Ethical Concerns if Surrogates Report Decisional Conflict
March 1, 2025
By Stacey Kusterbeck
Surrogates face challenging decisions on life-sustaining treatments in the intensive care unit (ICU) setting. “We know that surrogates report decisional conflict during decision-making in the ICU. We have a limited understanding, however, of how surrogates experience decisional conflict around treatment decisions preceding patient death, especially in the context of cardiac arrest, which can be sudden and unanticipated,” says Christine DeForge, PhD, RN, CCRN, a postdoctoral research fellow at Columbia University School of Nursing.
DeForge and colleagues analyzed decisional conflict of ICU surrogates about one month after a patient’s death.1 Of 16 surrogates interviewed, seven reported decisional conflict. “Decisional conflict scores were relatively low among the cohort. But this may have been because the survey was administered a month after their decision-making experience,” suggests DeForge.
The use of qualitative methods allowed for a deeper understanding of decisional conflict that surrogates experienced. Surrogates with decisional conflict reported poor medical understanding, suboptimal support, and lack of clarity about patients’ treatment preferences.
“Ethical issues may arise in the ICU when life-sustaining treatments are pursued in situations of medical futility,” says DeForge. Surrogate decision-making near end-of-life is complex and may involve factors unrelated to the patient’s medical condition. For example, there may be conflict among family members, or financial insecurity following patient death.
“Establishing therapeutic relationships with surrogates can offer insight into their decision-making process, allowing for unmet needs to be addressed and for additional support from the interdisciplinary care team,” offers DeForge.
Reference
- DeForge CE, Smaldone A, Agarwal S, George M. Medical decision-making and bereavement experiences after cardiac arrest: Qualitative insights from surrogates. Am J Crit Care. 2024;33(6):433-445.
Surrogates face challenging decisions on life-sustaining treatments in the intensive care unit setting. Those with decisional conflict reported poor medical understanding, suboptimal support, and lack of clarity about patients’ treatment preferences.
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