3)
 Directed by superior to continue care 62 (13.6)
 Owner failed to understand pet’s condition 331 (72.4)
 Financial incentive to continue care 15 (3.3)
 Other 55 (12.0)
If witnessed, what influenced decision? 470 (98.5)
 Satisfy owners request for all options to be exhausted 423 (90.0)
 Allow time for owner to be present for euthanasia 404 (86.0)
 Satisfy personal belief that all options were exhausted 298 (63.4)
 Directed by superior to continue care 114 (24.3)
 Owner failed to understand pet’s condition 369 (78.5)
 Financial incentive to continue care 76 (16.2)
 Other 30 (6.4)
Setting in which futile care occurred 477 (100)
 Inpatient setting (hospitalized patient) 173 (36.3)
 Outpatient setting (patient treated at home) 10 (2.1)
 Both inpatient and outpatient settings 293 (61.4)
 Not witnessed 1 (0.2)

Discussion

Results of the present study demonstrated that there is not currently a consensus among veterinarians for defining medical futility. Most respondents in our study associated medical futility with the achievement of physiologic goals; however, a large minority associated futility with subjective outcomes such as suffering and distress. An example of the challenge of defining medical futility would be a human study21 in which a focus group was asked to define medical futility, with responses ranging from the burden of care grossly outweighing the potential benefits, patients never surviving outside of an ICU environment, patients remaining permanently unconscious, treatment not achieving the patient’s goals, and imminent death. The Society of Critical Care Medicine published a consensus statement regarding futile treatments and identified 4 categories of treatment that patients receive that could be considered futile: 1. Uncertain or controversial benefit; 2. Beneficial but extremely costly; 3. Extremely unlikely to be beneficial; and 4. No beneficial physiologic effect. The last category was the only one accepted as truly futile by the Society of Critical Care Medicine, which assumes that the label of futility be limited to when treatments will not accomplish their intended goal, without addressing whether the intended goal is appropriate.22 The American Thoracic Society suggested that “A life sustaining intervention is futile if reasoning and experience indicate that the intervention would be highly unlikely to result in a meaningful survival (italics in original) for that patient,” noting that meaningful survival referred specifically to a quality and duration of survival that would have value to the patient as an individual.23 More recently, the American Thoracic Society proposed replacing the term futile treatment with “potentially inappropriate” treatment when there is at least some chance of accomplishing the effect sought by the patient and reserving the term futile for “rare situations in which surrogates request interventions that simply cannot accomplish their intended physiologic goal.”24

The veterinary profession is in need of a consensus definition, or at least a working definition, of medical futility to further the discussion surrounding futile and nonbeneficial care. Ideally, this definition would improve on the Society of Critical Care Medicine definition by taking into account factors such as owner belief structure and extenuating circumstances (owner desire to be present for death) and would introduce a fifth category that would encompass potentially harmful interventions. Over half (57.6%) of the respondents to the present survey indicated that the statement that most closely matched their own definition of futility was providing interventions that are unlikely to offer a reasonable expectation of recovery or achieve a desired therapeutic goal. If this is used as a definition, then consideration must be given to who decides what “reasonable” is and how “reasonable” should be determined. The question of who gets to determine what the care goals are or should be and which goals are valid is central in defining medical futility. Given the findings of our study, the authors propose the following definition of futile care: futile care occurs when the continuation of current treatment or institution of new treatment is not expected to alter the clinical course of the patient, even if such treatment confers some benefit to the owner.

There are many stakeholders involved in providing veterinary care to patients, and the complexity of identifying futile care increases when providing advanced care to critically ill patients. Patients and owners are obviously stakeholders, but other entities, including but not limited to family members, spouses, friends, and co-caregivers, may also have legitimate claims. Additionally, there may be more than 1 veterinarian involved, including 1 or more specialists, the patient’s primary care veterinarian, and, possibly, consulting veterinarians. Similarly, the technicians providing treatments to the patient, the animal care attendants keeping the patient clean and comfortable, the front office staff interacting with the owners in the lobby, and the phone operators fielding calls all hold an interest in the care of the patient. This is further complicated when pets are owned by a rescue organization or when funds are being raised through crowdsourcing. Finally, various institutions, including hospitals, universities, corporations, insurance companies, and the veterinary profession at large, may be impacted by the way that medical futility is defined.

With this many stakeholders involved, determining whose and which goals are the most valid becomes challenging. Consider the dog with lymphoma that has had no clinical response to chemotherapy but whose owners insist on 1 more dose or the cat with chronic pleural effusion that is presented weekly for thoracocentesis with the intervals getting ever shorter. What is to be done in these cases? Should temporal goals such as keeping a patient alive until an owner can be present for euthanasia be considered valid? If so, is this validity time dependent? In other words, is it ethically acceptable to keep a patient on a ventilator for an hour while an owner is stuck in traffic? What happens when that owner is traveling out of the country and cannot make it back for 48 hours? These are challenging questions that cannot be answered in a simple binary fashion. Perhaps all stakeholders could have a place at the table to determine the best course of treatment, and perhaps only when these agreed-upon goals cannot be achieved should care truly be deemed nonbeneficial. A shared decision-making paradigm such as this has the potential to mitigate the moral distress experienced by veterinarians, veterinary staff, and owners when these cases arise.2528 There is some indication that accepting a definition of nonbeneficial care that incorporates owners’ values systems is being practiced by many veterinarians already, in that the 2 most commonly selected reasons for providing nonbeneficial care in the present study were to allow time for owners to be present during euthanasia and to fulfill the owners desire that all possible treatment options be exhausted.

For most of the history of medicine, physicians have taken a paternalistic role, determining what was best for their patients while paying little attention to the patient’s goals. In the 1960s and 1970s, the concept of individual autonomy emerged, granting nearly absolute negative autonomy (ie, the right to refuse treatment) to patients. Positive autonomy, or the right to demand treatment, is less clearly established as a legal right.29 This concept is further complicated in veterinary medicine owing to the legal standing of animals in society as both property and their recognition as sentient beings, with the precise role for veterinarians left ambiguous.15 In the present study, 60% of respondents agreed with the statement that all treatment options should be presented to owners, whereas nearly 30% disagreed. This finding is consistent with the established movement away from a paternalistic approach to medicine in favor of a more patient-oriented approach.29 Paradoxically, this movement may increase the likelihood that veterinarians experience moral distress or ethical conflicts associated with owners electing to pursue treatment options about which the veterinarian has ethical reservations. Maintaining shared decision-making while providing definitive recommendations may help to mitigate this distress.26,30

In the present study, although veterinarians’ personal beliefs about medical futility indicated some reservations about providing futile care to patients and seeking futile care for their own pets, a large majority indicated that they believed the provision of futile care benefited the owner in some way. This finding suggests that despite their personal opinions, veterinarians are generally inclined to see some value to owners in the provision of futile care. Our study did not explore whether veterinarians perceived some value to the patients in providing futile care (such as providing time for owners to visit or be present for euthanasia, possibly reducing distress at the end of life) but it would stand to reason that, if veterinarians believed the treatments they were providing benefited the patient, such treatments would not be deemed futile.

Quantifying the frequency with which futile or nonbeneficial care occurs is challenging. A survey5 of professionals in human health care found that nearly half (47%) of respondents in total and 70% of house officers had acted against their conscience in providing care for the terminally ill. A study21 of 36 critical care doctors who provided care to nearly 1,136 patients found that 8.6% of patients received care that was probably futile and 11% received care that was futile. A recent survey1 of veterinarians that included a larger proportion of general practice veterinarians also found that the request to provide nonbeneficial care was common, with nearly 79% of respondents reporting they had encountered this request either sometimes or often. The results of the present study suggest that medical futility, as defined by the veterinarians administering care, is common in veterinary specialty practice, with nearly all respondents indicating they had either provided futile care or been asked to provide futile care at some point in their careers. When coupled with the responses indicating discomfort with providing futile care, this would suggest that medical futility could be an important contributor to moral distress and burnout. In fact, this conclusion is supported in the existing literature, with nearly 80% of veterinarians reporting feeling conflicted or upset because pet owners refuse to do what the veterinarian thinks is in the pet’s best interest.1

Elucidating the motivations for physicians or veterinarians who provide futile or nonbeneficial care is challenging, and the reasons are likely complex, as each care provider must rationalize their decisions based on their own moral and ethical principles. In the present study, the 3 most common reasons for providing futile care were owner oriented and included buying time for owners to be present for euthanasia, complying with an owner’s requests that all treatment options be exhausted, and handling an owner’s failure to understand the severity of the patient’s condition. The first reason suggests open, ethical communication between the owner and veterinarian, during which all vested parties identify objectives and reach a consensus on how to proceed. The second reason (exhausting all treatment options) may indicate a similar communication success but may alternatively represent a failure to identify common goals. The third reason (owner’s failure to understand) is indicative of a communication breakdown between stakeholders. In this case, there may be a true failure to understand the severity of a patient’s condition, there may be an erroneous judgment by the veterinarian about the degree of the owner’s understanding, or the owner may be experiencing the “pendulum of prognostic awareness” wherein acceptance and understanding of a life-limiting prognosis oscillate. If the latter occurs, a systematic approach to evaluating an owner’s readiness to discuss prognosis may be beneficial.31 The 3 most common reasons identified in the present study as causes for a colleague’s decision to provide futile care were the same as those self-identified reasons, with nearly two-thirds of respondents indicating that they believed the colleague did so to fulfill a feel that they had exhausted all treatment options for a case. The disconnect between self-identified motivation and inferred motivation bears further exploration. In human futility conflicts, an independent entity (ethics consultant or mediator) is often enrolled to facilitate identification of common goals and to come to a mutually acceptable resolution. Importantly, this process is transparent, and a protocol for resolution of ethical conflicts exists.22 The findings of the present study confirm that provision of futile care is common in veterinary medicine and suggest the need for veterinary hospitals to establish a similar transparent, objective approach to resolve these conflicts.

An unexpected finding in the present study was that most respondents believed futile care was provided in both inpatient and outpatient settings. It is possible that some respondents interpreted provision of hospice care in an outpatient setting as futile. True hospice care indicates a deliberate decision to redirect treatment efforts away from addressing the underlying disease and toward mitigating the effects of disease that may be leading to suffering when death is imminent. Veterinary hospice care is an emerging field with the goal of ensuring compassionate end-of-life care while providing comfort to patients and families.32 Further investigation is needed to elucidate the precise circumstances in which futile outpatient care is occurring. Given that formal hospice and palliative care services are uncommon in veterinary medicine, it might be possible that greater access to services aimed at reducing suffering in seriously ill patients could reduce futile care in outpatient settings.

Future studies should attempt to document medical futility across a wider sample of veterinarians; this may include distribution through broader professional organizations such as local and national veterinary medical associations and alumni groups and at local and national continuing education events. Concepts associated with medical futility as perceived by veterinarians at various points in their career warrant investigation. Additionally, investigations into the impact of futile care provision on technicians, assistants, and nonveterinary staff should be conducted. Efforts should be made to determine whether providing futile care contributes to moral distress experienced by veterinarians, technicians, and assistants and whether this contributes to high rates of burnout and leaving the profession. The authors are in the process of attempting to document the emotional, physical, and professional toll that providing futile care takes on members of the veterinary care team.

The present study is an important first step in the process of understanding medical futility in the veterinary profession. The authors have used the results to propose a working definition of medical futility for veterinarians and have offered some ideas about future investigations in the hope that this can facilitate a profession-wide discussion of this challenging topic.

Our study has some limitations, the most important of which relate to distribution of the survey instrument. Rules governing the posting of surveys vary widely among specialty organizations, limiting the distribution to those organizations that agreed to allow distribution to their members. By attempting to reach veterinarians likely to encounter instances of medical futility, the authors may have introduced both selection and volunteer biases. It is impossible to know the response rate for the present survey because total distribution number was not known. Therefore, the generalizability of the results is unknown. A second limitation is that the survey offered no free-text options for responding to complex ethical questions, and respondents may have been forced to choose an answer that most closely approximated their true feelings but lacked the nuance that follow-up interviews or free-text responses may have provided.

Virtually all respondents in the present study reported experience with medical futility in their practice. This study begins the process of documenting the occurrence of medical futility in veterinary medicine. The authors hope to stimulate discussion within the profession surrounding the concept of medical futility and leading to the development of consensus definitions and guidance that may help veterinarians and their staffs navigate this difficult topic.

Acknowledgments

No third-party funding or support was received in connection with this study or the writing or publication of the manuscript. The authors declare that there were no conflicts of interest.

References

  • 1.

    Moses L, Malowney MJ, Boyd JW. Ethical conflict and moral distress in veterinary practice: a survey of North American veterinarians. J Vet Intern Med. 2018;32(6):21152122.

    • Search Google Scholar
    • Export Citation
  • 2.

    Jones WHS. Hippocrates. Vol II. Harvard University Press; 1959.

  • 3.

    Schneiderman LJ, Jecker NS, Jonsen AR. Medical futility: its meaning and ethical implications. Ann Intern Med. 1990;112(12):949954.

  • 4.

    Schneiderman LJ. Defining medical futility and improving medical care. J Bioeth Inq. 2011;8(2):123131.

  • 5.

    Solomon MZ, O’Donnell LO, Jennings B, et al. Decisions near the end of life: professional views on life-sustaining treatments. Am J Public Health. 1993;83(1):1423.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Meltzer LS, Huckabay LM. Critical care nurses’ perceptions of futile care and its effect on burnout. Am J Crit Care. 2004;13(3):202208.

  • 7.

    Clark PA. Medical futility: legal and ethical analysis. Virtual Mentor. 2007;9(5):375383.

  • 8.

    Huynh TN, Kleerup EC, Raj PP, Wenger NS. The opportunity cost of futile treatment in the ICU. Crit Care Med. 2014;42(9):19771982.

  • 9.

    Jox RJ, Schaider A, Marckmann G, Borasio GD. Medical futility at the end of life: the perspectives of intensive care and palliative care clinicians. J Med Ethics. 2012;38(9):540545.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10.

    Coonan E. Medical futility: a contemporary review. J Clin Ethics. 2016;27(4):359362.

  • 11.

    Truog RD. Tackling medical futility in Texas. N Engl J Med. 2007;357(1):13. doi:10.1056/MEJMp078109

  • 12.

    Mohindra RK. Medical futility: a conceptual model. J Med Ethics. 2007;33(2):7175.

  • 13.

    Batchelor CEM, McKeegan DEF. Survey of the frequency and perceived stressfulness of ethical dilemmas encountered in UK veterinary practice. Vet Rec. 2012;170(1):19. doi:10.1136/vr.100262

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14.

    Herzog HA, Vore TL, New JC Jr. Conversations with veterinary students: attitudes, ethics, and animals. Anthrozoos. 1989;2(3):181188.

  • 15.

    Fordyce PS. Welfare, law and ethics in the veterinary intensive care unit. Vet Anaesth Analg. 2017;44(2):203211.

  • 16.

    Clutton RE. Recognising the boundary between heroism and futility in veterinary intensive care. Vet Anaesth Analg. 2017;44(2):199202.

  • 17.

    Dean W, Talbot SG, Caplan A. Clarifying the language of clinician distress. JA MA. 2020;323(10):923924.

  • 18.

    Montoya AI, Hazel S, Matthew SM, McArthur ML. Moral distress of veterinarians. Vet Rec. 2019;185(20):631. doi:10.1136/vr.105289

  • 19.

    Hernandez E, Fawcett A, Brouwer E, Rau J, Turner PV. Speaking up: veterinary ethical responsibilities and animal welfare issues in everyday practice. Animals (Basel). 2018;8(1):15. doi:10.3390/ani8010015

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    Nett RJ, Witte TK, Holzbauer SM, et al. Risk factors for suicide, attitudes toward mental illness, and practice-related stressors among US veterinarians. J Am Vet Med Assoc. 2015;247(8):945955.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21.

    Huynh TN, Kleerup EC, Wiley JF. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173(20):18871894.

  • 22.

    Danis M, Truog R, Devita M, et al. Consensus statement of the Society of Critical Care Medicine’s Ethics Committee regarding futile and other possibly inadvisable treatments. Crit Care Med. 1997;25(5):887891.

    • Search Google Scholar
    • Export Citation
  • 23.

    American Thoracic Society. Withholding and withdrawing life-sustaining therapy. Ann Intern Med. 1991;115(6):478485.

  • 24.

    Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med. 2015;191(11):13181330.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Cornell KK, Kopcha M. Client-veterinarian communication: skills for client centered dialogue and shared decision making. Vet Clin North Am Small Anim Pract. 2007;37(1):3747.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Christiansen SB, Kristensen AT, Lassen J, Sandøe P. Veterinarians’ role in clients’ decision-making regarding seriously ill companion animal patients. Acta Vet Scand. 2016;58(1):30. doi:10.1186/s13028-016-0211-x

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Charles C, Gafni A, Whelan T. Decision-making in the physician–patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med. 1999;49(5):651661.

    • Search Google Scholar
    • Export Citation
  • 28.

    Hardingham LB. Integrity and moral residue: nurses as participants in a moral community. Nurs Philos. 2004;5(2):127134.

  • 29.

    Mealer M, Moss M. Moral distress in ICU nurses. Intensive Care Med. 2016;42(10):16151617.

  • 30.

    Colville GA, Dawson D, Rabinthiran S, Chaudry-Daley Z, Perkins-Porras L. A survey of moral distress in staff working in intensive care in the UK. J Intensive Care Soc. 2019;20(3):196203.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Jackson VA, Jacobsen J, Greer JA, Pril WF, Temel JS, Back AL. The cultivation of prognostic awareness through the provision of early palliative care in the ambulatory setting: a communication guide. J Palliat Med. 2013;16(8):894900.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Yaxley PE. Michigan State University veterinary hospice care: an academic hospice practice 2011 to 2014. Vet Clin North Am Small Anim Pract. 2019;49(3):351362.

    • PubMed
    • Search Google Scholar
    • Export Citation
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