Futility: unilateral decision making is not the default for pediatric intensivists

Many hospitals have established medical futility policies allowing a physician to withdraw or withhold treatment considered futile against families' wishes, although little is known on how these policies are used. The goal of our study was to elucidate the perspective of pediatric critical care physicians on futility.

We sent an anonymous survey to all active members of the American Academy of Pediatrics Section of Critical Care, using Survey Monkey http://www.surveymonkey.com as the questionnaire tool. The survey included four clinical vignettes where families desired care that could be perceived as futile care. In each scenario, participants were asked if they would go against the families' wishes and how they would resolve the conflict.

There were 266 of 618 (43%) respondents. For an infant with severe hypoxic ischemic injury and intestinal failure, the majority of physicians (83.7%) would not enact a unilateral do not attempt resuscitation order. For an oncology patient with multiorgan system failure and encephalopathy, the majority (90.4%) would not enact a unilateral donotattemptresuscitation. In the case where a child was declared brain dead, 54.3% of physicians would support unilateral donotattemptresuscitation, yet a third (33.1%) would continue mechanical ventilation. In the case of cardiac surgery for a patient with trisomy 13, the majority (67.1%) would not advocate for surgery. In most scenarios, intensivists cited consultation from the ethics committee (53.8%-76.6%) as the most appropriate way to resolve the conflict. Qualitative data revealed intensivists would prefer to honor families' wishes and utilize time with support from a multidisciplinary team rather than unilateral do not attempt resuscitation to resolve these conflicts.

The majority of pediatric intensivists are not in support of unilateral do-not-attempt resuscitation or withholding care against families' wishes for a variety of reasons. Given this understandable reluctance on the part of the physicians for enforcing decisions, providing unqualified support to families at this difficult time is imperative. Further research is needed to facilitate decision making that respects the moral integrity of families and physicians.