Do physicians give life support recommendations? Practices vary
Surrogates often aren't asked preferences
Approximately one in five (22%) out of 608 critical care physicians surveyed reported always providing surrogates of critically ill adult patients with a recommendation about limiting life support, while one in 10 (11%) reported rarely or never doing so, according to a just-published study.1 Surrogates' desires for recommendations and physicians' agreements with surrogates' likely decisions may influence whether recommendations are provided.
"We were surprised to find that while there was broad support for providing life support recommendations to surrogates, there was considerable variation in physicians' reports of providing such recommendations," says David R. Brush, MD, the study's lead author and a former fellow in the Section of Pulmonary and Critical Care Medicine and the MacLean Center for Clinical Medical Ethics at the University of Chicago.
The majority of physicians felt it was their duty to provide such recommendations, felt comfortable providing them, and felt they were appropriate, adds Brush, noting that additional factors such as physicians' personal values, fear of litigation, and prognostic uncertainty might determine whether physicians actually do so.
Forty-one percent of surveyed physicians believed recommendations were only appropriate if sought by surrogates. "We were surprised by the size of the effect that surrogates' desires for a recommendation had on whether a physician would be likely to provide a recommendation, especially when one-third of physicians reported rarely or never inquiring whether surrogates wanted physicians' recommendations," says Brush.
Nearly half of surrogates for intensive care unit (ICU) patients might prefer not to have a physicians recommendation, according to another recent study.2 "Most critical care physicians seem to be willing to modify their provision of recommendations if surrogates explicitly make it clear whether a recommendation is wanted. But physicians are not routinely asking surrogates to clarify their wishes about receiving recommendations," says Brush.
Shared decision making
Previous research suggests that the majority of surrogates want physicians' input in decision making for critically ill adults.2-4 "Providing recommendations to surrogates is a component of shared decision making, which has been endorsed by ethicists and professional societies as the preferred approach to medical decision making, especially in decisions about limiting life support," says Brush.5-8
Physicians who never or rarely provide recommendations to surrogates may be interested to read about their colleagues' broad support for, and frequent provision of, recommendations to surrogates, says Brush. The study's findings about physicians' sensitivities to surrogate preferences for recommendations raise important ethical issues, such as how much physicians should adjust recommendations based on their own preferences, he adds.
"If physicians feel strongly about their recommendations, and view themselves as the patient's advocate, should they withhold their recommendations if the surrogate does not want it?" asks Brush.
As patient advocates, physicians clearly have a duty to provide unwanted recommendations when surrogates are making decisions that seem to go against patient preferences, says Brush. "But should physicians provide unwanted recommendations when there is more uncertainty about patient preferences?" he asks. "In such circumstances, physicians can be placed in a difficult position of wanting to avoid conflict with surrogates, but also to advocate for their vulnerable patients."
"Moral distress" for providers
The primary ethical consideration for physicians who are making recommendations to limit life support is whether or not the treatment offers a reasonable likelihood and quality of life benefit for the patient, according to Nancy S. Jecker, PhD, a professor in the Department of Bioethics and Humanities at University of Washington in Seattle. "When life-saving medical interventions are withheld or withdrawn, health professionals remain obligated to pursue treatment that maximizes comfort and dignity for the patient," she says.
Instead of saying to the patient, "There is nothing I can do for you," health professionals should instead affirm that everything possible will be done to ensure the patient's comfort and dignity, says Jecker. "Too often, patients and families insist on futile efforts because such efforts symbolize caring. There are better ways of caring for patients," she adds. "Medicine, nursing, and the other healing professions are not practiced merely on demand, but instead aspire to moral goals, such as helping the sick."
For instance, Jecker says physicians are committed to helping patients understand the disease and its effects on their life, lessening the pain or disability caused by disease, and helping patients die with dignity and peace. "Physicians should not undertake medical efforts that frustrate these goals," she says.
One of the greatest ethical challenges for health care professionals is to avoid over-treating patients, says Jecker. "When providers act contrary to their own sense of what is right, over-treatment creates moral distress' — understood as the suffering that occurs when the right course of action is known but is not carried out," she says. "Moral distress is not just a bad feeling. It has been demonstrated to be seriously detrimental to a provider's family relationships and professional performance."
To address the problem of over-treatment, physicians need to focus on benefitting the patient, Jecker underscores. "If a treatment produces an effect, not a benefit, then it is not a duty to use that treatment," she says. "Where futile therapies provide psychological benefits, such benefits can be achieved in other, and better, ways."
References
- Brush DR, Rasinski KA, Hall JB, et al. Recommendations to limit life support: A national survey of critical care physicians. Am J Respir Crit Care Med 2012 Jul 26. [Epub ahead of print].
- White DB, Evans LR, Bautista CA, et al. Are physicians' recommendations to limit life support beneficial or burdensome? Bringing empirical data to the debate. Am J Respir Crit Care Med 2009;180:320-325.
- Heyland DK, Cook DJ, Rocker GM, et al. Decision-making in the ICU: Perspectives of the surrogate decision maker. Intensive Care Med 2003;29:75-82.
- Johnson SK, Bautista CA, Hong SY, et al. An empirical study of surrogates' preferred level of control over value-laden life support decisions in intensive care units. Am J Respir Crit Care Med 2011;183:915-921.
- Quill TE, Brody H. Physician recommendations and patient autonomy: Finding a balance between physician power and patient choice. Ann Intern Med 1996;125:763-769.
- Emanuel EJ, Emanuel LL. Four models of the physician-patient relationship. JAMA 1992;267:2221-2226.
- Thompson BT, Cox PN, Antonelli M, et al. Challenges in end-of-life care in the ICU: Statement of the 5th International Consensus Conference in Critical Care: Brussels, Belgium, April 2003: Executive summary. Crit Care Med 2004;32:1781-1784.
- Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 20042005. Crit Care Med 2007;35:605-622.
Sources
- David R. Brush, MD, Walnut Creek, CA. Phone: (925) 295-4050. Email: [email protected].
- Nancy S. Jecker, PhD, Professor, Department of Bioethics and Humanities, University of Washington, Seattle. Phone: (296) 616-1865. Email: [email protected].
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