0
Point and Counterpoint |

POINT: Do Physicians Have a Responsibility to Provide Recommendations Regarding Goals of Care to Surrogates of Dying Patients in the ICU? YesRecommend Care to Surrogates of the Dying? Yes FREE TO VIEW

Paul J. Hutchison, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care, Stritch School of Medicine, Loyola University Chicago.

CORRESPONDENCE TO: Paul J. Hutchison, MD, Loyola University Medical Center, 2160 S First Ave, Bldg 54 Room 131A, Maywood, IL 60153; e-mail: paul.hutchison@lumc.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(6):1453-1455. doi:10.1378/chest.15-0273
Text Size: A A A
Published online

Approximately 20% of Americans spend time in an ICU around the time of their death, and most deaths follow a decision to limit life-sustaining therapies.1,2 Many factors contribute to treatment limitation decisions, including patient prognosis, expected benefits and burdens of available treatments, and patient preferences. Because many patients in the ICU lack decision-making capacity, a surrogate decision-maker often speaks on behalf of the patient and collaborates with the treating physician to determine treatment goals.

Research evaluating surrogate preferences has revealed that surrogates prefer varied degrees of involvement in end-of-life decisions. Canadian and French studies suggest that many surrogates prefer physician participation when making end-of-life decisions.3,4 Recognizing surrogates’ need for physician guidance during the decision-making process, the American College of Critical Care Medicine in 2008 urged physicians to “take seriously their responsibility” to provide recommendations during goals of care discussions.5 In contrast, an American study of surrogate preferences for recommendations in the ICU found > 40% of surrogates preferred family meetings in which an intensivist did not provide a recommendation.6 As a result of these data, some authors suggest asking surrogates how they prefer to make decisions, acknowledging the variability in surrogate preferences for decisional support from physicians.5-7

In this Point editorial, I argue that a physician has a responsibility to present surrogates with the plan of care he or she believes to be the best application of a patient’s authentic values and interests to a specific clinical situation. Contrasting positions hold that recommendations are optional or even inappropriate. Two clinical scenarios will help illustrate my position: (1) a surrogate’s request for a recommendation and (2) a surrogate’s request for aggressive therapies for a dying patient. The basis for this physician responsibility is tied to surrogates’ trust in physicians and the need for a shared decision-making process that thoughtfully balances clinical judgment with patient interests.

Many surrogates have no experience making end-of-life decisions for another person and struggle in this decision-making role.8 Surrogates commonly exhibit symptoms of depression and anxiety related to the illness of their loved one, and, under these circumstances, making a decision without a recommendation may be overwhelming.9 If a surrogate has not explicitly discussed end-of-life preferences with the loved one, the surrogate must make inferences about the patient’s values to make the “right” decision. When the patient’s prognosis is uncertain and the treatments are potentially burdensome, surrogates often look to the physician for assistance with treatment limitation decisions.

Understanding the patient’s authentic values and interests is an essential component of the substituted interests model for surrogate decision-making.10 After soliciting the patient’s values from the surrogate and integrating them into the specific clinical context, a physician is equipped to offer a recommendation, providing that the recommendation (1) is a reflection of the patient’s known values and not of the physician’s personal, political, or spiritual beliefs; (2) acknowledges the uncertainty of the prognosis; and (3) is subject to further consideration and discussion with the surrogate. The recommended plan is never the final word without the surrogate’s assent.

Demonstrating that physicians can provide ethically appropriate recommendations is necessary but not sufficient to assign physicians a responsibility to provide them. This obligation derives from a physician’s responsibility to the patient and, by extension, to the surrogate. A surrogate’s request for a recommendation is an expression of his trust in the physician who has a reciprocal duty to provide guidance and support. Failure to accept this role amounts to abandonment and requires the surrogate to bear the entire burden of the decision. When surrogates asks, “What would you do if this were your loved one?” they are expressing their trust not only in the physician’s medical acumen, but also in the physician as a human being with common needs, emotions, and desires. Providing a recommendation satisfies a physician’s commitment to the personal and professional trust bestowed on him by patients and their families.

For patients with a critical illness and poor prognosis, physicians face significant challenges and competing obligations to manage requests for treatments they believe will offer marginal benefit. One of these obligations concerns the responsible use of medical resources. Appeals to the principle of justice have described public health consequences and monetary costs of providing medical care that has a small likelihood of accomplishing long-term goals for dying patients. Antibiotic administration as a symbolic gesture at the end of life may pose risks to the greater population via acquired bacterial resistance,11 and the annual cost of “futile” care at one academic medical center was estimated to be > $10 million.12 While physicians should not be individual arbiters of resource allocation at the bedside, medical resources are not infinite, and most would agree that they need to be used responsibly. As such, the principle of “strict futility” permits physicians to withhold treatments that have no pathophysiologic rationale, such as continued CPR after an hour of resuscitation for persistent asystole.13 Similarly, some have suggested that strong recommendations and informed assent be used when discussing ICU treatments that are not medically indicated but might be expected by the surrogate.14 Using assent as opposed to formal consent relieves the surrogate from the full psychologic burden of consent for procedures that are not indicated.

In both unilateral withholding of treatments and withholding after informed assent, the treatment in question is believed to be futile in the strict sense of the word. But for many patients who are dying in the ICU, treatments requested by surrogates may provide a marginal physiologic benefit without reversing the course of disease. Treatments with small potential benefit are not strictly futile, but could be judged inadequate to achieve appreciable clinical benefit. A physician is charged with the daunting task of integrating this analysis, the uncertainty of his prognosis, and the patient’s authentic values to reach a mutually agreeable decision with the surrogate.

A comprehensive shared decision-making process that includes a recommendation satisfies and effectively balances these requirements. Limitations of prognostication underscore the importance of providing a recommendation instead of unilaterally withholding marginally beneficial treatments.15 But just as we do not permit physicians to make end-of-life decisions without exploring a surrogate’s preference for treatments, it is equally peculiar to allow surrogates, possessing no medical background or training, to make decisions without a physician’s recommendation. For treatment decisions at the end of life, medical facts and a patient’s values and preferences are so intimately entwined that the responsibility to integrate the two falls on both the surrogate and the physician. The physician’s recommendation is the means by which the physician communicates his clinical judgment that has been shaped by years of education, apprenticeship, and independent practice. Without a recommendation, the decision is not truly “shared.”

Certainly a recommendation need not be formally verbalized when a surrogate proposes a plan of care with which the physician agrees, since agreement implicitly conveys the physician’s recommendation. But when a surrogate requests a treatment with mere physiologic benefit that, in the judgment of the physician, will not achieve its intended clinical goals or is inconsistent with the patient’s authentic values, then it is the physician’s responsibility to advocate for the patient and recommend an alternate plan of care.16 Recommendations for time-limited trials of marginally beneficial treatments often strike a balance between responsible use of resources and respect for surrogate and patient preferences. No matter what the content of the recommendation, however, it must always be offered with humility and with openness to contrasting perspectives. After all, the physician and surrogate are on the same team with the same ultimate goal: respect for the interests and dignity of the critically ill patient.

Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. [CrossRef] [PubMed]
 
Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1167. [CrossRef] [PubMed]
 
Heyland DK, Cook DJ, Rocker GM, et al. Decision-making in the ICU: perspectives of the substitute decision-maker. Intensive Care Med. 2003;29(1):75-82. [PubMed]
 
Azoulay E, Pochard F, Chevret S, et al; FAMIREA Study Group. Half the family members of intensive care unit patients do not want to share in the decision-making process: a study in 78 French intensive care units. Crit Care Med. 2004;32(9):1832-1838. [CrossRef] [PubMed]
 
Truog RD, Campbell ML, Curtis JR, et al; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36(3):953-963. [CrossRef] [PubMed]
 
White DB, Evans LR, Bautista CA, Luce JM, Lo B. Are physicians’ recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med. 2009;180(4):320-325. [CrossRef] [PubMed]
 
Curtis JR. Communicating about end-of-life care with patients and families in the intensive care unit. Crit Care Clin. 2004;20(3):363-380. [CrossRef] [PubMed]
 
Majesko A, Hong SY, Weissfeld L, White DB. Identifying family members who may struggle in the role of surrogate decision maker. Crit Care Med. 2012;40(8):2281-2286. [CrossRef] [PubMed]
 
Anderson WG, Arnold RM, Angus DC, Bryce CL. Passive decision-making preference is associated with anxiety and depression in relatives of patients in the intensive care unit. J Crit Care. 2009;24(2):249-254. [CrossRef] [PubMed]
 
Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010;304(17):1946-1947. [CrossRef] [PubMed]
 
Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med. 2010;38(suppl 10):S518-S522. [CrossRef] [PubMed]
 
Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173(20):1887-1894. [CrossRef] [PubMed]
 
Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians.4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009:71-76.
 
Curtis JR, Burt RA. Point: the ethics of unilateral “do not resuscitate” orders: the role of “informed assent”. Chest. 2007;132(3):748-751. [CrossRef] [PubMed]
 
Frick S, Uehlinger DE, Zuercher Zenklusen RM. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors—a prospective comparative study. Crit Care Med. 2003;31(2):456-461. [CrossRef] [PubMed]
 
Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125(9):763-769. [CrossRef] [PubMed]
 

Figures

Tables

References

Angus DC, Barnato AE, Linde-Zwirble WT, et al; Robert Wood Johnson Foundation ICU End-Of-Life Peer Group. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643. [CrossRef] [PubMed]
 
Prendergast TJ, Claessens MT, Luce JM. A national survey of end-of-life care for critically ill patients. Am J Respir Crit Care Med. 1998;158(4):1163-1167. [CrossRef] [PubMed]
 
Heyland DK, Cook DJ, Rocker GM, et al. Decision-making in the ICU: perspectives of the substitute decision-maker. Intensive Care Med. 2003;29(1):75-82. [PubMed]
 
Azoulay E, Pochard F, Chevret S, et al; FAMIREA Study Group. Half the family members of intensive care unit patients do not want to share in the decision-making process: a study in 78 French intensive care units. Crit Care Med. 2004;32(9):1832-1838. [CrossRef] [PubMed]
 
Truog RD, Campbell ML, Curtis JR, et al; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36(3):953-963. [CrossRef] [PubMed]
 
White DB, Evans LR, Bautista CA, Luce JM, Lo B. Are physicians’ recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med. 2009;180(4):320-325. [CrossRef] [PubMed]
 
Curtis JR. Communicating about end-of-life care with patients and families in the intensive care unit. Crit Care Clin. 2004;20(3):363-380. [CrossRef] [PubMed]
 
Majesko A, Hong SY, Weissfeld L, White DB. Identifying family members who may struggle in the role of surrogate decision maker. Crit Care Med. 2012;40(8):2281-2286. [CrossRef] [PubMed]
 
Anderson WG, Arnold RM, Angus DC, Bryce CL. Passive decision-making preference is associated with anxiety and depression in relatives of patients in the intensive care unit. J Crit Care. 2009;24(2):249-254. [CrossRef] [PubMed]
 
Sulmasy DP, Snyder L. Substituted interests and best judgments: an integrated model of surrogate decision making. JAMA. 2010;304(17):1946-1947. [CrossRef] [PubMed]
 
Niederman MS, Berger JT. The delivery of futile care is harmful to other patients. Crit Care Med. 2010;38(suppl 10):S518-S522. [CrossRef] [PubMed]
 
Huynh TN, Kleerup EC, Wiley JF, et al. The frequency and cost of treatment perceived to be futile in critical care. JAMA Intern Med. 2013;173(20):1887-1894. [CrossRef] [PubMed]
 
Lo B. Resolving Ethical Dilemmas: A Guide for Clinicians.4th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2009:71-76.
 
Curtis JR, Burt RA. Point: the ethics of unilateral “do not resuscitate” orders: the role of “informed assent”. Chest. 2007;132(3):748-751. [CrossRef] [PubMed]
 
Frick S, Uehlinger DE, Zuercher Zenklusen RM. Medical futility: predicting outcome of intensive care unit patients by nurses and doctors—a prospective comparative study. Crit Care Med. 2003;31(2):456-461. [CrossRef] [PubMed]
 
Quill TE, Brody H. Physician recommendations and patient autonomy: finding a balance between physician power and patient choice. Ann Intern Med. 1996;125(9):763-769. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
PubMed Articles
Guidelines
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543