Perception of futile care and the reasons behind providing it for the patients at end-of-life stages from the care providers’ perspective

Abstract

Background

The concept of medical futility has exposed the medical staff to many complicated conflicts. Through identifying some of these conflicts, it will be possible to have control over such situations and make plans for managing them better. The present study was conducted to determine the perception of futile care and the reasons behind it among the patients at end-of-life stages from care providers’ perspective.

Methods

This research is an analytical descriptive study which was conducted in Dezful in Iran on 308 care providers including physicians, nurses, and medical and nursing interns, in 2022. The data collection tools included 3 areas: demographic variables, investigating the perception of futile care, and investigating the reasons behind futile care.

Results

The mean score of perception of futile care was 103.20 ± 32.89 and the mean scores of the reasons behind providing futile care, 118.03 ± 26.09. A significant correlation was observed between the mean scores of the questionnaire for perception of futile care and the reasons behind providing futile care among end-of-life patients (P-value = 0.000, r = 0.465).

Conclusions

Based on the findings, almost half of the care providers had a moderate perception of futile care and the reasons behind providing it. The reasons behind providing futile care mentioned by the participants, as well as the positive relationship between the level of perception and the level of education, point out the need for training courses to become more familiar with the concept of futile care and change care providers’ perspectives and attitudes towards end-of-life care.

Introduction

All health-related disciplines encounter ethical challenges in some way in their own profession [1]. Some of the reasons behind care providers’ facing new challenges and ethical questions in clinical settings are the development of medical technology (such as the invention of dialysis machines, life-prolonging treatments, assisted reproductive techniques), the increase in the aging population, the discovery of various chronic diseases, and paying attention to individual rights and changes in roles [2]. End-of-life care presents some of the most complex ethical issues in healthcare, including practices such as Do-Not-Resuscitate (DNR) orders, euthanasia, and medically assisted dying. It is crucial to distinguish clearly between these practices. Futile care and ineffective treatments—though often discussed in the context of end-of-life care—are categorically distinct from interventions designed to end life intentionally. Futile care refers to medical interventions that provide no reasonable likelihood of benefit to the patient, either in terms of outcomes or quality of life, such as prolonged suffering or irreversible unconsciousness [3–5]. Conversely, euthanasia and medically-assisted dying involve the deliberate ending of life and are governed by different ethical and legal standards [6].

Determining medical futility has an immediate ethical outcome: since treatment is mostly futile in such a situation and cannot help the patient, physicians have no ethical commitment to provide it, even when the treatment is requested by the patient’s family. Some scholars have also discussed that, based on the concepts of justice, physicians are ethically obliged to avoid prescribing futile treatment [7]. There is widespread agreement among ethicists that physicians are not morally obligated to initiate or continue treatments that are ineffective or unhelpful. Withholding such treatments is considered a professional duty under medical ethics [8].”

The intuitive simplicity and the practical usefulness of determining medical futility has led to its inclusion in many hospital policies, commission reports, and judicial decisions, as a criterion based on which physicians can terminate aggressive treatments [9]. Modern controversies about medical futility arise when doctors and patients (or family members) disagree about whether a particular treatment is futile. In some analyses of such controversies, the word “futility” is avoided, and treatments are instead described as inappropriate, inadvisable, not indicated, potentially inappropriate, or nonbeneficial. Regardless of which term is used, controversy arises because of different perspectives about what, exactly, constitutes a benefit to a particular patient. Physicians, patients, and family members may have different views about, for example, the value of a brief prolongation of life when death is inevitable. At times, the quality of a patient’s life (e.g., lack of awareness of surroundings and/or inability to interact with surroundings without anticipated recovery) would lead many to determine there is little value in continuing life-sustaining interventions. In short, medical technological capacities may provide the opportunity to challenge moral and ethical beliefs and frameworks [10].

The American Medical Association (AMA) has repointed out futility as a solid reason for physicians to write a DNR order even without the patient’s consent [11]. In addition, there is disagreement about the existing statistics concerning futility. The results of a study of futility determination by physicians and nurses in the intensive care unit showed that in 63% of dying patients, there is at least one case of disagreement in decision making regarding futile care [11]. Studies have shown that nearly 50% of the ICU patients who pass away receive futile care and allocate many resources to themselves [12]. The concept of medical futility, especially CRP, has also been studied in COVID-19 patients. The results of the Shah et al.’s study (2021) showed that 63 of the 1094 patients who were hospitalized due to COVID-19 experienced in-hospital cardiac arrest, all of whom (100%) passed away after resuscitation attempts, regardless of personal factors and underlying diseases [13]. This report indicates a high level of futile treatment interventions in the end-of-life stages in COVID-19 patients; however, this does not mean that other treatment interventions will not work for them, either. Therefore, perceiving futile care is an important challenge that is nowadays common due to its uncertain prognosis in life-saving care and the limited facilities and resources in clinical practice [14].

Thus, providing futile care is accompanied by many challenges, one of which is the cost of medical futility. Annually, billions of Rials of national per capita income are spent on unnecessary antibiotic therapy, endoscopy, ultrasound, etc., while there is no acceptable medical indication for them [15]. In addition, many hospital beds, operating rooms, and ICUs are used for cases where there is no significant medical indication [16]. Furthermore, the unknown length of delivering these types of care can burden the patient, the family, and the health system with high costs, and indirectly impact the medical staff [17]. This is not the only cost that is paid for futile care, there are also insurance and extra costs [18]. In addition to health organizations, families will also incur heavy costs and feel helpless. Finally, there are nurses who will be negatively affected due to organizational restrictions [19]. In addition to the costs of medical futility, ethical challenges are also raised and ethical principles such as autonomy, not committing crime, not harming others, beneficence, and justice become a subject of debate. The principle of autonomy states that the patient must be able to make decisions in all the stages of treatment and have the right to choose [20]. If this principle applies to physicians, it gives them the right to do the decision-making, meaning that the physician can prescribe or limit a specific type of care for the patient according to his/her experience or the patient’s condition [21].

Due to the different roles of physicians and nurses, their perception of the nature and the examples of futile care in the patients at end-of-life stages vary significantly. The gap among the perceptions of health care providers is due to the inconsistency between the judgment and the definition of realistic goals of treatment and intervention for the treatment team [5, 22]. People’s different perceptions of the meaning of futility and futile care have caused many challenges among the members of the treatment team and the patients’ families in deciding whether to continue or to stop this type of intervention [14]. What is considered as futile care for one treatment team, may not be regarded as futile care for another team or in another city or country, or for the patients and their families [23]. Therefore, while talking about the futility or the lack of care, the definition of futility must be discussed in each context and culture separately. In medicine and medical ethics, there are many questions in this regard leading to numerous discussions [24], because deciding about the futility of care and medical services and how to deal with patients receiving these types of services is one of the most sensitive issues that can lead to unethical decisions by the medical staff. Therefore, judging whether medical measures are futile or helpful takes more consideration, and such decisions can’t be made easily [18]. In general, the concept of medical futility has caused many complex conflicts for the medical staff. It is possible to address such conflicts and make plans to better manage them, by identifying some of these conflicts [10]. Despite the prevalence and the complexity of the issues related to futile care and treatment among physicians and nurses, this concept has not received much attention in the Iranian society and little research has been conducted in this field, especially among physicians. Therefore, considering the importance of the treatment team members’ perception of the concept of medical futility and the impact of this perception on the quality of clinical service provision and the physical and mental health of the treatment team, the present study was conducted to determine the level of perception and the reasons behind providing futile care from care providers’ perspective, in Ganjaviyan Hospital, Dezful in Iran in 2022.

Methods

Study design and study setting

This descriptive study was done in Ganjavian, Dezful, Iran in the year 2022.

Study participants

The research population consisted of the physicians, medical interns, nurses, and nursing students working at Ganjavian Hospital, Dezful. The Ganjavian Hospital is the largest teaching and referral hospital in Dezful, Iran. It serves as a major healthcare center for northern Khuzestan Province and surrounding regions. The sample size for this research is determined to be at least 300, based on the equation below, where d = 0.05, p = 0.5, and α = 0.05. The studies by Rezaei et al., Rostami et al., and Mohammadi et al. were also used to determine the sample size [19, 25].

The inclusion criteria for nurses consisted of a bachelor’s or a master’s and P.h.D degree in nursing; for nursing students, being at the 7th or the 8th semester of university; for physicians, having a professional doctorate, medical specialty, or being a medical intern, as well as the willingness to participate in the research. Additionally, all participants were required to have had a minimum of six months of direct contact with end-stage patients in their workplace.Unwillingness to participate in the study, and not filling out the questionnaires completely were the exclusion criteria. The samples were selected through stratified random sampling, according to the size of each group. Based on the number of care providers in each group (category) and according to mathematical proportionality, the required number of care providers in each sample group was calculated. After determining the number of care providers in each group, a number was assigned to each participating care provider using a table of random numbers. Then the researcher referred to each group and after assigning a random number to each sample from the list of the care providers, provided them with the research questionnaire.

Study process

The researcher visited the hospital during different working shifts, and distributed the questionnaires. Before completing the questionnaire, the research objectives and its importance were explained to the care providers and they were also assured of data confidentiality, anonymity, and their right to withdraw from the study at any time of their choice. In addition, after the proposal draft was approved by the research council, it was registered in Pajoohan system of Dezful University of Medical Sciences to obtain an ethics permit.

Study instruments

The data collection tool in this study consisted of 3 parts. The first part included demographic variables such as age, gender, education, marital status, work history, average working hours per week, the type of department, clinical experience, the level of interest in the job and the field of study, the type of work shift, working in more than one hospital, and having had the experience of having a family member at the end-of-life stage.

The second part was the tool for assessing the level of perception of futile care, which was a combination of the two questionnaires Perception of Futile Care and PIC (Perceived Inappropriate Care) [25, 26]. PIC was developed by Pierce et al. (2011) and the researcher translated some of the items as suggested by Wild et al., after the tool was requested from the original developer and the permission for Farsi translation was granted [26, 27]. The tool Perception of Futile Care consists of 30 items, and is scored on a 6-point Likert scale, ranging from 1 to 6. The lowest score for each item is “1: strongly disagree”, and the highest is “6: strongly agree”. All the items are in the same direction. The minimum score for each participant is 30, and the maximum score is 180. The scores indicate the level of futile care perception. The scores 30–80 are considered as poor; 81–130, moderate; and 131–180, good. The validity of the tool was approved by 10 members of the Faculty of Medicine and Nursing of Tehran University of Medical Sciences. The reliability of the tool was confirmed as the stability was measured through the test-retest method (0.75), and the Cronbach’s alpha was calculated to be 0.85 [25].

The third part of the tool investigates the reasons behind futile care. The questionnaire on the reasons behind futile care was designed and validated by Yekkeh Fallah (2013). This questionnaire contains 39 items on a 5-point Likert scale, and measures the related factors in 5 dimensions. The dimensions of the questionnaire include personal beliefs and values (items 1–4, scoring 4–20), professional competence (items 5–18, scoring 14–70), organizational policy (items 19–27, scoring 9 to 45), legal issues (items 28–32, scoring 5–25), and sociocultural factors (items 32–39, scoring 7–35). The questionnaire is scored on a 5-point Likert scale, from completely disagree to completely agree. The scores range between 39 and 195, where a high score indicates the presence of multiple reasons behind providing ineffective care. If the scores fall between 39 and 77, reflect a low perception of reasons behind futile care. If the scores are between 78 and 154 indicate a moderate perception of these reasons. If the scores are above 154, suggest the presence of multiple and strong perceived reasons for futile care. In the study by Yekkeh Fallah (2013), the reliability of the tool was calculated to be 0.91 for the whole questionnaire, and 0.77–0.87 for its dimensions, based on Cronbach’s alpha coefficient [22]. The validity of the questionnaire was approved based on the opinions of supervisor professor and several other professors, specialists, and experts. They were surveyed about the relevance, clarity, and perceptibility of the items, and whether the questions were appropriate as research items.

Study analysis

After entering the data into SPSS version 24, they were statistically analyzed. First, according to the responses of the research participants to the questions, the scores obtained by them for the two main variables of the research, i.e. the perception of futile care and the reasons behind providing it, were calculated and classified based on the Likert scale. In order to achieve special goals and describe the main and background variables of the research, descriptive statistics including frequency distribution tables and central indicators such as mean and dispersion indicators such as standard deviation and inferential statistics including independent t-tests, Chi-squared test, analysis of variance, and non-parametric Mann-Whitney and Kruskal-Wallis test were used. To achieve the main goal of the research, Pearson’s correlation coefficient was calculated for both variables under study in the two sample groups.

Patient and public involvement

Patients and/or the public were involved in the design and dissemination plans of this research.

Results

According to the findings of the research, the mean age of the participants in the research was 28.21 ± 7.44 with an age range of 26–70 years. 59.41% of the participants were women and 40.58% were men. The mean work experience of the care providers who were not students was 5.45 ± 3.71 years, and the mean work experience of those working at the special care department 2.54 ± 1.51 years. Other demographic and clinical variables are given in Table 1.

Table 1.

Demographic and clinical characteristics of the research participants (N = 308)

Variables		N	%		Level of perception of futile care (Mean ± SD)	Level reasons behind of futile care (Mean ± SD)
Gender	Female	183	59.41		100.44 ± 32.33	112.66 ± 27.66
	Man	125	40.85		103.24 ± 34.13	116.77 ± 25.09
	P-value				0.663*	0.163*
Marital status	Married	105	34		100.8 ± 30.94	115.21 ± 24.45
	Single	203	66		104.84 ± 36.17	114.19 ± 28.58
	P-value				0.297*	0.641*
Academic discipline	Nursing	205	66.55		105.85 ± 32.71	118.22 ± 26.41
	Medicine	103	33.44		94.49 ± 35.14	108.16 ± 26.12
	P-value				0.036*	0.004*
Educational status	General practitioner	87	28.24		90.24 ± 33.81	106.86 ± 23.29
	Specialization student (Resident)	3	0.9		153.00 ± 19.07	115.10 ± 7.75
	Assistant Specialist (Clinical Specialist)	13	4.2		116.50 ± 7.18	103.50 ± 6.36
	Bachelor of Nursing and Nursing Student	172	55.8		102.03 ± 32.71	115.63. ± 27.00
	Master of Nursing	25	8.1		123.43 ± 26.56	125.39 ± 26.30
	PhD of nursing	8	2.6		122.25 ± 19.07	124.42 ± 27.62
	P-value				0.000**	0.031**
Shift type	Fixed at morning	33	10.7		109.33 ± 30.02	122.13 ± 29.09
	Fixed at evening	5	1.6		135.50 ± 30.35	122.00 ± 24.27
	Fixed at night	6	1.9		108.25 ± 16.52	109.20 ± 27.35
	Fixed morning-evening	12	3.9		106.11 ± 24.06	116.91 ± 16.11
	Rotation	252	81.81		99.65 ± 30.35	113.27 ± 26.53
	P-value				0.117**	0.811**
Do you get overtime?	Yes	128	41.55		100.48 ± 31.94	113.73 ± 27.07
	No	180	58.44		103.08 ± 32.28	115.53 ± 25.97
	P-value				0.451*	0.783*
Have you completed a course of palliative care?	Yes	33	10.7		113.92 ± 37.59	119.30 ± 31.62
	No	275	89.30		100.28 ± 31.88	113.96 ± 25.44
	P-value				0.078*	0.558*

Comment: For binary variables, due to the non-normal distribution, the Mann–Whitney test was used (indicated by * in the table), and for multi-category variables, the Kruskal–Wallis test was applied (indicated by ** in the table)

The mean perception of futile care was 103.20 ± 32.89 with a range of 30–180. Moreover, the mean of the reasons behind futile care was 118.03 ± 26.09 with a range of 39–195 (Table 2).

Table 2.

Mean and standard deviation of perception of futile care and the reasons behind it from the perspective of care providers

Variables		Mean	SD	Min	Max
Perception of futile care		103.20	33.44	30	180
Causes of futile care	Personal beliefs and values	4.90	14.30	4	20
	Individual competence	42.24	12.00	14	70
	Organizational policy	24.61	7.33	9	45
	Legal issues	12.41	4.31	5	25
	Cultural and social issues	24.79	6.90	7	35
	Total	118.39	26.18	39	195

59.67% (n = 153) of the care providers, had moderate perception of futile care in the patients at end-of-life stages, and 84.41% (n = 260), obtained moderate scores on the questionnaire about the reasons behind futile care in the patients at end-of-life stages. (Table 3).

Table 3.

Distribution of the frequency of perception of futile care and the reasons behind it in end-of-life patients from the point of view of care providers (N = 308)

Variables		N	%
Perception of futile care	weak (30–80)	80	25.97
	Moderate (81–130)	153	49.67
	Good (131–180)	75	24.35
Causes of futile care	Little (39–77)	25	8.11
	Moderate (78–154)	260	84.41
	High (155–195)	23	7.46

Regarding the questionnaire of perception of futile care, the participants had the highest rate of agreement on the items ineffective communication on the part of the treatment team, the patient’s uncertain prognosis and the patient and the family’s being misinformed about the diagnosis of the patient’s prognosis. The lowest rate of agreement belonged to the items “I think I am providing the patient with insufficient care”, “In my opinion, caring for a patient with little chance of recovery is futile”, and “I think caring for a patient at the end-of-life stage because of feeling responsible is futile.” (Table 4).

Table 4.

The lowest and the highest mean scores of the items of perception and causes of futile care in the patients at end-of-life stages

Perception of futile care		Mean	SD	Likert frequency agree and strongly agree (N)	%
Highest mean scores	Ineffective communication on the part of the treatment team	4.07	1.06	140	45.4
	The patient’s uncertain prognosis	3.79	1.61	118	38.3
	The patient and the family’s being misinformed about the diagnosis of the patient’s prognosis	3.71	1.56	110	35.7
Lowest mean scores	I think I am providing the patient with insufficient care	2.79	1.61	57	18.5
	In my opinion, caring for a patient with little chance of recovery is futile	2.80	1.59	58	18.6
	I think caring for a patient at the end-of-life stage because of feeling responsible is futile	2.94	1.82	58	18.6
Causes of futile care		Mean	SD	Likert frequency agree and strongly agree (N)	%
Personal beliefs and values	Being committed to performing professional duties	3.54	1.34	203	65.9
	The nurse’s positive experiences regarding the recovery of dying patients	3.43	1.34	190	61.7
Individual competence	Non-use of experienced nurses and performing inappropriate care in the ICU	3.34	1.52	177	57.4
	Keeping the patient alive with medicine due to the unwillingness to accept a new patient during the shift	2.61	1.36	103	33.5
Organizational policies	Lack of a committee to decide on transfer of dying patients from ICU to home or general ward	3.36	1.42	177	57.4
	Ignoring the opinions of supervisors and nursing managers in the process of transferring patients from ICU	3.04	1.39	147	47.7
Legal issues	Registration of some orders by physicains just because of the obligation to answer in hospital committees and meetings	3.30	1.41	179	58.1
	Disregarding the patient or the family’s wish to avoid performing CPR	2.81	1.43	124	40.3
cultural and social issues	The financial poverty of the patient’s family to provide facilities for continuing care at home	3.83	1.32	222	72.1
	Unreasonable expectations of the family regarding the complete recovery of the patient	3.24	1.41	168	54.6

In this table, the frequency and percentage of respondents who selected “Agree” or “Strongly Agree” have been reported. Consequently, items with the highest and lowest response rates for both variables are presented according to their respective dimensions. Additionally, the mean and standard deviation of the Likert scale scores are provided in two separate columns

Regarding the questionnaire on the reasons behind futile care in the patients at end-of-life stages, from the perspective of the care providers, the most common reasons include the financial poverty of the patient’s family to provide facilities for continuing care at home from the aspect of cultural and social issues, being committed to performing professional duties, and the nurse’s positive experiences regarding the recovery of dying patients from the aspect of personal beliefs and values. The rarest causes of providing futile care are keeping the patient alive with medicine due to the unwillingness to accept a new patient during the shift, from the aspect of individual competence; disregarding the patient or the family’s wish to avoid performing CPR, from the aspect of legal issues; and ignoring the opinions of supervisors and nursing managers in the process of transferring patients from ICU, from the aspect of organizational policies. (Table 4)

In the correlation analysis, the results of this study showed that there was no statistically significant relationship between age (P-value = 0.102, r = 0.113), work experience (P-value = 0.394, r = 0.067), special work experience (P-value = 0.527, r = 0.060), and average overtime hours (P-value = 0.336, r=-0.116) with the mean scores of the questionnaire of Perception of Futile Care. Also, the results of this study showed that there was no statistically significant relationship between age (P-value = 0.232, r=-0.075), work experience (P-value = 0.766, r=-0.022), special work experience (P-value = 0.383 r = 0.076), and average overtime hours (P-value = 0.855, r = 0.020) with the mean scores of the questionnaire on the reasons behind providing futile care.

Examining the relationship between the mean scores of the questionnaire of Perception of Futile Care and the questionnaire on the reasons behind providing futile care for the patients at end-of-Life stages, a statistically significant correlation was observed (P-value = 0.000, r = 0.465). Also, there were statistically significant relationships between the level of education and perception of futile care (P-value = 0.000) and the reasons behind the provision of futile care (P-value = 0.031). Moreover, there were statistically significant relationships between the academic discipline and perception of futile care (P-value = 0.036) and the reasons behind the provision of futile care (P-value = 0.004).

Discussion

According to the findings of the present study, almost half of the care providers had a moderate perception of futile care. This finding is consistent with the findings of the study by BeigJani et al. [28], while it is inconsistent with the study results of Moaddabi et al. [29]. It can be said that futile care is a concept that is influenced by cultural, ethical, and religious issues; the manner of communication between the medical staff, the patient and the family; the uncertain prognosis of diseases; instructions; rules; and working conditions [25].

In addition, regarding the perception of futile care, the participants’ highest rate of agreement belonged to the items ineffective communication on the part of the treatment team, the patient’s uncertain prognosis, and the patient and the family’s being misinformed regarding the diagnosis of the patient’s prognosis. Various studies have pointed to ineffective communication between the treatment team and the family, lack of participation of nurses in decision-making, and unrealistic family expectations as factors contributing to futile care [30–32]. To improve communication between healthcare teams and patients’ families, it is recommended to implement strategies such as providing communication skills training for physicians and nurses (e.g., using STICC and BATHE models), utilizing secure, modern communication platforms integrated with electronic health records, and holding regular family meetings to explain the patient’s condition and prognosis [33]. Furthermore, managing unrealistic family expectations—especially during end-of-life stages—requires a stronger focus on educating families about the concept of futile care and disease prognosis. This can be supported by using empathetic, narrative-based approaches to convey medical information and offering psychological counseling to help families process and accept medical realities [34].

Furthermore, regarding the perception of futile care, the lowest rate of agreement belonged to the items “I think I am providing the patient with insufficient care”, “In my opinion, caring for a patient with a low chance of recovery is futile”, and “I think caring for a patient in the final stages of life because of feeling responsible is futile”. The review of similar studies does not show the same results; Kasim et al. stated that the participants in the study put more emphasis on not receiving futile care when there is no chance of recovery [35]. The divergence in perceptions between nurses and physicians may stem from their distinct professional roles and their varying levels of interaction with patients and families. Nurses often exhibit a more cautious stance toward futile care [4, 36].

Based on the findings of the present study, The most common causes of futile care, from the perspective of healthcare providers, were related to cultural and social factors, including the family’s financial poverty, inadequate education and lack of preparation for home care, lack of cultural awareness, lack of insurance coverage, absence of institutions providing specialized nursing services as a barrier to transferring the patient home, lack of support from social work or charitable organizations like “Behzisti Organization” (State Welfare Organization of Iran) for renting ventilators and care equipment to transfer the patient home, and unrealistic expectations of the family regarding the patient’s complete recovery. Among these, the index of “family’s financial poverty for providing the necessary facilities for continuing care at home” was of utmost importance from the perspective of the participants. In this regard, in line with our results, more than half of the participants in the study of Akbari et al. stated that the family’s inability to care for the patient in the terminal stages was due to a lack of knowledge, insufficient skills, absence of equipment, and financial issues [30]. The lack of knowledge about the ICU and resuscitation was clearly shown in the survey of Heyland et al., where only 11% of critically ill patients and their families could name more than 2 components of cardiopulmonary resuscitation (CPR) and less than 3% had an accurate understanding of the outcomes of cardiopulmonary resuscitation [37]. In the study of Yekeh Fallah et al., factors related to the socio-cultural domain, including “lack of support from social work or charitable organizations like Behzisti and also “lack of support from insurance organizations for home care services”, were ranked second among the most important reasons for performing futile care [22]. Overall, it can be said that these results have a high degree of overlap with our study’s findings. Although the ranking of the causes is somewhat different. It seems that improving the performance of healthcare systems in the field of futile care requires the adjustment of social infrastructure, creating and supporting various cultural platforms. Raising public awareness about about the realities of treatment and the consequences of invasive treatments at the end of life and changing social attitudes about death especially for families of patients hospitalized in intensive care units, becomes necessary. Charitable organizations and Behzisti can play a role in this area alongside the healthcare team [38].

The second dimension of the causes of futile care that was important from the perspective of the participants was personal beliefs and values. This dimension referred to religious beliefs, commitment to professional duties, feelings of guilt, and positive experiences regarding patient recovery. However, in this study, the index of “commitment to professional duties” and “positive experiences of caregivers regarding the recovery of dying patients” were ranked second and third, respectively, among the common reasons for performing futile care. Spiritual and religious beliefs can influence a person’s attitude toward futile care and job satisfaction [39]. physicians’ and nurses’ moral values and personal experiences with death also play an important role in the willingness to continue ineffective treatments [22]. Views on the role of religion in futile care vary, but traumatic experiences such as tragic deaths or the loss of family members can reduce the willingness to continue treatment [40]. On the other hand, professionalism, which is a fundamental concept of care, also refers to adhering to ethical principles, values, and professional standards in all circumstances [22]. Of course, in another study, “positive experiences of caregivers regarding the recovery of dying patients” were among the less common reasons for performing futile care [22]. However, it seems that personal and professional values and beliefs have a significant impact on the provision of futile care [41]. Differences in nurses’ perceptions in different studies could be due to cultural differences, the use of different study instruments, and variations in study design and subject matter.

The third dimension, in terms of importance, from the perspective of healthcare providers, is individual competencies. This includes dimensions such as the lack of experienced nurses and physicians, and the provision of inadequate care in the ICU as the most important index of this dimension. Futile care performed under the influence of psychological pressures present in the ICU, distrust among healthcare professionals, insufficient skills of physicians and nurses in patient resuscitation and the occurrence of subsequent futile actions, care errors by the treatment team and the occurrence of subsequent futile interventions, fear of reporting care errors by nurses and physicians, the requirement to record all care in the medical record as the only criterion for performing work, and keeping the patient alive with medication due to an unwillingness to accept a new patient during a shift, which were introduced as the least important index of this dimension. Hansen et al. (2009) believe that nurses typically lack sufficient knowledge and awareness of protocols and methods for guiding patients and their families in end-of-life care, palliative care and symptom-based treatment and the cessation of therapeutic interventions [42]. Also, the results of a study from the perspective of physicians often provide futile care due to their treatment-focused mindset, limited experience in end-of-life decisions, emotional attachment to patients, and inadequate training in palliative care [40]. Also, in the study by Yekeh Fallah (2018), in terms of professional competence, failure to adhere to ethical principles by physicians in dealing with the patient’s family, failure to tell the truth, and obtaining forced consent for various procedures, including the most important reasons for increasing futile care in the ICU, were providing false hope to the family and physicians’ failure to accept the facts, leading to a decrease in the number of patients transferred home and an increase in their length of stay in the ICU [22]. Physicians, nurses, medical, and nursing students should be trained in recognizing death, improving communication with patients and families about death and dying, to ensure their professional competence and effective performance [43].

Another dimension of the reasons for futile care is legal and ethical issues, which include dimensions such as the documentation of some orders by physicians solely due to the requirement to be accountable in committees and hospital meetings as the most important index of this dimension, documentation of futile orders due to fear of legal issues, failure to include a “Code No” order in the medical record and the requirement to perform futile CPR, the lack of national laws and standard procedures regarding the hospitalization and treatment of dying patients, and disregard for the patient’s or family’s wishes regarding the non-performance of CPR, which is considered as the least important index of this dimension. One of the reasons for futile care is the documentation of futile orders due to fear of legal and medical issues. A study by Andy et al. found that 70.7% of participants viewed futile treatment as an ethical dilemma, while over 82.9% reported administering such interventions at the instruction of a physician. Additionally, nurses who had not received formal ethics education were found to hold more permissive attitudes toward providing futile care [44]. Also, the most common reason for futile care in the study by Yekeh Fallah et al. in terms of legal issues was the lack of national laws or standard procedures regarding the hospitalization and treatment of dying patients [22]. Mismanagement by physicians over beds in the intensive care unit and issuing futile orders to avoid responsibility, legal consequences, fear of legal issues/ lawsuits and managers, lack of clear guidelines regarding futile care, the ambiguity of hospital policies lead to an increase in futile care in intensive care units [41, 45–47]. Santonocito et al. believe disagreement over situations requiring resuscitation is one of the most common sources of conflict in clinics [48]. It seems that there is no clear guideline to determine the limits and specifics of futile care in the context of accepting and implementing a do-not-resuscitate order (DNR), especially in Islamic countries like Iran, leading to numerous legal, ethical, and religious challenges. A harmonized framework for futile care and DNR orders—grounded in ethical rigor, religious compatibility, and legal clarity—is imperative to resolve conflicts and improve patient-centered outcomes in Islamic healthcare systems.

Finally, organizational factors are presented as another reason for futile care. These include the lack of a committee to decide on transferring dying patients from the ICU to home or another ward, which is considered the most important indicator of this dimension, unnecessary hospital admissions to avoid family complaints, performing futile invasive procedures by physicians solely to satisfy families and enhance their professional reputation, inadequate care for patients in general wards and physicians’ fear of transferring patients to those wards, centralized decision-making power within the medical team and the issuance of unnecessary orders by them, lack of a post-ICU unit in some hospitals, ignoring the opinions of head nurses and nursing managers in the process of transferring patients from the ICU, which is considered the least important indicator of this dimension. The findings of a study indicate that one of the organizational reasons for futile care is the lack of adequate palliative care centers, sanatoriums, and home care facilities in Iran. However, efforts have been made in recent years to establish such centers [49]. Although efforts have been made in recent years to establish such centers, their number is not proportional to the number of patients needing palliative and end-of-life care [50]. According to findings from other studies, one reason for physicians’ reluctance to withdraw futile care is the desire to satisfy the family of the patient [29]. Most participants in Robert Sibbald’s study reported that pressure from families or surrogate decision-makers was a driving force behind providing futile medical care [51]. In this case, differences in study populations, study settings, and the tools used could also explain the minor differences in results.

Furthermore, disregard for patient preferences is another factor. Research conducted in Germany revealed that elderly patients often had to fight for a peaceful death, as healthcare providers continued to administer treatments that patients neither wanted nor benefited from. Families reported emotional hardship and were frequently compelled to advocate aggressively on behalf of their loved ones’ end-of-life preferences [52]. Consequently, many terminally ill patients received care that conflicted with their values such as unnecessary ICU admissions leading to dissatisfaction and strain on medical resources [53]. In the study by Yekeh Fallah (2018), from an organizational policy perspective, the lack of a committee for making decisions about transferring dying patients to home or another ward was cited as the most common reason for futile care [22]. Therefore, decision-making regarding the futility of treatments is very difficult and challenging and requires teamwork and the support of an ethics committee [47]. In Iran, hospital ethics committees are largely inactive and ineffective, in part due to overlaps or conflicts with religious regulatory authorities. Medical staff often lack understanding of these committees’ functions, resulting in limited engagement in ethical decision-making processes [54]. Studies suggest that organizational reform could enhance the performance of ethics committees and improve their role in navigating complex treatment dilemmas [55]. Given the high risks associated with decisions about futile care, the current institutional limitations are deeply concerning, especially when they lead to the premature withdrawal of potentially beneficial treatment [15, 18]. Therefore, to reduce futile care and its impact on the treatment team, actions should be taken by officials to remove existing barriers and improve necessary facilities.

Findings from this study indicate a correlation between educational level and perceptions of futile care. For instance, medical residents and nurses with master’s or doctoral degrees reported the highest levels of awareness regarding futile care. This may be attributed to several factors, including more specialized training at higher academic levels, enhanced capacity for ethical analysis, and broader clinical experience—all of which contribute to a deeper understanding of end-of-life issues. Moreover, individuals with advanced education often demonstrate a more critical and holistic view of medical practices, showing greater sensitivity to the cultural, ethical, and systemic dimensions of futile care. In the study of Moaddabi et al. [29], Rezaei et al. [25], and Nazari et al. [41], the caregivers with higher levels of education had a better perception of futile care and the reasons behind providing it. On the other hand, in Andi et al.‘s [44] and Rostami et al.‘s study [19], no correlation was found between the level of education and perception of futile care. A study by Mohacsi et al. (2024) in Germany also highlighted the role of effective communication between healthcare teams and families, along with ethics education at higher academic levels, in reducing the incidence of futile care [52]. The observed difference may be due to different compositions of the samples in terms of educational level. Nevertheless, it can be said that probably obtaining higher academic degrees and participating in related training courses will lead care providers to a higher perception of the aspects related to caring for critically ill patients, especially futile care.

This study further revealed that nurses reported significantly higher perceptions of futile care and its causes compared to physicians. In Iran, nurses typically spend more time at the patient’s bedside and maintain closer contact with families. This direct interaction likely increases their sensitivity to the consequences of futile care, such as patient suffering, family distress, and resource waste. Additionally, while nurses in Iranian hospitals play a key role in implementing treatment plans, they are often excluded from final decision-making processes. This disconnect may contribute to ethical conflict and elevate their perception of futility. These findings align with those of Rezaei et al., who noted that nurses have a higher perception of futile care compared to physicians and experience greater stress as a result [25]. Similarly, Piers et al. found that ICU nurses are more likely than physicians to suffer from burnout associated with futile care, along with higher levels of perceived futility [26]. Ruth D. et al. (2014) also demonstrated that nurses, particularly in comparison to younger physicians, provide more futile care and report higher levels of moral distress [56]. Taken together, these results suggest that the perception of futile care is a multifaceted issue shaped by culture, professional structures, and clinical experience. The significant difference between nurses’ and physicians’ perceptions of futility in Iran underscores the need for reform in ethical education, decision-making frameworks, and the empowerment of nurses within care teams. Comparisons with international studies further emphasize this necessity.

Study limitations

There are several problems with descriptive studies and the data collected in the workplace, including the low interest of respondents, which may be due to various reasons such as people’s reluctance to discuss end-of-life issues and the barriers to it, as they may not have a complete perception of this issue. Another limitation of the present study was the use of self-reporting as a data collection method, and the actual behaviors of treatment and care providers have not been directly observed. Behavioral measures such as direct observation, peer assessment, and related methods can be added in the future studies for evaluation purposes.

Conclusion

In general, the results obtained from this study showed that almost half of the care providers had a moderate perception of futile care, and more than 80% of them had a moderate perception of the reasons behind providing this type of care. In addition, the most common reasons behind providing futile care from the participants’ perspective were related to two dimensions: cultural and social, and professional beliefs and values. On the other hand, in their opinion, the rarest reasons behind providing futile care respectively belonged to the dimensions of individual competence, legal issues, and organizational policy. Looking at the research conducted in the past reveals the existence of differences in the opinions and perspectives of care providers regarding the reasons behind the provision of futile care, since in the previous studies, the reasons related to organizational and legal dimensions were on the top of the list. Therefore, conducting more research in this field seems to be necessary. In addition, the reasons mentioned by the participants and the relationship between the increase in the level of perception and the increase in the level of education reflects the need to hold training courses with the aim of familiarizing care providers with the concept of futile care and changing their perspective and attitude towards the provision of end-of-life care, as well as the need to provide palliative and end-of-life care in order to increase patients’ comfort and enhance their quality of life. Therefore, policy and institutional reforms are necessary to review and update legal and organizational frameworks. These should aim to better integrate ethical consultations and decision-support systems into everyday clinical practice. It is also essential to develop clear, culturally sensitive protocols for handling suspected cases of futile care. Furthermore, encouraging transparent, timely discussions among healthcare teams, patients, and families about prognosis, treatment objectives, and end-of-life preferences is crucial. The development of tailored guidelines and communication tools can greatly facilitate such conversations.

Future research priorities

• Examine the evolving cultural, religious, and professional factors that shape perceptions of futile care in Iran and similar healthcare contexts.

• Assess how educational background and role-specific responsibilities influence attitudes and behaviors toward futile interventions.

• Conduct comparative institutional studies to identify best practices for minimizing futile care and improving patient-centered outcomes.

Author contributions

Contributors HA, the lead investigator, author and guarantor of the study, has designed the data analysis, advised on data creation and management and contributed to writing the article. RR, senior researcher and coauthor, has contributed by literature search and writing the article. SB, research fellow and coauthor, has contributed to the data creation and management, the data analysis and to writing the article. ZK, lecturer and coauthor, has contributed to the data creation and management, the data analyses and to writing the article. SD, lecturer and coauthor, has contributed to the data creation and management, the data analyses and to writing the article.

Funding

No funding was received for this article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study is the result of a professional doctorate thesis of the Corresponding author which was financially supported by the Faculty of Medicine of Dezful University of Medical Sciences (1401-MED-401073) and approved by the Research Ethics Committee of Dezful University of Medical Sciences (IR.DUMS.REC.1401.085). After receiving the introduction letter from the university, the research team visited Ganjavian Hospital and identified suitable participants. All ethical standards governing clinical research, such as obtaining informed and voluntary consents, not harming participants, data confidentiality, the awareness of having the right to withdraw from the study at any time, privacy, and justice have been observed.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.

Patient consent for publication

Consent obtained directly from patient(s).