How to keep patients involved in treatment

Strategies seek to achieve compatible outcome

As a result of its grand rounds program for residents in the surgical intensive care unit, the bioethics team at Deaconess Beth Israel Hospital in Boston identified seven key strategies to achieve an outcome compatible with a patient’s wishes regarding treatment.

They are as follows:

1. Learn and understand the patient’s wishes. The attending physician is the key person in initiating and continuing discussions with the family. However, there are no firm guidelines on when it is best to initiate those discussions; each family requires a different approach. However, in general, the sooner the discussions are initiated, the better the result.

2. Build an alliance with the patient and family members. It is important to maintain ongoing discussions with the patient, family members, and if necessary, surrogate decision makers, during the course of the patient’s disease and treatment. A key issue is maintaining effective communication with the family when the patient is incapacitated.

3. Document each communication with family members. Thorough documentation can be critical to resolving ethical issues by providing information on patients’ stated wishes and knowledge of their critical status. Other documentation issues include health care proxy, treatment options and decisions, planning among caregivers, use of time-limited trials, and institution of comfort needs when aggressive treatment is no longer desired or justified.

4. Build teamwork among direct caregivers for planning and providing care. Conflicts between attending physicians and residents are common in the intensive care setting and a mechanism for addressing and resolving these conflicts is vital.

5. Address family members’ fears of abandonment.

6. Use time-limited trials to evaluate treatment alternatives for dying patients.

7. Implement "comfort measures only" orders when appropriate. Effective use of the policy resulted in significant reduction in the length of stay in the intensive care unit for dying patients at Deaconess.