By Stacey Kusterbeck
Surrogate decision-making was the primary ethical issue for clinical ethics consults involving patients with liver disease, according to a recent study.1 Researchers evaluated 38 ethics consults from 2015-2023 for people with severe liver, heart, and lung disease. Most consults for patients with liver disease involved one of these scenarios:
- There was no identified durable power of attorney.
- The surrogate’s decision conflicted with the clinical team’s recommendations.
“Given that advanced liver disease can often lead to complications affecting mental status, as well as the unpredictable course of end-stage liver disease, it is perhaps not surprising that surrogates had not been identified or had not been prepared for their roles,” says Alexis Holman, MD, JD, the study’s lead author and a resident in internal medicine at University of Michigan Medical School.
Code status and futility were other common ethical issues. Some ethics consults involved clinicians who did not offer cardiopulmonary resuscitation to patients in situations where providing these measures would be nonbeneficial or harmful, but the family disagreed.
One such case involved a male patient in his 30s with decompensated liver cirrhosis during a prolonged hospitalization complicated by multiorgan failure. In the clinical judgment of the care team, he was determined to be approaching the end of his life with few to no treatment options. Since the patient did not have capacity, the care team initiated a conversation with his parents about changing his code status to “do not attempt resuscitation” (DNAR), since an attempt at resuscitation could harm him without clinical benefit. However, his parents disagreed with a DNAR order, maintaining hope that he would recover. Ethics was consulted regarding the ethical permissibility of unilaterally changing his code status to DNAR.
In other cases, the surrogate or family requested aggressive medical interventions in patients with multisystem organ failure against the clinical team’s recommendations for comfort-based approaches. “In those situations, ethicists can serve as mediators, and provide guidance regarding complex communication between the patient, family, and clinicians,” says Holman. For example, clinicians can inform the family about the discontinuation of certain treatments rather than seeking their permission. This can prevent situations where families feel burdened by having to make the decision to reject harmful or nonbeneficial treatments.
Ethicists also provide guidance on the ethical justification for withholding interventions that have no reasonable chance of success or are more likely to cause harm than provide benefit. At the same time, ethicists support the continuation of interventions that do offer benefit and align with the patient’s and family’s goals.
Disputes among family members, quality of life concerns, and poor communication were common contextual factors for the ethics consults. The communication issues all involved patients’ families, as opposed to patients themselves. “This may reflect the high rate of hepatic encephalopathy interfering with the patient’s participation in care-related discussions. This can lead to conflicts within families, especially when these discussions happen late in the disease course,” says Holman.
Ethicists can encourage compassionate communication that provides the family as much time as possible to process information, make decisions, and make arrangements to be present, offers Janice Firn, PhD, MSW, HEC-C, another of the study’s authors and a clinical ethicist at Michigan Medicine and Center for Bioethics and Social Sciences in Medicine.
Overall, the study findings underscore the need for early advanced care planning discussions in the outpatient setting. To facilitate earlier conversations, ethicists can advocate for hospital policies that promote these discussions in outpatient settings. Ethicists also can review documents and wishes at key transitions in the illness trajectory (such as signs of decompensation, escalated care needs, or hospital admission). Ethicists also could encourage clinicians to review advance directive documentation proactively during ethics rounds. “Discussions earlier in the course of care are needed, especially regarding invasive measures at the end of life that may not extend life in a meaningful way,” says Holman.
Reference
1. Holman A, Solano Q, Firn J, Tapper E. Clinical ethics consultations in cirrhosis care. Dig Dis Sci. 2025;70(3):1008-1015.
Surrogate decision-making was the primary ethical issue for clinical ethics consults involving patients with liver disease, according to a recent study.
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