By Stacey Kusterbeck
Ethicists often are consulted when patients are receiving life-sustaining interventions that the treating team no longer considers beneficial. “Many patients and families have commitments regarding never giving up, doing everything, or hoping for a miracle that are incompatible with the treating team’s expectations for a given patient,” says Joanna Smolenski, PhD, assistant professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy.
Many patients and families wrongly assume they are entitled to pursue all treatment options indefinitely. In reality, treating teams are permitted to exercise their clinical judgment to limit certain treatment modalities when they no longer are indicated, or even to not offer them in the first place. “This can create a challenging clinical dynamic, where patients and their families may feel like they are arbitrarily being declined lifesaving care,” says Smolenski.
Ethicists can help bridge that gap by emphasizing that care for patients never stops, even when so-called “aggressive” treatment no longer is possible. Ethicists also can help clinicians to understand why not offering treatment, although it may feel morally troublesome, is ethically justified. “Sometimes, particularly in our very autonomy-driven medical environments, it can be easy to justify offering a treatment merely because it is being requested. However, this ignores the importance of appropriateness — ethically, professionally, and clinically — for all medical interventions. Ethicists can help the team understand that when a given intervention is inappropriate, not only is it permissible not to provide it, it ought not be provided,” says Smolenski. For example, offering a treatment that is not clinically appropriate can harm a patient without any associated medical benefit.
Hospital policies can be an invaluable tool for clinical teams managing requests for medically inappropriate treatment, says Smolenski. One reason unilateral limits are not pursued, even when ethically appropriate, is that healthcare providers worry it would open them up to liability. It can be a matter of debate whether a given intervention should be withheld or withdrawn. In some cases, though, it is very clear that ongoing treatment is medically inappropriate. “The fear of legal repercussions or accusations of clinician overreach for overriding a patient or surrogate’s requests can cause hesitation,” says Smolenski.
Clinicians may perceive a lack of support on the part of their institution. Support from hospital administration, in the form of a policy, can help assuage these worries. “Formalizing the institution’s perspective via policy can help provide a sense of safety to providers that this is not something they have to take on by themselves, but rather that they have the weight of the hospital system behind them. Hospital policy can provide formal, procedure-based opportunities for patients and families to justify their requests, which may actually amplify their perceived ability to advocate for the patient,” says Smolenski.
Hospital policies also serve an important function with respect to the ethical principle of justice. “A core principle in clinical ethics is the treating of like cases alike,” explains Smolenski. A standardized policy ensures that requests for inappropriate treatment are not managed idiosyncratically by providers. Hospital policies can provide criteria for what constitutes inappropriate treatment and outline the steps that will be taken in the process of pursuing unilateral limits, should the need arise. This ensures that medical inappropriateness is defined consistently, and offers guidance to resolve concerns about procedural fairness, says Smolenski. “It provides solvency for concerns about procedural fairness and due process,” says Smolenski.
The vast majority (92%) of hospitals and health systems had policies addressing decisions to withhold or withdraw life-sustaining treatment, according to a recent survey.1 However, it is unclear how such policies actually influence clinician behavior. A group of researchers interviewed 10 intensive care unit (ICU) nurses and eight attending physicians in 2024 about their views and experiences with hospital policies on withholding or withdrawing life-sustaining treatment and how the policies affected decision-making in ethically complex cases.2 Some key findings include:
- Clinicians had limited awareness or understanding of the policies.
- Some clinicians knew there was a policy but did not know where to find it. One nurse stated, “I do know how to get to the webpage to look for them, but it is pretty difficult to search … We’ve had these issues where, for six hours, nobody can figure out what the proper one is and one kind of says one thing and one kind of says another.”
- Clinicians found policies helpful for ethical guidance and legal protection.
- Clinicians felt that the policies addressed neither sociodemographic disparities nor the use of clinician value judgments in decision-making. For example, clinicians may conclude that a patient lacks quality of life based on the clinician’s own views (even if the patient finds their quality of life acceptable). Therefore, the clinician decides that life support should be withheld from the patient.
- Clinicians varied as to whether they followed hospital policy when making decisions to withhold or withdraw life-sustaining interventions.
“Our findings suggest that these hospital policies may have little influence on clinician behavior,” says Gina Piscitello, MD, MS, assistant professor at the University of Pittsburgh School of Medicine.
For ethicists, it is important to be aware that clinicians may not be following internal hospital policies that provide guidance on decisions to withhold or withdraw life-sustaining treatment. “Lack of alignment of clinician behavior with these policies may put clinicians and hospital systems at risk for malpractice lawsuits,” warns Piscitello.
The study authors recommend hospitals educate clinicians about the policies, using interactive strategies and providing feedback. The authors also suggest that resources spent on developing and updating hospital policies might be better spent on educating clinicians about recommended approaches to withhold or withdraw life-sustaining treatment.
“Ethicists could be involved in providing this education, such as organizing case discussions where clinicians and ethicists discuss how to approach specific situations addressing withholding or withdrawing life-sustaining treatment that align with hospital policies,” suggests Piscitello.
Hospital policies will be most useful to clinicians if they provide a stepwise or flowchart approach to responding to requests for inappropriate treatment, according to Thaddeus Mason Pope, JD, PhD, HEC-C, professor of law at Mitchell Hamline School of Law in Saint Paul, MN.
“Given the preeminence of patient autonomy in U.S. healthcare, refusing treatment requests is extraordinary,” adds Pope. Different responses are called for, depending on the reason for the patient or surrogate request. For example, the request could be motivated by the patient’s religion or by a misunderstanding about the effectiveness of requested interventions. Education would help with the misunderstanding, but probably not with a religiously based request.
“Fortunately, most conflicts are not based on values and are not intractable. Instead, requests for inappropriate treatment are typically caused by misunderstanding of the patient’s diagnosis or prognosis,” says Pope.
Hospital policies should guide clinicians to ensure that the patient or surrogate understands the true clinical situation. But because requests for inappropriate treatment have different causes, hospital policies should address a range of situations and responses. For example, some surrogates are unwilling to accept treatment refusal under any circumstances, even if it is not in the patient’s best interest. “Surrogates who cannot discharge their duties should be replaced with another surrogate or with a guardian/conservator. If that’s not possible, the patient might be transferred to another facility that is willing to provide the disputed intervention,” says Pope.
Disputes over inappropriate treatment remain one of the most common reasons for ethics consults. “Because ethicists typically have the most experience with these policies, they should advocate for updating these policies when necessary. And they should educate clinicians on these policies,” says Pope.
Sometimes the policy is freestanding. Other times, it is embedded as a section of policies on informed consent or withholding or withdrawing life-sustaining treatment. A fair dispute resolution policy assures due diligence and procedural due process. “But this often requires more time and energy than many clinicians are prepared to invest. Clinicians typically cave in to surrogate demands, and continue providing treatment they judge inappropriate,” says Pope.
Thus, hospital policies on inappropriate treatment remain underused. On the other hand, not all refusals of requests for inappropriate care need a full review process with independent second opinions and approval of an ethics or medical appropriateness review committee. Some situations are too time-sensitive; some are for obviously physiologically futile interventions. “But even these cases should receive a formal ethics consult at least, to ensure they are really proper for expedited review,” recommends Pope.
Stacey Kusterbeck is an award-winning contributing author for Relias. She has more than 20 years of medical journalism experience and greatly enjoys keeping on top of constant changes in the healthcare field.
References
1. Piscitello GM, Lopez Wolwowicz E, Huber MT, et al. The influence of hospital policies on clinicians’ decisions to withhold or withdraw life-sustaining treatment. Chest. 2025; Jul 3. doi: 10.1016/j.chest.2025.06.036. [Online ahead of print].
2. Piscitello GM, Lyons PG, Gutmann Koch V, et al. Hospital policy variation in addressing decisions to withhold and withdraw life-sustaining treatment. Chest. 2024;165(4):950-958.
