Assault or homicide: treating and letting die without consent

Making Medical Treatment Decisions for Unrepresented Patients in the ICU. An Official American Thoracic Society/American Geriatrics Society Policy Statement

Background and Rationale: ICU clinicians regularly care for patients who lack capacity, an applicable advance directive, and an available surrogate decision-maker. Although there is no consensus on terminology, we refer to these patients as “unrepresented.” There is considerable controversy about how to make treatment decisions for these patients, and there is significant variability in both law and clinical practice.

Purpose and Objectives: This multisociety statement provides clinicians and hospital administrators with recommendations for decision-making on behalf of unrepresented patients in the critical care setting.

Methods: An interprofessional, multidisciplinary expert committee developed this policy statement by using an iterative consensus process with a diverse working group representing critical care medicine, palliative care, pediatric medicine, nursing, social work, gerontology, geriatrics, patient advocacy, bioethics, philosophy, elder law, and health law.

Main Results: The committee designed its policy recommendations to promote five ethical goals: 1) to protect highly vulnerable patients, 2) to demonstrate respect for persons, 3) to provide appropriate medical care, 4) to safeguard against unacceptable discrimination, and 5) to avoid undue influence of competing obligations and conflicting interests. These recommendations also are intended to strike an appropriate balance between excessive and insufficient procedural safeguards. The committee makes the following recommendations: 1) institutions should offer advance care planning to prevent patients at high risk for becoming unrepresented from meeting this definition; 2) institutions should implement strategies to determine whether seemingly unrepresented patients are actually unrepresented, including careful capacity assessments and diligent searches for potential surrogates; 3) institutions should manage decision-making for unrepresented patients using input from a diverse interprofessional, multidisciplinary committee rather than ad hoc by treating clinicians; 4) institutions should use all available information on the patient’s preferences and values to guide treatment decisions; 5) institutions should manage decision-making for unrepresented patients using a fair process that comports with procedural due process; 6) institutions should employ this fair process even when state law authorizes procedures with less oversight.

Conclusions: This multisociety statement provides guidance for clinicians and hospital administrators on medical decision-making for unrepresented patients in the critical care setting.

"Do-Not-Attempt-Resuscitation"-orders in ICCUs: a survey of attitudes and experiences of nurses in Norway

OBJECTIVE

A "Do-Not-Attempt-Resuscitation" (DNAR)-order can be ordered for a critically ill coronary patient. One question that arises is whether the patient should be informed about the DNAR-decision? The purpose of the present study was to investigate attitudes and experiences towards DNAR-orders of nurses working in Intensive Coronary Care Units (ICCUs) in Norway.

METHODS

A web-based questionnaire.

RESULTS

The response rate was 60% (176/295). A total of 74% of the respondents thought the patient should be informed about a DNAR-order. Given a mentally competent and conscious patient, 50% answered that they "to a relatively high" or "a very high degree" had experienced non-informed patients with a DNAR-order.

CONCLUSION

The study revealed a positive attitude among respondents to inform patients about a DNAR-order. However, one half of the respondents had experienced that this information was not given. There may be several explanations for this discrepancy. Patients are treated individually and the right to know does not mean that every patient would want to know or needs to know. The timing of the information and the opportunity to provide it can also be a problem for such critically ill patients in the ICCU.

Decisions to limit life-sustaining treatment for critically ill patients who lack both decision-making capacity and surrogate decision-makers

OBJECTIVE

Many intensive care unit (ICU) physicians have withdrawn life-support from a patient who lacked decision-making capacity and a surrogate decision-maker, yet little is known about the decision-making practices for these patients. We sought to determine how often such patients are admitted to the ICU of a metropolitan hospital and how end-of-life decisions are made for them.

DESIGN

Prospective, observational cohort study.

PATIENTS AND SETTING

Consecutive adult patients admitted to the medical ICU of a metropolitan West Coast hospital during a 7-month period in 2003 to 2004.

MEASUREMENTS

Attending physicians completed a questionnaire about the decision-making process for each patient for whom they considered limiting life-support who lacked decisional capacity and a legally recognized surrogate decision-maker.

MAIN RESULTS

Of the 303 patients admitted during the study period, 49 (16%; 95% confidence interval [CI], 12-21%) lacked decision-making capacity and a surrogate during the entire ICU stay. Compared with all other ICU patients, these patients were more likely to be male (88% vs. 69%; p = .002), white (42% vs. 23%; p = .028), and > or =65 yrs old (29% vs. 13%; p = .007). Physicians considered withholding or withdrawing treatment from 37% (18) of the 49 patients who lacked both decision-making capacity and a surrogate decision-maker. For 56% (10) of these 18 patients, the opinion of another attending physician was obtained; for 33% (6 of 18), the ICU team made the decision independently, and for 11% (2 of 18), the input of the courts or the hospital ethics committee was obtained. Overall, 27% of deaths (13 of 49) during the study period were in incapacitated patients who lacked a surrogate (95% CI, 15-41%).

CONCLUSIONS

Sixteen percent of patients admitted to the medical ICU of this hospital lacked both decision-making capacity and a surrogate decision-maker. Decisions to limit life support were generally made by physicians without judicial or institutional review. Further research and debate are needed to develop optimal decision-making strategies for these difficult cases.