The family wants clinicians to do everything possible, but clinicians believe continued treatment would only result in extended suffering for a dying patient. Most hospitals have instituted policies to address these difficult cases.
“This is especially true among academic medical centers, where cases involving alleged inappropriate treatment are often transferred from community hospitals,” says Thaddeus Mason Pope, JD, PhD, HEC-C, professor of law at Mitchell Hamline School of Law in St. Paul, MN.
Ethicists used a policy on inappropriate treatment in one-quarter of consults, according to an analysis of a volunteer ethics committee’s work.1 The hospital’s conscientious practice policy was used in 42 of 178 consultations between 2013 and 2018. “This suggests that providers are looking for definitive tools, in addition to the ethics committee, to help resolve these difficult end-of-life cases,” says Bryan Kaps, MD, MHS, the study’s lead author.
Many hospital policies reflect professional society policy statements.2 “Because most of those documents focus on consensus-building, so do most hospital policies,” Pope explains.
Most recommend seeking an outside second opinion involving a clinical ethics consultant, and convening a multidisciplinary committee to review the case. “Only a subset of inappropriate treatment policies permit clinicians to withhold or withdraw treatment without surrogate consent,” Pope notes.
Usually, this happens only after committee review and an opportunity to transfer to a facility willing to provide the disputed treatment. “Policies on inappropriate treatment are not needed for conflicts over brain death, which are increasingly common,” Pope says.
In those cases, both legal and ethical standards are clear. Clinicians and hospitals are not obligated to treat after a determination and declaration of death, other than affording a brief (often less than 24 hours) period of accommodation. Policies are most helpful when the patient is permanently unconscious (or otherwise catastrophically critically ill) with no chance of recovery or discharge from the ICU.
Clinicians find it helpful to be able to point to a policy if the family demands life-sustaining interventions in that situation. Some policies require the approval of the facility vice president of medical affairs or chief medical officer. “Yet that official will sometimes not authorize withholding or withdrawal of treatment over family objections,” Pope says.
Ethicists can help families and clinicians reach a consensus. “But even attending physicians decline to use inappropriate treatment policies in intractable disputes,” Pope says.
There are no data on how many hospitals have created a policy on addressing requests for inappropriate treatment. “There’s also a big difference between having a policy on the books, and having a policy that providers are aware of and look to when making clinical decisions,” says Alison E. Turnbull, DVM, MPH, PhD, an assistant professor in the division of pulmonary and critical care medicine at Johns Hopkins University.
Policies are invoked most frequently when clinicians do not want to initiate a form of life support (e.g., intubation, continuous veno-venous hemodialysis, or extracorporeal membrane oxygenation) that may prolong a patient’s life but will not heal their underlying terminal condition or permit them to live outside the ICU ever again. Ideally, ethicists would have been involved in the case early to avoid conflict before it becomes intractable.
Often, though, ethicists’ role is as part of the committee that is convened after the conflict resolution process has failed. At that point, a second medical opinion has been obtained already.
“That committee should convene promptly, review the case, and generate a written document that includes recommendations and rationale,” Turnbull suggests.
- Kaps B, Kopf G. Functions, operations and policy of a volunteer ethics committee: A quantitative and qualitative analysis of ethics consultations from 2013 to 2018. HEC Forum 2020; Sep 26. doi: 10.1007/s10730-020-09426-4. [Online ahead of print].
- Bosslet GT, Pope TM, Rubenfeld GD, et al. An official ATS/AACN/ACCP/ESICM/SCCM policy statement: Responding to requests for potentially inappropriate treatments in intensive care units. Am J Respir Crit Care Med 2015;191:1318-1330.