included age, arterial lactate and cardiorespiratory co-morbidity. Frailty was associated with a 38% increased risk of early mortality and surgery for intestinal ischaemia was associated with a two times greater chance of futile surgery. These findings suggest that quantitative futility after emergency laparotomy is associated with quantifiable risk factors available to decision-makers preoperatively and should be incorporated into shared decision-making discussions with extremely high-risk patients. Over the last four decades, the clinical community has improved the quality of prognostic efforts. As a result, simple but imprecise rules of thumb like "percent mortality = age + percent burn" to judge the futility of burn cases involving elderly patients, have now given way to sophisticated algorithms based on multiple linear regression and other advanced statistical techniques. These are complex clinical algorithms that have been scientifically validated and have considerable clinical predictive value, particularly in the case of patients with severe burns. Such algorithms may provide high-quality prognostic information to aid patients and families in making difficult decisions, and have the potential to be used to guide resource allocation. These prognostic algorithms estimate the probability of the patient surviving. In a study of patients so severely burned that survival was clinically unprecedented, during the initial lucid period (before sepsis and other complications set in) patients were told that survival was extremely unlikely (i.e., that death was essentially inevitable) and were asked to choose between palliative care and aggressive clinical measures. Most chose aggressive clinical measures, which may suggest that the will to live in patients can be very strong even situations deemed hopeless by the clinician. Another practical clinical example that often occurs in large hospitals is the decision about whether or not to continue resuscitation when the resuscitation efforts following an in-hospital cardiac arrest have been prolonged. A 1999 study in the Journal of the American Medical Association has validated an algorithm developed for these purposes. As medical care improves and affects more and more chronic conditions, questions of futility have continued to arise. A relatively recent response to this difficulty in the United States is the introduction of the hospice concept, in which palliative care is initiated for someone thought to be within about six months of death. Numerous social and practical barriers exist that complicate the issue of initiating hospice status for someone unlikely to recover. Options for futile care and futile care as a commodity Another issue in futile