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Point and Counterpoint |

Rebuttal From Dr HutchisonRebuttal From Dr Hutchison 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):1457-1458. doi:10.1378/chest.15-0274
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In his Counterpoint editorial, Dr Veatch1 argues that physicians cannot presume to know what is best for patients, that recommendations can sway patients’ decisions about medical treatments, and, therefore, recommendations may result in decisions that are not in patients’ best interests. Not surprisingly, we share considerable ground on each of these points. I, too, acknowledge that there are challenges determining what is best for patients, and I recognize the risk of misleading surrogates with recommendations. However, when a patient lacks decisional capacity, has no advance directive, and is in the process of dying, clinical decisions require thoughtful integration of medical facts and patient values. The physician has access to the medical facts by virtue of his training, and he comes to know the patient’s values through discussion with a surrogate. The physician is the most appropriate person to integrate these factors into a recommended plan of care.

A key difference between our commentaries concerns the definition of “goals of care.” While Dr Veatch takes this to mean broader life aspirations and goals, I define it more narrowly in terms of the utility of specific treatments. If a patient is dying and aggressive therapies are unlikely to help the patient achieve his life goals, then the goals of medical treatment should reflect this fact. I certainly do not hold that physicians can suggest life goals or values. But once these are provided by the patient’s surrogate, the physician can differentiate between life goals that are attainable and those that are not. He or she can then recommend treatments that will achieve attainable goals, and, for many dying patients, comfort care might be an appropriate recommendation.

Integrating a patient’s known values into a recommendation is not an overextension of a physician’s expertise. No other profession requires its members to consistently make decisions that can prolong suffering or limit lifespan, or to integrate value judgments and medical facts. By virtue of their day-to-day responsibilities, critical care physicians acquire the skills necessary to help families with these decisions. With adequate training and mentorship, physicians become expert at this task.

Surrogates will always be better than physicians at identifying patients’ life goals. However, we know that surrogates’ ability to predict patient preferences is severely limited.2 If surrogates are left alone to design a plan of care for the patient, there is no guarantee that the plan will accurately reflect the patient’s authentic values. Furthermore, requiring a surrogate to recommend a treatment plan entails generalization of the surrogate’s expertise to the medical sphere, a proposition equally troubling as generalization of the physician’s expertise to the nonmedical sphere.

While physicians’ expertise is predominantly in the medical sciences, the last 40 years have seen increasing emphasis on spirituality, ethics, and the humanities in medical school curricula.3 We seek to mold young doctors into well-rounded healers of mind, body, and spirit, rather than mere biologic technicians. If physicians ought not integrate nonmedical spheres of patient well-being into their recommendations and practice, then we risk returning to an era of impersonal medicine that we abandoned decades ago.

References

Veatch RM. Counterpoint: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? No. Chest. 2015;147(6):1455-1457.
 
Sulmasy DP, Terry PB, Weisman CS, et al. The accuracy of substituted judgments in patients with terminal diagnoses. Ann Intern Med. 1998;128(8):621-629. [CrossRef] [PubMed]
 
Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85(2):318-323. [CrossRef] [PubMed]
 

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References

Veatch RM. Counterpoint: do physicians have a responsibility to provide recommendations regarding goals of care to surrogates of dying patients in the ICU? No. Chest. 2015;147(6):1455-1457.
 
Sulmasy DP, Terry PB, Weisman CS, et al. The accuracy of substituted judgments in patients with terminal diagnoses. Ann Intern Med. 1998;128(8):621-629. [CrossRef] [PubMed]
 
Doukas DJ, McCullough LB, Wear S. Reforming medical education in ethics and humanities by finding common ground with Abraham Flexner. Acad Med. 2010;85(2):318-323. [CrossRef] [PubMed]
 
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