EXECUTIVE SUMMARY

Ethicists at University of Virginia helped develop a new resuscitation policy stating that patients or surrogates can accept or refuse offered treatment, and that the healthcare team should not offer treatments unless clinically indicated.

  • The hospital’s previous policy stated that patients or their surrogates decided whether CPR would be attempted.
  • Clinicians were experiencing moral distress due to end-of-life care they believed was harmful to patients.
  • Risk managers and general counsel support clinicians in adhering to the standard of care if families threaten litigation.

Over the past several years, ethicists at Charlottesville-based University of Virginia received many requests for consults from clinicians who felt aggressive end-of-life care was causing a patient to suffer.

“Families often ask for treatment at the end of life that’s not medically indicated,” says Mary Faith Marshall, PhD, FCCM, co-director of the hospital’s Center for Biomedical Ethics and Humanities.

The hospital’s previous policy stated that patients or their surrogates were the ones who decided whether resuscitation was attempted if the patient went into cardiac arrest. A group of ethicists set out to update the policy.

“When a family member says, ‘I want you to do everything possible for my mom,’ when mom has terminal cancer and multisystem organ failure and is dying in the ICU, the patient is the one who suffers from that, as do the staff,” says Marshall.

The issue of overly aggressive end-of-life care goes beyond psychological distress of clinical team members. “Offering interventions that aren’t clinically indicated is failing to follow recognized professional practice norms,” says Marshall.

Transparent Process

Development of the new resuscitation policy involved dozens of people with diverse views and took two years. “We were very careful to make sure that the process was totally transparent,” says Marshall. The process involved a great deal of back and forth between stakeholder groups such as the critical care committee, the nursing governance organization, and the patient experience program.

“We wanted them all at the table from the beginning,” explains Marshall. “By the time we rolled the policy out, it was not a big deal. People knew it was coming, and they wanted it.”

The new policy sends a clear message to clinicians: They’re supported in offering only treatments that are clinically indicated. “Clinicians were in an awkward position with the old policy where the surrogate or family got to decide,” says Marshall. “They didn’t have an institutional policy behind them.”

There always were some physicians who refused to acquiesce to families’ demands for inappropriate care. “We had physicians who would say, ‘I am not resuscitating this person.’ Now, they have a policy to back it up,” says Marshall.

The team discusses a plan based on realistic goals of care. “Just as some patients are told they are not a candidate for liver transplant or for surgery, some patients are told they are not a candidate for resuscitation,” says Marshall. Some families want to transfer elsewhere. “If they say, ‘we want to try and find someone who will provide that,’ we certainly make a good faith effort to make that happen,” says Marshall.

Shared Decision-making Model

The new policy, which took effect in early 2017, is a shared decision-making model between patients (or authorized surrogates) and the healthcare team, rather than a unilateral decision by either party. “It begins with the team making a collective decision on what is appropriate to offer,” says Marshall. The policy has three levels:

  • Level A: Clinicians do not attempt resuscitation. The word “attempt” was purposely chosen to stress that the majority of resuscitations aren’t successful. “Of in-house cardiopulmonary arrests, the national data is that they are successful about 24% of the time,” notes Marshall. Clinicians will do everything they can to prevent a cardiopulmonary arrest. This may include intubation, vasopressors, or sending the patient to the ICU — but if the patient stops breathing or has a pulseless cardiac rhythm, clinicians don’t resuscitate.
  • Level B: “This means we do not escalate,” says Marshall. For example, clinicians will continue with the current plan of care but won’t add antibiotics or vasopressors.
  • Level C: Comfort care only.

“There are a couple of things we built into the policy that we are particularly proud of,” says Marshall. The policy states: “The patient or the surrogate are entitled to consent to or refuse offered medical treatment. The healthcare team should not offer or provide treatment that is not the standard of practice.”

“We use the word ‘team’ strategically,” says Marshall. The policy defines “team” as the attending physician and the licensed independent professionals — residents, nurse practitioners or physician’s assistants, nursing staff, and respiratory therapists. “The thinking is that those are the people at the bedside taking care of the patient, especially if the patient has a cardiopulmonary arrest,” says Marshall.

Instead of the old model of a physician walking into the patient’s room and asking, “If your heart stops beating, do you want us to try and start it again?” the team comes to a prospective decision about what to offer. This means that an individual physician can’t make a decision to offer a treatment simply because the family is demanding it. “It also means that a new attending can’t come in on Monday morning and do a 180-degree reversal on the plan of care and reverse the DNR order,” says Marshall.

Some clinicians fear litigation if they don’t offer treatments the family is demanding. “We bring in the general counsel and risk managers right up front,” says Marshall. “They are very good at letting the staff know, ‘We’ve got your back. You should be following the standard of care.’”

Some families do threaten to sue. Marshall tells clinicians, “If you ever do find yourself in court, you want to be able to say, ‘I followed the standard of care,’ not ‘I did this because I thought the family was going to sue me.’”

Fears of being sued for not providing aggressive end-of-life care, for the most part, are unwarranted, she says. “I think it’s kind of amazing there is so much fear there,” Marshall adds. “Basically, those lawsuits, for the most part, don’t exist. And if they do, they are unsuccessful.”

SOURCE

  • Mary Faith Marshall, PhD, FCCM, Director, Program in Bioethics/Co-Director, Center for Biomedical Ethics and Humanities, University of Virginia, Charlottesville. Phone: (434) 924-1934. Fax: (434) 982-3971. Email: mfm@virginia.edu.