Medical Care

New Guidelines for Making Critical-Care Decisions

Experts have developed guidelines aimed at avoiding conflicts between physicians caring for patients with advanced illness, and the families of those patients.

“Neither individual clinicians nor families should be given unchecked authority to determine what treatments will be given to a patient,” explained Douglas White, M.D., M.A.S., UPMC Chair for Ethics in Critical Care Medicine, associate professor in the University of Pittsburgh Department of Critical Care Medicine, and co-chair of the committee that produced these guidelines.

“Clinicians should neither simply acquiesce to treatment requests that they believe are not in a patient’s best interest, nor should they unilaterally refuse to provide treatment. Instead, if conflicts arise between clinicians and patients’ families, a fair process of dispute resolution should be undertaken, in which neither individual can unilaterally impose his or her will on the other.”

The guidelines, which will appear in the June 1st issue of the American Journal of Respiratory and Critical Care Medicine, are a new resource for an estimated 80,000 health professionals, according to a news release from the University of Pittsburgh Medical Center. They are supported by the Society of Critical Care Medicine, the American Association of Critical Care Nurses, the American College of Chest Physicians and the European Society of Intensive Care.

If a clinician is asked by the family of a critically ill patient to administer invasive interventions that the clinician believes will not benefit the patient, “such disagreements can present particular challenges, since they bring into conflict important interests of patients, clinicians and society,”White said. “The cases are difficult because there are generally no clear, substantive rules to appeal to and because ICU patients are especially vulnerable because of their overwhelming illness and lack of ability to seek out another doctor if they disagree with the plan.”

The guidelines emphasize that conflicts in the ICU can and should be prevented through early and intensive communication between the patient’s family and the health care team. When conflicts cannot be resolved with ongoing dialogue, the policy statement recommends early involvement of expert consultants, such as palliative care and ethics consultants, to help reach an agreement.

If that approach fails, the committee recommends a fair process of dispute resolution, involving a review of the case by a multidisciplinary ethics committee within the hospital, ongoing mediation, a second medical opinion, and offering the family the right to transfer the patient to another facility and to appeal to the courts.