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.^3–12 The concept of futile or nonbeneficial care as it relates to veterinary medicine has been lightly explored in recent years.^13–16 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

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.^25–28 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.