Ethical challenges often arise in intensive care units when families disagree with healthcare providers over when to stop treatments that might do more harm than good. In response to these challenges, a new paper entitled “An Official ATS/AACN/ACCP/ESICM/SCCM Policy Statement: Responding to Requests for Potentially Inappropriate Treatments in Intensive Care Units” was recently published in the American Journal of Respiratory and Critical Care Medicine. The ad hoc Committee on Futile and Potentially Inappropriate Care’s publication is now the official policy statement of the American Thoracic Society and has been approved by the American Association of Critical Care Nurses, the American College of Chest Physicians, the European Society for Intensive Care Medicine, and the Society of Critical Care Medicine.

 

Rushton_JHU1140_a_square-100x100Our own Cynda Hylton Rushton, PhD, RN, FAAN, was a member of the committee representing the American Association of Critical Care Nurses. Here, she answers our questions about potentially inappropriate treatment in the intensive care unit.

 

 

 

Why do patients or their families ask for potentially inappropriate treatment? Is it common?

In the ICU setting, patients and families are often in crisis when confronted with devastating illness or injury. Sometimes patients or their surrogates are desperate to forestall death and may request treatments that are contrary to the recommendations of their clinicians. In other cases, they may have unrealistic or misinformed expectations about the effectiveness or probability of benefit of ICU treatments. This may be particularly difficult if the patient has had a protracted and complicated ICU course and clinicians feel they have exhausted all reasonable treatments to restore the patient to health or a quality of life they desire.

 

How do you distinguish between treatments that are “potentially inappropriate” and those that are “futile”?

The term “futility” has been interpreted in imprecise ways; often conveying the determination depends solely on technical medical expertise. The phrase “potentially inappropriate” reflects more clearly that such claims include both technical medical expertise and value judgments, and that such judgments are provisional and therefore require reflection and review before being implemented.

 

How can disagreements between surrogates (e.g., family members) and healthcare providers be resolved?

Our paper recommends a formal process for resolving conflicts that balances the interests of both patient/family and clinicians. This process is an option of last resort for relatively rare cases in which informal negotiation breaks down. A few of the highlights follow:

  • Families (or other surrogates) should be given a clear roadmap of the conflict-resolution process in advance of the need for it.
  • It is recommended that a second opinion be sought to double-check the patient’s prognosis and the judgment that a treatment isn’t appropriate, as well as to involve experts not involved in the case.
  • An interdisciplinary hospital committee should review the case. If the committee agrees with the healthcare providers that the treatment isn’t appropriate, the family/surrogate should be offered the opportunity to seek a willing doctor at another institution and help facilitating a transfer there. If there is no willing provider even at another institution, the family should be informed of their right to seek another review from an independent appeals committee. If the family does not seek appeal (or the appeals committee also determines that the treatment is inappropriate), healthcare providers may withhold or withdraw the contested treatment and should provide high-quality palliative care.
  • On the other hand, if the committee or appeals body agrees with the patient or family’s request for life-prolonging treatment, clinicians should provide these treatments or transfer the patient to a willing provider.

 

Your paper concludes with a recommendation that the medical profession should engage with the public to develop policies and legislation about when life-prolonging technologies should not be used. Why is public engagement so important to this process?

The ICU setting is fraught with the ethical challenges that arise in response to the double-edged sword of technology and innovation. Many lives have been saved and others have suffered as a result of the over-use of our technologies. Because of this progress, many people have begun to believe that death is “optional” and expect unbridled access to all ICU technologies. Clearly, our ICU technologies ought to be used in a manner that produces desirable benefits and is safe, effective and fairly distributed. A new dialogue in our communities is needed to explore the proper use of ICU technologies and promote a greater understanding of what ICU care can (and cannot) achieve so that we as a nation can begin to accept those limits. Dialogue such as this opens the door for the development of policies and legislation to create the needed frameworks and safeguards to preserve the integrity of patients, families, and clinicians.

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