Addressing 'futility' in psychiatry: a consensus statement

While the concept of futility has been used widely in somatic medicine, to date, there has been limited consideration of its relevance to psychiatry. We summarize the findings of an international, multidisciplinary workshop involving clinicians, ethicists, philosophers, patient advocates, and persons with lived experience, which was focused on describing futility in psychiatry and developing ethical guidelines for making futility judgments. We outline three leading concepts of futility as they have been used in somatic medicine: physiological futility, quantitative futility, and qualitative futility. We examine the application of these concepts to the care of persons with mental illness, finding that the notion of qualitative futility is most likely to be fruitful. We consider how the concept of qualitative futility in psychiatry could relate to other ethically salient concepts such as terminal mental illness and recovery. We consider (1) who should have authority to make futility judgments in psychiatry (i.e. patients, providers, others), (2) what the process for introducing and evaluating futility judgments should be, and (3) how futility assessments should respond to patients' goals and values. We identify potential risks of futility assessments, including psychological harms and premature treatment discontinuation, as well as potential benefits, such as reductions in harmful treatments and helpful reevaluation of the goals of care. Workshop participants regarded the concept of psychiatric futility as potentially useful. They identified how the concept could be applied to psychiatric care, as well as ethical limits on doing so.