Limits on Clinicians' Discretion to Unilaterally Refuse Treatment
Limits on Clinicians' Discretion to Unilaterally Refuse Treatment
There is an increasing expectation in society that clinicians will engage patients as partners in selecting medically appropriate treatment options rather than simply dictating what treatments patients will and will not receive. To be sure, this is a positive advance that recognizes citizens in multicultural societies have diverse values and will likely have different treatment preferences for a variety of medical decisions. One implication in intensive care units (ICUs) is that patients vary regarding the amount and type of treatment they are willing to accept in the face of advanced critical illness.
This collaborative approach to decision making requires a degree of clarity about which medical options should be described and offered to patients. Unfortunately, the boundaries of acceptable medical practice in patients with advanced critical illness are poorly defined for some circumstances. For example, there is disagreement about whether patients in a persistent vegetative state should be offered intensive care. Similarly, when surrogates of patients with advanced multiorgan failure superimposed on multiple severe comorbidities insist on doing everything to keep patients alive, it is uncertain whether clinicians are obligated to provide requested therapies that could potentially extend the patient's life by some small amount.
One response to this lack of clarity might be to create a rule stating that if a treatment stands any chance of achieving the patient's goals, it should be offered, no matter how small that chance or how expensive the treatment. Yet, this approach conflicts philosophically with the competing view that mere extension of physiologic life is not an appropriate goal of medicine, and that clinicians also have some ethical obligation to be prudent stewards of medical resources.
Most current recommendations about how to resolve such conflicts in ICUs center around ensuring a fair process of dispute resolution. Although clinicians may generally withdraw from a case, provided another clinician is ready and willing to assume care, the American Medical Association (AMA) policy on medical futility advises against unilateral decisions by clinicians to forgo treatment. The AMA and others recommend a processbased approach that includes intensive communication, case review by a hospital committee, and attempts to transfer the patient to a willing provider. ICU clinicians are sometimes frustrated by these requirements. One reason is their belief that clinicians in other medical settings seem to have more freedom to make unilateral treatment decisions.
ICU clinicians often express their frustration by demanding to know why they can't unilaterally decide to discontinue life support in patients with extremely poor prognoses but oncologists can unilaterally decide that patients are not suitable candidates for 4th line chemotherapy and surgeons can unilaterally decide that high risk patients are "not operative candidates." An ICU physician might ask, "Why, can I refuse to offer treatment only after a 'fair process' validates my judgment whereas there are no similar constraints on oncologists and surgeons?"
Abstract and Introduction
Introduction
There is an increasing expectation in society that clinicians will engage patients as partners in selecting medically appropriate treatment options rather than simply dictating what treatments patients will and will not receive. To be sure, this is a positive advance that recognizes citizens in multicultural societies have diverse values and will likely have different treatment preferences for a variety of medical decisions. One implication in intensive care units (ICUs) is that patients vary regarding the amount and type of treatment they are willing to accept in the face of advanced critical illness.
This collaborative approach to decision making requires a degree of clarity about which medical options should be described and offered to patients. Unfortunately, the boundaries of acceptable medical practice in patients with advanced critical illness are poorly defined for some circumstances. For example, there is disagreement about whether patients in a persistent vegetative state should be offered intensive care. Similarly, when surrogates of patients with advanced multiorgan failure superimposed on multiple severe comorbidities insist on doing everything to keep patients alive, it is uncertain whether clinicians are obligated to provide requested therapies that could potentially extend the patient's life by some small amount.
One response to this lack of clarity might be to create a rule stating that if a treatment stands any chance of achieving the patient's goals, it should be offered, no matter how small that chance or how expensive the treatment. Yet, this approach conflicts philosophically with the competing view that mere extension of physiologic life is not an appropriate goal of medicine, and that clinicians also have some ethical obligation to be prudent stewards of medical resources.
Most current recommendations about how to resolve such conflicts in ICUs center around ensuring a fair process of dispute resolution. Although clinicians may generally withdraw from a case, provided another clinician is ready and willing to assume care, the American Medical Association (AMA) policy on medical futility advises against unilateral decisions by clinicians to forgo treatment. The AMA and others recommend a processbased approach that includes intensive communication, case review by a hospital committee, and attempts to transfer the patient to a willing provider. ICU clinicians are sometimes frustrated by these requirements. One reason is their belief that clinicians in other medical settings seem to have more freedom to make unilateral treatment decisions.
ICU clinicians often express their frustration by demanding to know why they can't unilaterally decide to discontinue life support in patients with extremely poor prognoses but oncologists can unilaterally decide that patients are not suitable candidates for 4th line chemotherapy and surgeons can unilaterally decide that high risk patients are "not operative candidates." An ICU physician might ask, "Why, can I refuse to offer treatment only after a 'fair process' validates my judgment whereas there are no similar constraints on oncologists and surgeons?"