Chapter 84 Ethics
1 Where is the locus of decision-making authority in the intensive care unit (ICU) regarding end-of-life care?
The process of shared decision making locates the responsibility between the patient or surrogate and the caregivers, thus aiming to respect the autonomy of the patient or surrogate, as well as the beneficent and nonmaleficent intentions of clinicians. The surrogate’s responsibility is to express a substituted judgment, that is, to convey an understanding of what the patient would want. If the patient’s preferences are unknown, the best interests standard is used—a presumed understanding of what a reasonable person would want. The attending physician has the ultimate responsibility in deciding on a reasonable plan.
2 Describe the shared decision-making paradigm
The key to the paradigm is communication. The process includes meetings to allow the caregivers to learn about the patient’s values and goals, as well as to allow the patient or surrogates to learn about the patient’s condition and about the interventions that might be reasonable to use, in light of the patient’s values and prognosis. The dynamic process allows for reassessment and readjustment of plans, befitting the patient’s changing condition and goals.
3 What if clinicians disagree with the patient or surrogate?
After additional clarification of values, goals, prognosis, and treatment options, both parties can try to persuade the other and/or seek common ground. A time-limited trial of continued therapy, followed by reassessment, may bring about resolution. Consider additional informational or supportive services from other persons and clinicians who know the patient well, second-opinion consultations, social services, chaplaincy, ethics consultation, psychiatry, and/or palliative care.
4 What if the clinical team believes some interventions are futile?
There is no agreement on a precise definition of futility, yet clinicians clearly recognize when they are in a futility quagmire. The term comes up when “the team” thinks some interventions are ineffective, overburdensome, wasteful, and harmful, but they are faced with a family that demands that “everything be done” to prolong the patient’s life. Tensions increase, and people get edgy, cagey, defensive, or elusive in reaction to conflict, mistrust, and power struggles. If the procedures described in answers 2 and 3 have been tried and are unsuccessful, then the clinicians might:
Attempt to transfer the patient to another caregiver
Seek adjudication (possibly to replace the surrogate)
Override the patient or surrogate and decide to withhold or withdraw life-sustaining treatment (LST), with institutional support plus forewarning to the surrogate so that she or he has the opportunity to seek legal action.
Some institutions have developed a procedural “Futility Policy” or “Conflict Resolution Policy” that outlines a stepwise process for a committee to review the perspectives of the team and family before making a recommendation regarding the LSTs in question.
5 What if there is no surrogate decision maker for the patient?
Gather as much information as possible about the person to best understand the patient’s story, lifestyle, functional status, and values. Consider contacting neighbors, work colleagues, clergy, community members, primary care providers, and other outside health care providers. Use the information gained to approximate a substituted judgment to supplement the “best interests” standard to make decisions. Ethics consultation and advice from hospital legal counsel may be required to complement the plans devised by the attending physician and ICU team.
6 How prevalent is conflict in ICUs, and what are some of the sources and consequences of conflict?
The prevalence of conflict in ICUs is high, up to 70%, and most conflicts are rated as “severe,” “dangerous,” and/or “harmful.” Yet 70% of conflicts are perceived to be preventable. Conflicts occur among staff members and between staff and families. Sources of conflict include personal animosity, mistrust, poor communication, and troublesome end-of-life care. Concerns about end-of-life care include lack of psychological support, suboptimal decision making, suboptimal symptom control, treatment futility, and disregard for family and patient preferences. The perception that futile care is being rendered is strongly associated with moral distress, especially among nurses. Conflict contributes to moral distress, burnout, and job turnover. A high level of burnout has been measured in intensivists. This is disturbing, because burnout is characterized by a detached or dehumanizing attitude and a lack of concern for others.
7 List means to lessen or resolve moral distress and intrateam or team-family conflicts
Proactive family meetings, open visitation, family presence on rounds, respect of cultural norms, routine unit-level meetings, staff debriefings, collaborative care, spiritual support, relieving patients’ distressing symptoms, ethics consultation, and integration of palliative care principles and practices into the ICU.
8 What will an ethics consultant want to know when a consultation is requested?
An ethics consultant will want to know:
What are the issues that led to the consultation?
What is the prognosis (likelihood of best case and worst case scenarios)?
Code status and patient’s decision-making capacity or identification of surrogate
Understanding of patient’s values and advance directives
Identification of others who know the patient well
Involvement of social worker and pastoral care
Current goals of care (and areas of agreement and disagreement regarding these)
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