A History of Resolving Conflicts over End-of-life Care in Intensive Care Units in the United States *

Luce, John M. MD, FCCM

Disclosures

Crit Care Med. 2010;38(8):1623-1629. 

In This Article

Abstract and Introduction

Abstract

Objectives: To present a case of conflict over end-of-life care in the intensive care unit (ICU) and to describe how such conflicts have been resolved in the United States since the inception of ICUs.
Data Sources: A nonsystematically derived sample of published studies and professional and lay commentaries on end-of-life care, ethical principles, medical decision-making, medical futility, and especially conflict resolution in the ICU.
Study Selection: Some of those studies and commentaries dealing specifically with conflicts over end-of-life care in the ICU and their resolution.
Data Synthesis: An historical review of conflict resolution over end-of-life issues in U.S. ICUs.
Results and Conclusions: Conflict at the end of life in ICUs in the United States is relatively rare because most families and physicians agree about how patients should be treated. Nevertheless, conflict still exists over some patients whose families insist on care that physicians consider inappropriate and hence inadvisable, and over other patients whose families object to care that physicians prefer to provide. When such conflict occurs, mediation between families and physicians is usually successful in resolving it. Consultation from ethics committees also may be helpful in achieving resolution, and one state actually allows such committees to adjudicate disputes. Physicians who act unilaterally against family wishes run the risk of malpractice suits, although such suits usually are unsuccessful because the physicians are not shown to have violated standards of care.

Introduction

I recently encountered a case of conflict over care at the end of life that is similar to others that occur, albeit uncommonly, in the United States. It involved an 86-year-old man named James McGilvray (I have changed the patient's name and several details of his history to avoid his being identified) from San Francisco. Mr. McGilvray had chronic hypertension, heart failure, and vascular dementia, in addition to the new onset of acute myelogenous lymphoma. At his request and that of his spouse and adult son, he was treated with conventional chemotherapy by a community oncologist after being deemed ineligible for experimental protocols at a nearby university medical center.

After several months, Mr. McGilvray no longer responded to chemotherapy, and he and his family was informed that his lymphoma could never be controlled. Nevertheless, he was admitted by his oncologist to an intensive care unit (ICU) for respiratory failure caused by tumor infiltrates in his lungs. An intensivist treated Mr. McGilvray with noninvasive ventilation delivered through a face mask. Mr. McGilvray's thinking had clouded by this point. He could no longer make medical decisions, and he had never prepared an advance directive to assist others in making them.

During this hospitalization, Mr. McGilvray's wife and son were advised by his oncologist and intensivist that it would be best not to intubate him if could not be maintained on noninvasive ventilation because he would soon die of his lymphoma. They also advised the family that he not undergo cardiopulmonary resuscitation (CPR) in the event of a cardiopulmonary arrest. The family rejected this advice on the grounds that Mr. McGilvray was "a fighter" who would want full support. The family also stated that every day Mr. McGilvray lived was a blessing bestowed by God.

One night as his respiratory status was declining, presumably because of progressive tumor infiltration, his family was told by a physician covering the ICU that Mr. McGilvray could maintain adequate oxygenation only if his trachea was intubated. The family requested this procedure. During intubation, however, Mr. McGilvray suffered a cardiopulmonary arrest. It took half an hour of CPR to restore his heartbeat, after which he was placed on the ventilator in an unconscious state.

After performing a thorough neurologic examination the next morning, Mr. McGilvray's intensivist concluded that he had suffered severe hypoxic-ischemic brain damage. She then advised the family that he was unlikely to regain consciousness and asked that the mechanical ventilator be removed. The family refused, insisting that he would recover, even if "a miracle" were required. The intensivist then met with the hospital ethics committee, a representative of which tried to convince the family that further treatment could not benefit Mr. McGilvray and that he might not want the treatment his family requested for him if he were able to speak for himself.

The family was not persuaded by the ethics committee representative, and mechanical ventilation was continued. Mr. McGilvray's intensivist tried to interest other physicians in assuming his care but was unsuccessful. After another week in the ICU, during which he received full support (including vasopressors, antibiotics, fluids, and nutrition) but never regained consciousness, Mr. McGilvray suffered another cardiopulmonary arrest and could not be resuscitated. The family subsequently sued the hospital and Mr. McGilvray's oncologist and intensivist for alleged medical malpractice, claiming that they had not "done everything to save him."

From what I know of Mr. McGilvray's case, communication between his family and physicians was excellent, as it was between the family and the ethics committee representative. Nevertheless, the family members never accepted the prognosis offered them and insisted on life-sustaining therapy until Mr. McGilvray died. End-of-life care is not contentious for most ICU patients because their families and physicians usually agree on a plan of treatment. Nevertheless, Mr. McGilvray's case is a reminder that seemingly unsolvable conflicts still occur despite extensive negotiations and, like conflicts in other arenas, may ultimately be played out in the legal system.

In this article, I trace the history of how conflicts over care at the end of life have been dealt with in American ICUs since their inception and discuss several court cases involving such conflicts. In the process, I explore the ethical principles that underlie end-of-life care in the ICU and other settings. I do not discuss the financial implications of such care in detail, because this complex and important topic deserves an independent review.

*See also p. 1742.

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