Applying futility in psychiatry: a concept whose time has come

Correspondence to Dr Sarah Levitt, Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON M6G 1A5, Canada; [email protected]

Introduction

The debate around the concept of futility emerged in the 1980s as life-sustaining interventions became increasingly commonplace and sophisticated. Questions were raised about when to continue treatments of uncertain benefit that were coupled with potential harm.¹ Futility remains controversial because of a lack of consensus on the definition of futility, the primacy of individual autonomy in Western contexts, uncertainty in prognostication and varied understandings of quality of life. Moreover, futility is a moving target. Advances in technology and medical expertise, not to mention the setting in which care occurs, influence the potential for clinical improvement in any illness.

Though futility has an extensive literature within multiple medical disciplines, rarely has it been discussed within psychiatry. This absence is notable given a recent survey of psychiatrists: over 50% of respondents deemed further treatment futile across case examples of treatment refractory psychiatric illnesses.² However, the current orientation of psychiatric care—which includes promoting recovery, distinguishing between physical and mental illness, and making findings of incapacity to compel treatment—challenges the legitimacy of naming futility in clinical decision making.

Particularly controversial is how futility might apply to patientsi living with severe and persistent mental illness (SPMI), a term that most commonly refers to individuals diagnosed with chronic schizophrenia or affective illnesses. The National Institute of Mental Health defines serious mental illness (SMI) as ‘(a) mental, behavioural, or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities’.³ The Substance Abuse and Mental Health Services Administration further clarifies that SMI is distinct from SPMI in that not only are SPMI conditions serious, but also ‘chronic and always disabling’.⁴ Unlike recent arguments against futility in psychiatry,⁵ we argue that the time has come to apply futility within psychiatric practice specifically in the care of individuals living with SPMI. Futility is helpful in delineating the limits of psychiatric intervention. Once determined, futility may lead to conversations about the realities of ongoing treatments that are not evidence based and potentially harmful. Naming futility acts as a signal that our approach to care must change.

In this paper, we clarify...