Gerald Neitzke

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.

Was ist neu?: Klinisches Setting Angehörige können bei langen Krankheitsverläufen eine Situation ähnlich einer posttraumatischen Belastungsstörung (PTBS) durchleben: Diese Form wird als „post-intensive care syndrome-family“ beschrieben und untersucht. Einer PTBS von Angehörigen vorzubeugen, fördert das Patientenwohl, da sie die Patienten besser unterstützen können. Kommunikation In der Kommunikation mit verzweifelten An- und Zugehörigen soll neben der Vermittlung von Informationen auch beruhigt und emotional unterstützt werden. Eine gute Kommunikation hilft, eine tragfähige Beziehung aufzubauen und ggf. rechtzeitig auf mögliche Entscheidungsszenarien hinzuweisen. Angehörige als Entscheider Agieren die An- und Zugehörigen als juristischer Stellvertreter für den Patienten, ist das ärztliche Team auf eine Entscheidung durch den Angehörigen angewiesen. Die Kommunikation verfolgt dann auch das Ziel, den Angehörigen in die Lage zu versetzen, eine Behandlungsentscheidung im Sinne des Patienten zu treffen. Angehörigenzentrierte Versorgung Angehörige von stationär versorgten Patient*innen müssen eine Reihe unterschiedlicher (sozialer) Rollen erfüllen: Als Entscheider, Co-Therapeut, als Kümmerer, als (Mit-)Betroffener. Die Erwartungen an diese Rollen können erheblich divergieren. In jeder einzelnen Rolle bedarf der oder die Angehörige einer Unterstützung durch das Stationsteam.

Veterinary and human medicine share the challenges of end-of-life decisions. While there are legal and practical differences, there might be parallels and convergences regarding decision-making criteria and reasoning patterns in the two disciplines. In this online survey, six variants of a fictitious thought experiment aimed at pointing out crucial criteria relevant for decision-making within and across both professional fields. The six variants introduced four human and two animal patients with the same disease but differing in age, gender and, in case of the human patients, in terms of their state of consciousness. Participants could choose between four different treatment options: euthanasia, continuous sedation, a potentially curative treatment with severe side effects and no intervention. Study participants were human and veterinary medical professionals and an additional control group of lay people. Decisions and justifications for the six variants differed but the three groups of participants answered rather homogeneously. Besides the patient’s “suffering” as a main criterion, “age”, “autonomy” and, to a lesser extent, “species” were identified as important criteria for decision-making in all three groups. The unexpected convergences as well as subtle differences in argumentation patterns give rise to more in-depth research in this cross-disciplinary field.

Standard views of good death in human and veterinary medicine considerably differ from one another. Whereas the good death ideal in palliative medicine emphasizes the positive aspects of non-induced dying, veterinarians typically promote a quick and painless killing with the aim to end suffering. Recent developments suggest a convergence of both professions and professional attitudes, however. Palliative physicians are confronted with patients wishing to be ‘put to sleep’, while veterinarians have begun to integrate principles and practices from hospice care. We will argue that the discourses on good human and animal deaths are not distinct, but that they interact and influence each other. On the one hand, veterinary medicine adapts techniques like chemotherapy or sedation from palliative end-of-life care. On the other hand, philosophers, veterinarians, pet owners, patients and the general public alike make certain assumptions about the (dis)analogy of human and animal dying or killing. Unfortunately, these interactions have only scarcely been reflected normatively, especially on the part of human medicine. Conflicts and misattributions with potential serious negative consequences for the (animal and human) patients’ wellbeing are provoked. For these reasons, palliative physicians and veterinarians are invited to engage in the debate around human and animal end-of-life care.