A liver transplant recipient at University of Minnesota Medical Center returned a month later with signs of infection and brain damage. His family wished to withdraw aggressive treatments in light of a grave and uncertain prognosis. The transplantation team made several emphatic statements about the obligations they and the patient had to protect the longevity of the transplanted liver — and, therefore, to aggressively treat the patient.

“We were surprised by the intense emotional reactions from all participants in the case,” says Nathan Scheiner, MD, who co-authored an analysis of the case.1

Strong Emotional Reactions

Some family members expressed near certainty the patient would not want treatment. “They had a very strong emotional reaction to repeated conversations about switching from full-code status to Do Not Resuscitate/Do Not Intubate,” recalls Scheiner.

The paper explores ethical considerations if patients consent to a treatment plan with the understanding that it carries risks of complications, then revoke consent when complications arise. “We wanted to better understand both the reason for the intense reactions we saw, and what was ethically at stake,” says Scheiner.

Some interesting insights came out of the case analysis. “There is a small but significant body of literature on surgical buy-in,” says Scheiner. This is a contract surgeons believe they make with patients when entering into a surgical relationship. This literature helped the ethicists to understand the transplant team’s reactions. “However, we were surprised that there has been a lack of examination of the patient and family perspective,” says Scheiner. “Our analysis helps to fill that gap.”

The authors called the family’s reaction in this case “cashing out,” which is the reciprocal of “buying in.” “This helped us make sense of the intense emotional reactions and seemingly irrational refusals that patients or families occasionally express in response to new complications or perceived intolerable treatments,” says Scheiner.

Resources Are Concern

It should be possible for a patient to withdraw consent at almost any time, even after a treatment has commenced, says Tyler S. Gibb, JD, PhD, co-chief of the program in medical ethics, humanities, and law at Western Michigan University in Kalamazoo.

However, it also is possible that a subsequent withdrawal of consent places the patient at greater risk of harm by interrupting the treatment than if the treatment was completed. “There is also some concern about the squandering of resources that would result if a treatment is begun but not completed,” says Gibb. This is particularly true of scarce or precious resources such as transplantable tissue or organs.

“There is some discussion about a ‘Ulysses contract’ type of discussion between providers and patients,” notes Gibb. In essence, these agreements require some degree of perseverance by the patient even if there are subsequent complications or setbacks. “These are interesting proposals that would be difficult to enforce, but may be helpful in guiding pre-treatment informed consent discussions,” says Gibb.

REFERENCE

1. Scheiner N, Liaschenko J. “Buying-in” and “cashing-out”: Patients’ experience and the refusal of life-prolonging treatment. J Clin Ethics 2018; 29(1):15-19.

SOURCES

• Tyler S. Gibb, JD, PhD, Co-chief, Program in Medical Ethics, Humanities, and Law, Western Michigan University, Kalamazoo. Phone: (269) 337-4400. Email: tyler.gibb@med.wmich.edu.

• Nathan Scheiner, MD, MA, Emory University School of Medicine, Atlanta, GA. Email: scheiner.n@gmail.com.