Clear communication is essential to any patient-clinician interaction, perhaps especially when discussing end-of-life care. Conversations in these circumstances often contain content that may be troubling or distressing for patients, as well as their family or substitute decision-maker(s). If this kind of information is incumbent on medical knowledge, then practitioners are not fulfilling their duty to patients to ensure they have the tools they need to make decisions that align with their best interests. Patients may not be able to grasp the meanings and implications of medical terminology, which may prevent them from fully understanding relevant social and clinical information about their condition. Misunderstandings are often avoidable, if the information is conveyed in a way that is both specific and accessible.

“Medical futility” is one such term that can cause these misunderstandings. Terms like this are often rife with scientific and sociocultural ambiguity, which can cause confusion in a clinical setting. I do not intend to say that healthcare practitioners have not come to a consensus on the meanings of these kinds of terms (though some may still be up for debate). Rather that, for most patients, the definitions are not obvious, nor do they necessarily align with their goals or expectations from clinical treatment. There are numerous considerations surrounding ethical clinician-patient communication. One such consideration is to promote informed decision-making and prevent harm, which involves being mindful of – and avoiding – the use of potentially ambiguous terms that may be interpreted differently by providers and patients. As mentioned, futility is an example of one term that may be misunderstood and cause entirely avoidable patient distress.

In considering ethical clinical communication, words must be clear and easily interpreted in order for healthcare providers to fulfil their duty of care to the patients that they serve.

Futility is often defined in terms of actions; a futile action is one that cannot accomplish a useful result. “Useful” is, however, a relative judgement. In a clinical setting, the term “futile” often extends to treatment that will not improve a patient’s condition. “Futility” can apply to treatment in any stage of health, but the ambiguity becomes most obvious in end-of-life care circumstances, particularly with life-prolonging treatments in cases involving brain death. It may be important to note that medical futility applies to the clinical condition of the patient without necessarily taking into consideration other facets of the patient’s life. Thus, this strictly clinical definition of futility can easily be misunderstood as the end of the line for patients when it comes to their end-of-life care. If patients believe that there is nothing to be done, since the treatment is not improving their condition, then they may feel as though they are being rushed to die without having the time to make plans or say goodbye to their loved ones. Alternatively, the patient or family may not believe that the treatment is futile based on their perception of what is “useful”, broadly speaking. Of course, this is not necessarily the case. But for a patient to hear that their treatment is futile, especially when it is their last option, it can be incredibly distressing for many reasons. For example, consider the brief case below:

Harriette is an 85-year-old woman who has multiple co-morbidities and recently had a stroke. Unfortunately, her wife, Bessie, was not home when the stroke occurred. By the time Harriette got to the hospital, she had already suffered significant brain damage and was not expected to make a full, if any, recovery. Although Bessie (as Harriette’s substitute decision-maker) wanted “everything done” for Harriette, the physician confirmed after a few days that Harriette’s condition was not expected to improve and that further treatment would be futile. Based on Bessie’s cultural perspectives, however, further treatment was not at all futile, since Harriette’s heart was still beating. Bessie did not understand nor agree with the physician calling the treatment “futile” and hearing this term being used without further explanation caused her significant angst. Bessie questioned the clinical team’s motives since her wife was still alive. Why would the medical team say that treating her was futile? This idea simply didn’t make sense to Bessie, and her trust in the medical team waned as a consequence.

The case of Harriette and Bessie provides just one brief example of how, given clinical and sociocultural contexts, shorthand medical terminology can be misconstrued and cause avoidable distress. In this case, the ambiguity in – and the expected reception of – the term influenced Bessie to be skeptical and untrusting of the medical team. Bessie’s perspective of “futility” was heavily influenced by her cultural upbringing and, consequently, the physician’s use of the term simply did resonate with her. As such, Bessie incurred a great deal of stress in this already emotional situation. However, if the clinical team had been clearer and more concise about Harriette’s condition, and about what they meant when they said that the treatment was “futile” then Bessie may have continued to trust the team. Additionally, having a conversation in which potentially ambiguous terminology is broken down allows conceptual clarity to be achieved and trust to be maintained. If a more fulsome conversation occurred, with Bessie and the medical team learning about their differing perspectives by explaining their rationale to a greater extent, clarity about the concepts and options could have been achieved. Perhaps then a description of “futility” may have allowed Bessie to align her options with her family’s values and goals, changing the outcome entirely.

Language matters when communicating in a clinical setting; only with clear and concise conversations can clinical discussions occur in an ethically defensible manner. It is the duty of healthcare practitioners to provide care and it is of the utmost importance to do no harm while providing it. However, if ambiguous terms are used without clear context and supporting information, it is not clear whether no harm has been done. I do not intend to say that being clear in communication can solve all challenges that may occur amongst clinical teams and patients/families. But by being unambiguous and striving for conceptual clarity, perhaps we can lessen the burden on all parties, prevent misunderstandings, gain insight into each other’s values and perspectives, and potentially prevent (non-physical) harm from being done. In considering ethical clinical communication, words must be clear and easily interpreted in order for healthcare providers to fulfil their duty of care to the patients that they serve. Otherwise, communication is bound to cause distress and harm, undermining the goals of clinical practice.

George Magafas graduated from the University of Toronto with a BSc in Biochemistry and also majored in Bioethics. George has a continued interest in clinical and biomedical ethics with a specific focus on the ethics of medical education, patient-clinician interaction, gender-affirming care, and equitable access to care.

The author would like to acknowledge Andria Bianchi for her editorial support.