Recognising Medical Futility and Navigating End-of-Life Care

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A blog written by Professor Alison Mudge, Clinician Researcher, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital

 

Caring for patients in the last months of life is a delicate balance of compassion, communication, and clinical expertise. While striving for optimal clinical outcomes is the cornerstone of healthcare, recognising when further treatment becomes futile is equally important. As an example, let’s consider Jean, a moderately frail 81-year-old woman who has had four hospital admissions with decompensated heart failure with preserved ejection fraction in the past 6 months. Her renal function is also deteriorating.

Here are five key takeaways to guide clinicians through these challenging moments:

1. Navigating Prognostication

Estimating life expectancy is often challenging especially in patients with relapsing chronic diseases and/or frailty. Using frameworks like the Supportive and Palliative Care Indicators Tool (SPICT™) or the Surprise Question can help clinicians identify patients in the last months of life. While a precise prognosis is impossible, it is very likely that Jean will experience additional episodes of acute heart failure over the next few months and that her worsening kidney function will limit available therapies. Offering timeframes in terms of “short” or “long” days, weeks, or months can provide clarity for families.

2. Recognising Medical Futility

Not every treatment leads to meaningful improvement in quality of life. In cases where interventions become more burdensome than beneficial, it’s essential to acknowledge this tipping point. For example, renal replacement therapy will be poorly tolerated by Jean, a frail person with diastolic heart failure.

Anticipating and recognising such scenarios early enables clinicians to pivot towards a focus on comfort and dignity.

3. Prioritising Sensitive Communication

Effective communication is vital when transitioning from active treatment to palliative care. Clinicians must navigate these discussions sensitively, ensuring patients and their family members (as appropriate) feel heard and supported. Understanding who is supporting Jean at home, and involving them in discussions with Jean about her current needs, goals and wishes and how these will be met in the event of future deterioration in her function or symptoms (including the potential need for someone to support her making health decisions) will help to ensure that ongoing decisions align with her values. This may require a series of discussions and might be assisted by formal processes such as a Statement of Choices.

4. Understanding a ‘Good Death’

A ‘good death’ honours the patient’s physical, emotional, and spiritual needs. It minimises pain and distress, respects their dignity, and prioritises quality of life. For Jean, this might mean choosing whether to receive symptom management for a future exacerbation at home with a palliative care outreach service rather than being admitted to hospital. These choices will be shaped by her home and family situation, her previous experiences, and available service models. Clear communication with Jean’s GP, family, hospital team and community services will be essential to support her choice.

5. Continuous Learning in End-of-Life Care
Developing confidence and skill in discussing medical futility and end-of-life care takes time and mentorship. Observing experienced colleagues can help younger clinicians learn how to handle these moments with empathy and professionalism. Identifying and linking hospital and community care systems to provide person-centred support requires multidisciplinary collaboration.

Final Thoughts

End-of-life care is as much about listening and understanding as it is about medical expertise. Fostering open conversations, recognising when treatments are no longer effective, collaborating across systems and focusing on the patient’s individual needs and values will help to ensure patients and their families receive compassionate and respectful care during this time.

You can learn more in the End-of-Life Essentials Planning End-of-Life Care - Goals of Care module.

 

Professor Alison Mudge
Clinician Rearcher, Department of Internal Medicine and Aged Care, Royal Brisbane and Women's Hospital