Abstract
The moral ends of medicine established thousands of years ago through the work of historical figures like Imhotep and Hippocrates taught us what it means to be a healer and a clinician. Imhotep embodied being a physician; Hippocrates outlined our duties. Today, we focus on patient-centered care. We strive to provide the best possible care options, even when that means caring while they die. Providing a carefully considered treatment plan that focuses on symptom management, comfort measures, and quality of life is both good medicine and a necessary component of ethically appropriate care. The ability to provide appropriate interventions and transition to comfort care in a timely manner is often difficult. This Chapter explores the issues surrounding requests for potentially inappropriate treatments, the feelings of clinician obligation to respect patient/surrogate autonomy, the inherent conflict between physician autonomy and patient/surrogate autonomy, and how to use a seven-step conflict resolution process to address irreconcilable discord.
The moral ends of medicine established thousands of years ago through the work of historical figures like Imhotep and Hippocrates taught us what it means to be a healer and a clinician. Imhotep embodied being a physician; Hippocrates outlined our duties. Today, we focus on patient-centered care. We strive to provide the best possible care options, even when that means caring while they die. Providing a carefully considered treatment plan that focuses on symptom management, comfort measures, and quality of life is both good medicine and a necessary component of ethically appropriate care. The ability to provide appropriate interventions and transition to comfort care in a timely manner is often difficult. This Chapter explores the issues surrounding requests for potentially inappropriate treatments, the feelings of clinician obligation to respect patient/surrogate autonomy, the inherent conflict between physician autonomy and patient/surrogate autonomy, and how to use a seven-step conflict resolution process to address irreconcilable discord.
A 27-year-old patient with cystic fibrosis arrived in the emergency department with his mother and wife, and complaining of dyspnea and respiratory distress. He was found to be in acute respiratory failure requiring intubation with right-sided pneumothorax necessitating chest tube placement. A subsequent workup found carbapenem-resistant Pseudomonas aeruginosa pneumonia, leading to septic shock requiring multiple pressors. The patient was well-known to the pulmonary service as a “noncompliant” clinic patient who frequently missed appointments and skipped tests for potential lung transplant workup. On arrival, the nurses noted that the patient’s wife seemed to have “slurred speech, droopy eyes, and an unsteady gait.” The patient was stabilized and admitted to the intensive care unit (ICU). During the first 3 days of the hospital stay, his wife was seen sporadically and evaluated by nursing as “incapacitated due to apparent alcohol and drug use.” During chart review, they noticed a note from a previous stay discussing an altercation between the wife and the patient’s mother for unknown reasons requiring intervention by hospital security.
The critical care attending decided the patient’s mother would be the best decision maker, but she refused to agree with the outlined plan of care, instead demanding incorrect interventions. The mother agreed and consented for tracheostomy placement on intubation day 25. The patient’s neurologic function did not improve as expected; he opened his eyes and moved only in response to pain. Kidney damage sustained during septic shock worsened, and the patient was diagnosed with end-stage renal disease and was placed on hemodialysis. He was also found to have worsening right-sided heart failure from his chronic pulmonary disease, and the heart failure team was consulted.
After evaluation by the heart failure service, they determined his condition was reversible with time. This team continually validated the possibility for the patient to return to prior baseline despite the new diagnoses of ventilator-dependent respiratory failure and end-stage renal disease. The critical care team felt the prognosis was poor and sought out prognostic opinions from the other care teams, including pulmonary, nephrology, and primary care. All other teams deemed the prognosis to be poor with no anticipated meaningful recovery in functional status, and recommended transitioning goals of care to comfort without escalation of aggressive interventions. Despite multiple interdisciplinary care meetings, the heart failure service continued to recommend aggressive interventions, including referral for a right ventricular assist device. The patient’s mother refused to engage in discussions with the primary team or discussions with the palliative care team to initiate comfort measures. She insisted that her son was a “fighter” and the ICU team needed to “do everything.” This created an ethical conflict with three components: (1) providing medically appropriate comfort care and hospice to a patient suffering from a nonsurvivable condition, (2) dealing with a surrogate decision maker who has demonstrated repeated intransigence and absolutism in her son’s care, and (3) dealing with other clinical colleagues who disagree with the prognosis and continue to offer interventions contradictory to the primary team’s plan of nonescalation and withdrawal.
14.1 Determining Appropriate Decision Makers and Patient Autonomy
The case presented highlights a common ethical dilemma around identifying the appropriate decision maker for a patient. Ideally, a patient is fully able to engage in a therapeutic relationship with the clinical team and partner in decision-making. This process of shared decision-making is the best way to respect patient autonomy and should be the standard for all situations where capacity is not of concern.1 In cases where capacity is called into question, assessing for decision-making capacity is mandated. Most states have laws dictating who is allowed to determine capacity, although any physician can evaluate a patient for capacity to make medical decisions.2 If a patient lacks capacity, the clinical team should not have conversations about the goals of care or medical interventions with just anyone from the patient’s life. Only a life-threatening emergency grants exemption from this principle, allowing providers to provide necessary care immediately. In all other cases, although it can be onerous, there is time to determine who in the patient’s life is the most appropriate surrogate decision maker. ICUs should have processes to determine the appropriate decision maker and engage her or him within a reasonable time after admission, the standard being 24–48 hours following admission.1 In the case presented herein, the ICU physician appropriately decided that the mother was the appropriate surrogate based on the patient’s incapacity, the wife’s unstable behavior and chemical dependency, and the legal right for the patient’s mother to be considered an appropriate surrogate.
14.2 Clinician Autonomy and Clinical Decision-Making
It is oftentimes assumed that the clinical team does not have its own autonomy for decision-making and must comply with all requests from a patient and/or surrogate in order to be compliant in respecting patient autonomy, even if the request requires the clinician to compromise her or his personal values. Clinicians, as autonomous agents themselves, have the right to accept or refuse requests to perform interventions against which they have a moral objection – the sticking point being the maintenance of patient safety and upholding the adage of primum non nocere. A physician’s ability to opt out of providing objectionable treatments for religious or moral reasons has been reinforced by state and federal laws, as well as by the American Medical Association’s Code of Medical Ethics.3 These opt-out clauses assume a nonemergent situation that allows for alternative physicians to replace the objecting physician. In the reality of urgent ICU situations where no other qualified physician may be available, the ethical duty to treat according to the best interest of the patient takes precedence, and personal objection may be forfeited.
Related posts:
Chapter 2 – How Much Does the Family Want to Be Involved in Decision-Making?
Chapter 4 – Communication Skills for Critical Care Family Meetings
Chapter 5 – The Do-Not-Resuscitate Order
Chapter 6 – The Do-Not-Intubate Order
Chapter 20 – Brain Death Discussions
Chapter 13 – Severe Traumatic Spinal Cord Injury
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