New Guidelines Address Conflicts in Critical Care Treatment

Laurie Barclay, MD

May 15, 2015

New guidelines from the American Thoracic Society address crucial decision-making regarding the care of patients with critical illness. The policy statement aims to prevent conflicts and ensure cooperation between medical staff and family caregivers.

"Neither individual clinicians nor families should be given unchecked authority to determine what treatments will be given to a patient," guideline cochair Douglas White, MD, MAS, from the University of Pittsburgh Department of Critical Care Medicine in Pennsylvania, said in an ATS news release. "Clinicians should neither simply acquiesce to treatment requests that they believe are not in a patient's best interest, nor should they unilaterally refuse to provide treatment. Instead, if conflicts arise between clinicians and patients' families, a fair process of dispute resolution should be undertaken, in which neither individual can unilaterally impose his or her will on the other."

Researchers will present the guidelines at the American Thoracic Society (ATS) 2015 International Conference on May 18; the guidelines were also published online May 15 and in the June 1 print issue of the American Journal of Respiratory Research and Critical Care Medicine.

Specific recommendations include the following:

  • To prevent irreconcilable treatment conflicts, institutions should implement proactive communication and early involvement of expert consultants such as palliative care and ethics consultants.

  • Treatments that have a chance of accomplishing the effect desired by the patient, but that clinicians believe should be withheld because of competing ethical considerations, should be referred to as "potentially inappropriate," rather than as "futile."

  • If conflicts regarding potentially inappropriate treatments remain intractable despite intensive communication and negotiation, there should be a fair process of dispute resolution including hospital review by a multidisciplinary ethics committee, attempts to transfer the patient, external review if feasible, and informing the family of their right to appeal to the courts.

  • If time pressures prevent these measures and the requested treatment is outside accepted practice, clinicians should seek procedural oversight and need not provide the treatment.

  • Clinicians should not provide futile interventions, defined as those that simply cannot accomplish their intended physiologic goal.

  • Physicians should lead efforts to educate the public and advocate for policies and legislation about when life-prolonging technologies should not be used.

"Families need to be given a voice regarding what treatments are consistent with the patient's values and preferences, and physicians' professional integrity also needs to be respected, meaning that they should not be compelled to administer treatments that violate good medical practice," Dr White said in the news release.

He noted, "The cases are difficult because there are generally no clear, substantive rules to appeal to and because [intensive care unit] patients are especially vulnerable because of their overwhelming illness and lack of ability to seek out another doctor if they disagree with the plan."

The Society of Critical Care Medicine, the American Association of Critical Care Nurses, the American College of Chest Physicians, and the European Society of Intensive Care Medicine also supported the American Thoracic Society policy statement.

"These guidelines provide clinicians with a framework to manage treatment disputes with an emphasis on procedural fairness, frequent communication, expert consultation and timeliness," cochair Gabriel T. Bosslet, MD, from the Charles Warren Fairbanks Center for Medical Ethics at Indiana University, Indianapolis, said in the news release. "We hope that states will adopt laws similar to these guidelines, so that all sides in a particular dispute can have the resources they need to come to a resolution."

The American Thoracic Society, in collaboration with the American Association for Critical Care Nurses, the American College of Chest Physicians, the European Society for Intensive Care Medicine, and the Society of Critical Care Medicine, provided financial support for development of the policy statement. The authors have disclosed no relevant financial relationships.

Am J Respir Crit Care Med. 2015;191:1318-1330.

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