USE OF THE MEDICAL FUTILITY RATIONALE IN DO-NOT-ATTEMPT-RESUSCITATIONORDERS

Objective.-To describe the use of the medical futility rationale in do -not-attempt-resuscitation (DNAR) orders written for medical inpatient s. Design.-Structured interviews with medical residents. Methods.-Seco nd- and third-year internal medicine residents (n=44) were telephoned weekly and briefly interviewed about each patient who received a DNAR order in the preceding week, Setting.-Two university-affiliate hospita ls: a veterans affairs medical center and a municipal hospital. Patien ts.-One hundred forty-five medical inpatients for whom DNAR orders wer e written during their hospitalization. Results.-Residents stated that the medical futility rationale applied for 91 patients (63%), but thi s rationale was invoked independent of patient or surrogate choice for only 17 patients (12%). Of the 91 patients for whom futility applied, both quantitative futility (low probability of success) and qualitati ve futility (poor quality of life if cardiopulmonary resuscitation [CP R] were performed) applied to 45 (49%), quantitative futility alone to 30 (33%), and qualitative futility atone to 16 (18%). Residents repor t that they discussed resuscitation issues with all communicative pati ents for whom the medical futility rationale was invoked, Among patien ts for whom quantitative futility applied, residents' predictions of t he probability that patients would survive to hospital discharge after CPR varied from 0% (for 60% of patients) to 75%, For 32% of these pat ients, residents predicted survival at 5% or more, Logistic regression modeling showed that the presence of organ failure (odds ratio [OR], 8.9; 95% confidence interval [CI], 3.3 to 23.9), the residents' estima tes of the probability of surviving CPR (OR, 0.94; 95% CI, 0.88 to 0.9 9), and nonwhite race (OR, 2.7; 95% CI, 1.1 to 6.3) were associated wi th the determination of quantitative futility, In one third of the cas es where qualitative futility applied, residents made the judgment of qualitative futility without discussing quality of life with communica tive patients. Logistic regression modeling showed immobility (OR, 3.2 ; 95% CI, 1.1 to 9.0) and age greater than or equal to 75 years (OR, 0 .3; 95% CI, 0.1 to 0.8) to be associated with the determination of qua litative futility. Conclusions.-While residents did not appear to use the medical futility rationale to avoid discussing DNAR issues with pa tients, we found evidence of important misunderstandings of the concep ts of both quantitative and qualitative futility, tf the futility rati onale is to be applied to withholding or withdrawing medical intervent ions, practice guidelines for its use should be developed, and educati on about medical futility must be incorporated into medical school, re sidency training, and continuing medical education programs.