By Stacey Kusterbeck
Many ethics consults center around a conflict between a family who wants to continue life-prolonging interventions and a physician who refuses to provide it. But does the family understand the rationale for the decision? “When physicians’ reasoning is not clear, it can cause conflict — especially when patients or their families request treatment that physicians are unwilling to provide,” says Joelle Marie Robertson-Preidler, PhD, an assistant professor in the McGovern Center for Humanities and Ethics at the University of Texas Health Science Center at Houston.
Clinical ethicists often facilitate goals of care discussions in these cases. “We found that, during these meetings, physicians often struggle to communicate their rationale for offering, or refusing to offer, interventions that are viewed as life-prolonging,” says Robertson-Preidler. The two most common scenarios are:
- a family requests continued interventions (such as ventilatory support, dialysis, or chemotherapy) even though it will only prolong death;
- families seek a procedure or medication without clear benefits for the patient.
Physicians may decline to provide dialysis if it will not help the patient’s other underlying conditions. Doctors may disagree with intubating a patient in respiratory failure who is unlikely to survive to be discharged home. Surgical teams may decline to offer surgery that carries the risk of severe side effects or hastened death. “Sometimes, families are willing to take the risk, but physicians are not,” says Robertson-Preidler.
Ethicists get involved in cases where families want to continue curative care, but physicians believe the patient is unlikely to recover. “A common phrase that ethicists hear from families is that they want ‘everything’ done. That is usually interpreted by the team to mean that they want any and all possible interventions to extend life,” says Robertson-Preidler. The most common cases occur in the intensive care unit (ICU), with patients in multi-organ failure. When an additional issue comes up or another organ fails, the medical team often wants to stop to discuss whether doing another intervention is appropriate or not. “It is in this context that physicians may initiate difficult discussions with patients or families, and conflict may arise,” says Robertson-Preidler.
In a recent case, the surgical team thought a procedure was too risky — but without it, the patient would die. “The family couldn’t understand how the risks of surgery could outweigh the chance of benefit, when the alternative was death,” says Janet Malek, PhD, a professor at Baylor College of Medicine’s Center for Medical Ethics and Health Policy, who consulted on the case.
Robertson-Preidler, Malek, and colleagues wanted to better understand what physicians considered when deciding whether to offer interventions to patients near the end of life. The researchers interviewed 25 surgeons, intensivists, oncologists, emergency physicians, and nephrologists at a large academic medical center.1 Physicians primarily took into account these factors:
- The patient’s characteristics at baseline (such as physiological condition, age, and overall prognosis).
- How likely the patient is to achieve an identifiable goal or benefit (such as breathing more comfortably or doing a valued activity).
- How likely the intervention is to harm the patient (such as by causing pain, poor functionality, or death). Physicians considered the likelihood of a serious complication (such as unexpected bleeding or an infection) that could put the patient in a worse situation. Physicians were reluctant to offer interventions that they thought could not improve, and might worsen, the patient’s quality of life.
Some physicians also considered nonmedical factors that could help or harm the patient, such as financial burden or family dynamics. A nephologist stated, “You have to take the whole situation, the patient, the family, the psychosocial — all that — into consideration when you make these decisions.” Even if interventions did not directly benefit patients, physicians noted that there could be some possible benefits to families. A nephrologist stated, for instance, that time-limited trials were useful if families are not quite ready to transition to comfort care.
- The patient’s and family’s preferences. Physicians explored patients’ religious beliefs and values to aid them in making decisions. Physicians were more likely to defer to patients’ or families’ preferences if treatment outcomes were uncertain. However, physicians also talked about feeling pressured to do procedures because the family wants it done. Some felt an ethical obligation to refuse interventions that offered no benefit to patients.
- Institutional factors. Some physicians viewed certain interventions as an inappropriate use of healthcare resources. One nephrologist said, “I do feel some social responsibility with respect to healthcare costs and [the] healthcare system.” Physicians also talked about payment schemes and quality metrics, which were perceived to carry certain behavioral incentives that did not always support good patient care.
- Personal and professional factors. “Physicians’ values seem to always implicitly influence their decisions,” says Robertson-Preidler. Physicians reflected on what they would do if the patient was a family member. Others acknowledged that physicians will have different views on how risky a given intervention is. This underscores the importance of physicians keeping an open mind when hearing different perspectives from colleagues.
Participants emphasized the importance of providing benefit or not causing harm, but sometimes varied in how they defined benefit and harm. Participants discussed benefits in different ways, including therapeutic effects, hospital discharge, palliative effects, extending life, or achieving a certain quality of life. “These benefits or goals could also potentially conflict,” observes Robertson-Preidler. For example, dialysis may provide a therapeutic effect, but may not provide a better quality of life for the patient and may not improve the patient’s chance of leaving the hospital.
Similarly, participants described harm in different ways, in terms of pain, side effects, hastening death, or even extending a poor quality of life in the hospital. “Using terms such as ‘benefit,’ ‘harm,’ ‘futility,’ and ‘suffering’ can cause confusion and conflict if physicians do not explicitly define them,” concludes Robertson-Preidler.
Few physicians identified the possible benefits associated with a “good death” for patients who are near the end of life. “One thing that struck us was how infrequently clinicians identified a controlled, peaceful death as a benefit of foregoing interventions near the end of life,” observes Malek. Physicians who did discuss a good death generally described it as being in a comfortable setting, with pain controlled, among loved ones. “Dying suffering from chest compressions vs. with pain controlled by morphine while you hold your loved one’s hand are very different situations,” said one oncologist.
To ensure ethical decision-making, physicians can reflect on the role that their values play in decisions, identify whether those values are relevant to the decision at hand, and clarify their reasoning with patients and family. An example of a value that might influence physicians’ decisions would be their perception of quality of life. If a physician thinks that a prolonged episode of care in the hospital at the end of life is a poor quality of life, that physician may not offer treatment or may recommend against treatment without making their value regarding quality of life explicit. One physician stated that they thought a patient should not receive more interventions because it was preventing their soul from transitioning to the next life.
“If physicians’ considerations are not made clear and explicit to patients and families, it can hinder informed, value-concordant care,” says Robertson-Preidler. Ethicists also can help physicians to challenge pressure from the family, or from the institution, that does not align with patients’ best interests or values. Knowing the range of considerations that might contribute to a clinician’s decision helps ethicists to explore the clinician’s reasoning. “Ethicists can then support the clinician in explaining their reasoning more effectively to patients and families,” says Malek.
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.
Reference
1. Robertson-Preidler J, Kim M, Fantus S, Malek J. Whether to offer interventions at the end of life: What physicians consider and how clinical ethicists can help. AJOB Empir Bioeth. 2025;Feb 4. doi: 10.1080/23294515.2025.2457705. [Online ahead of print].
Many ethics consults center around a conflict between a family who wants to continue life-prolonging interventions and a physician who refuses to provide it. But does the family understand the rationale for the decision?
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content