BACKGROUND: Non-beneficial treatment is closely tied to inappropriate treatment at the end-of-life. Understanding the interplay between how and why these situations arise in acute care settings according to the various stakeholders is pivotal to informing decision-making and best practice at end-of-life.
OBJECTIVE: To define and understand determinants of  non-beneficial and inappropriate treatments for patients with a non-cancer diagnosis, in acute care settings at the end-of-life.
METHODS: Systematic review of peer-reviewed studies focusing on the above and conducted in upper-middle- and high-income countries. A narrative synthesis was undertaken, guided by Realist principles.
METHODS: Cochrane; PubMed; Scopus; Embase; CINAHL; and Web of Science.
RESULTS: Sixty-six studies (32 qualitative, 28 quantitative, and 6 mixed-methods) were included after screening 4,754 papers. Non-beneficial treatment was largely defined as when the burden of treatment outweighs any benefit to the patient. Inappropriate treatment at the end-of-life was similar to this, but additionally accounted for patient and family preferences. Contexts in which outcomes related to non-beneficial treatment and/or inappropriate treatment occurred were described as veiled by uncertainty, driven by organizational culture, and limited by profiles and characteristics of involved stakeholders. Mechanisms relating to \'Motivation to Address Conflict & Seek Agreement\' helped to lessen uncertainty around decision-making. Establishing agreement was reliant on \'Valuing Clear Communication and Sharing of Information\'. Reaching consensus was dependent on \'Choices around Timing & Documenting of end-of-life Decisions\'.
CONCLUSIONS: A framework mapping determinants of non-beneficial and inappropriate end-of-life treatment is developed and proposed to be potentially transferable to diverse contexts. Future studies should test and update the framework as an implementation tool.
BACKGROUND: PROSPERO Protocol  CRD42021214137 .

Futile is defined as \'the fact of having no effect or of achieving nothing\'. Futility in medicine has been defined through seven guiding principles, which in the context of emergency surgery, have been relatively unexplored. This scoping review aimed to identify key concepts around surgical futility as it relates to emergency laparotomy.
Using the Arksey and O\'Malley framework, a scoping review was conducted. A search of the Cochrane Library, Google Scholar, MEDLINE, and Embase was performed up until 1 November 2021 to identify literature relevant to the topic of futility in emergency laparotomy.
Three cohort studies were included in the analysis. A total of 105 157 patients were included, with 1114 patients reported as futile. All studies were recent (2019 to 2020) and focused on the principle of quantitative futility (assessment of the probability of death after surgery) within a timeline after surgery: two defining futility as death within 48 hours of surgery and one as death within 72 hours. In all cases this was derived from a survival histogram. Predictors of defined futile procedures included age, level of independence prior to admission, surgical pathology, serum creatinine, arterial lactate, and pH.
There remains a paucity of research defining, exploring, and analysing futile surgery in patients undergoing emergency laparotomy. With limited published work focusing on quantitative futility and the binary outcome of death, research is urgently needed to explore all principles of futility, including the wishes of patients and their families.

BACKGROUND: The population worldwide is rapidly ageing, and demand for intensive care is increasing. People aged 85 years and above, known as the oldest old, are particularly vulnerable to critical illness owing to the physiological effects of ageing. Evidence surrounding admission of the oldest old to the intensive care is limited.
OBJECTIVE: The objective of this study was to systematically and comprehensively review and synthesise the published research investigating factors that influence decisions to admit the oldest old to the intensive care unit.
METHODS: This was a systematic review and narrative synthesis. Following a comprehensive search of CINAHL, Embase, and Medline databases, peer-reviewed primary research articles examining factors associated with admission or refusal to admit the oldest old to intensive care were selected. Data were extracted into tables and narratively synthesised.
RESULTS: Six studies met the inclusion criteria. Three studies identified factors associated with admission such as greater premorbid self-sufficiency, patient preferences, alignment between patient and physicians\' goals of treatment, age less than 85 years, and absence of cancer, or previous intensive care admission. Factors associated with refusal to admit were identified in all six studies and included limited or no bed availability, level of ICU physician experience, patients being deemed too ill or too well to benefit, and older age.
CONCLUSIONS: Published research investigating decision-making about admission or refusal to admit the oldest old to the intensive care unit is scant. The ageing population and increasing demand for intensive care unit resources has amplified the need for greater understanding of factors that influence decisions to admit or refuse admission of the oldest old to the intensive care unit. Such knowledge may inform guidelines regarding complex practice decisions about admission of the oldest old to an intensive care unit. Such guidelines would ensure the specialty needs of this population are considered and would reduce admission decisions that might disadvantage older people.

For some patients, survival with good neurologic function after cardiopulmonary resuscitation (CPR) is highly unlikely, thus CPR would be considered medically futile. Yet, in clinical practice, there are no well-established criteria, guidelines or measures to determine futility. We aimed to investigate how medical futility for CPR in adult patients is defined, measured, and associated with do-not-resuscitate (DNR) code status as well as to evaluate the predictive value of clinical risk scores through meta-analysis.
We searched Embase, PubMed, CINAHL, and PsycINFO from the inception of each database up to January 22, 2021. Data were pooled using a fixed-effects model. Data collection and reporting followed the PRISMA guidelines.
Thirty-one studies were included in the systematic review and 11 in the meta-analysis. Medical futility defined by risk scores was associated with a significantly higher risk of in-hospital mortality (5 studies, 3102 participants with Pre-Arrest Morbidity (PAM) and Prognosis After Resuscitation (PAR) score; overall RR 3.38 [95% CI 1.92-5.97]) and poor neurologic outcome/in-hospital mortality (6 studies, 115,213 participants with Good Outcome Following Attempted Resuscitation (GO-FAR) and Prediction of Outcome for In-Hospital Cardiac Arrest (PIHCA) score; RR 6.93 [95% CI 6.43-7.47]). All showed high specificity (>90%) for identifying patients with poor outcome.
There is no international consensus and a lack of specific definitions of CPR futility in adult patients. Clinical risk scores might aid decision-making when CPR is assumed to be futile. Future studies are needed to assess their clinical value and reliability as a measure of futility regarding CPR.

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UNASSIGNED: The coronavirus disease 2019 (COVID-19) pandemic has raised a variety of ethical dilemmas for health care providers. Limited data are available on how a patient\'s concomitant cancer diagnosis affected ethical concerns raised during the early stages of the pandemic.
UNASSIGNED: We performed a retrospective review of all COVID-related ethics consultations registered in a prospectively collected ethics database at a tertiary cancer center between March 14, 2020, and April 28, 2020. Primary and secondary ethical issues, as well as important contextual factors, were identified.
UNASSIGNED: Twenty-six clinical ethics consultations were performed on 24 patients with cancer (58.3% male; median age, 65.5 years). The most common primary ethical issues were code status (n = 11), obligation to provide nonbeneficial treatment (n = 3), patient autonomy (n = 3), resource allocation (n = 3), and delivery of care wherein the risk to staff might outweigh the potential benefit to the patient (n = 3). An additional nine consultations raised concerns about staff safety in the context of likely nonbeneficial treatment as a secondary issue. Unique contextual issues identified included concerns about public safety for patients requesting discharge against medical advice (n = 3) and difficulties around decision making, especially with regard to code status because of an inability to reach surrogates (n = 3).
UNASSIGNED: During the early pandemic, the care of patients with cancer and COVID-19 spurred a number of ethics consultations, which were largely focused on code status. Most cases also raised concerns about staff safety in the context of limited benefit to patients, a highly unusual scenario at our institution that may have been triggered by critical supply shortages.

A patient with a life-threatening intracranial insult presents a difficult situation to the neurosurgeon. In a few short minutes the neurosurgeon must assess the patient\'s neurologic status, imaging, and medical condition then confer with the patient\'s proxy regarding treatment. This assessment ideally includes recognition of situations where aggressive care is futile and therefore such treatments should not be offered. The proxy discussion must involve surgical and nonsurgical management options and the impact of these options on survival and residual disability. Surgical decision-making is frequently difficult, even for designated proxies armed with advance directives, as these documents are usually vague with regard to acceptable functional outcomes. To complicate things further, when emergencies are off-hours, housestaff or physician extenders may need to represent the medical team in these discussions so that surgical treatment, if desired, can be arranged expeditiously. These difficulties sometimes lead to the performance of emergent surgical procedures in situations where poor outcome is certain, with deleterious effects to the patient, family, and healthcare system. It is clear then that neurosurgeons as well as their housestaff and extenders should have working knowledge of prognostic information relating to intracranial insults and familiarity with the complex ethical concept of medical futility. In this paper we review the relevant literature and our goal is to juxtapose these topics so as to provide a framework for decision making in that critical time.

GUIDE-IT, the largest trial to date, published in August 2017, evaluating the effectiveness of natriuretic peptide (NP)-guided treatment of heart failure (HF), was stopped early for futility on a composite outcome. However, the reported effect sizes on individual outcomes of all-cause mortality and HF admissions are potentially clinically relevant.
This systematic review and meta-analysis aims to combine all available trial level evidence to determine if NP-guided treatment of HF reduces all-cause mortality and HF admissions in patients with HF.
Eight databases, no language restrictions, up to November 2017 were searched for all randomised controlled trials comparing NP-guided treatment versus clinical assessment alone in adult patients with HF. No language restrictions were applied. Publications were independently double screened and extracted. Fixed-effect meta-analyses were conducted.
89 papers were included, reporting 19 trials (4554 participants), average ages 62-80 years. Pooled risk ratio estimates for all-cause mortality (16 trials, 4063 participants) were 0.87, 95% CI 0.77 to 0.99 and 0.80, 95% CI 0.72 to 0.89 for HF admissions (11 trials, 2822 participants). Sensitivity analyses, restricted to low risk of bias, produced similar estimates, but were no longer statistically significant.
Considering all the evidence to date, the pooled effects suggest that NP-guided treatment is beneficial in reducing HF admissions and all-cause mortality. However, there is still insufficient high-quality evidence to make definitive recommendations on the use of NP-guided treatment in clinical practice.
Systematic Review Cochrane Database Number: CD008966.

In a context of global organ shortage, the Model for End-Stage Liver Disease (MELD) score seems to be a fair prioritization tool, with a paradigm: \"sickest first.\" Since its introduction in the United States in 2002, it has been rapidly adopted by transplant centers and organ sharing agencies around the world. The MELD score showed its effectiveness with a 12% reduction in waiting list mortality in the United States. Its success is linked to its simplicity, the use of basic variables (serum creatinine, serum bilirubin, and international normalized ratio [INR]), and its ability to predict short-term mortality, particularly on the transplant waiting list. However, this score is not perfect: its variables may have disadvantages for some patients, especially women, with serum creatinine and interlaboratory variability of the INR. The MELD score does not take into account some variables associated with poor short-term prognosis in cirrhotic patients. In addition, it is currently capped at 40, which results in the exclusion of sicker patients who could greatly benefit from transplantation. Finally, the MELD score does not accurately reflect the prognosis of several conditions, requiring a MELD exception system. Some solutions have been suggested such as MELD-Na or MELD uncapping, but it has not yet been fully accepted by all transplant centers.

BACKGROUND: Surgeons frequently deliver \"bad news\" to patients, but do they know how to address situations where further surgery is considered futile? Is there a clear definition of futile care in the literature? This paper explores these questions and seeks to start a conversation about how we can train future surgeons to deliver news of futile care.
METHODS: This paper describes how one surgical team handled a difficult case of futile care and provides an interview from the perspective of a surgical resident.
CONCLUSIONS: The case report gives one example of how the news of futile care was delivered and how appropriate steps were taken to provide continued management of the patient and support to the family. A systematic review of the literature surrounding futile care reveals no consensus on how to define futile care within the medical community.
CONCLUSIONS: There is a paucity of information surrounding how surgeons should manage cases of futile care. The literature focuses on the physician-patient relationship and includes methods for delivering bad news, yet it fails to identify a consensus definition of futile care and does not provide guidelines that future surgeons can follow when they encounter these cases. With this paper we seek to open a discussion about how to define futile care and how to teach future surgeons best practices when managing these cases.