Futility Disputes: A Review of the Literature and Proposed Model for Dispute Navigation Through Trust Building

Surrogate Wars: The "Best Interest Values" Hierarchy & End-of-Life Conflicts with Surrogate Decision-Makers

Conflicts involving end-of-life care between healthcare providers (HCPs) and surrogate decision-makers (SDMs) have received sustained attention for more than a quarter of a century, with early studies demonstrating a frequency of HCP-SDM conflict in ICUs ranging from 32-78% of all admissions (Abbott et al. 2001; Breen et al. 2001; Studdert et al. 2003; Azoulay et al. 2009). More recent studies not only acknowledge the persistence of clinical conflict in end-of-life care (Leland et al. 2017), but they have begun to focus on the ways in which these conflicts escalate to verbal or physical violence in the ICU (Slack et al. 2023; Bass et al. 2024; Berger et al. 2024; Sjöberg et al. 2024). I will argue that part of the explanation for the persistence-and even escalation-of ICU disputes is the incommensurable value systems held by many conflicting HCPs and SDMs. I will argue that a common value system among HCPs can be understood as a "Best Interest Values" (BIV) hierarchy, which I will argue is irreconcilable with the set of "Life-Continuation Values" (LCV) held by a sizable minority of families in the United States. I argue this values-conflict undergirds many ICU disputes. If I am correct that an incommensurable value system underlies many ICU conflicts, then it is not just ineffectual for HCPs to impose their BIV system on LCV families, but also wrong given the American commitment to values pluralism. I conclude that the way to navigate continuous ICU surrogate wars is for BIV-focused healthcare institutions to engage more constructively with LCV stakeholders.

A Concept Analysis of Trust Within the Surrogate Decision Maker to Health Care Professional Relationship in the Adult ICU Setting

Surrogate decision maker (SDM)-health care professional (HCP) trust is vital to the provision of high-quality care in the adult intensive care unit setting. This concept analysis, using Walker and Avant's methodology, examines the concept of SDM-HCP trust and provides a conceptual definition conducive to instrument development and future quantitative research into this topic. Trust in the SDM-HCP relationship exists on a spectrum and involves the voluntary placement of oneself into a position of vulnerability in relation to another party who is believed to have integrity, be reliable, and hold beneficent intent toward the truster.

Decision-Making and Ethical Considerations of Tracheostomy and Chronic Mechanical Ventilation in Children with Acute Neurological Injury

The decisions around whether or not to provide tracheostomy and chronic mechanical ventilation to children with acute neurologic injury are difficult for medical providers and surrogate decision makers. Consideration of the 4 primary principles of medical ethics-autonomy, beneficence, non-maleficence, and justice-can provide a framework from which constructive discussions can form. Determination of the goals of care is a good first step in navigating these complex decisions. A shared decision model should be used, including education of decision-makers by medical providers and appropriate recommendations based on the stated goals of care. In this paper, 2 illustrative cases are discussed highlighting the utility of this decision-making framework.

Exploring Ethical Dimensions of Physician Involvement in Requests for Organ Donation in Pediatric Brain Death

Pediatric organ transplantation remains a life-saving therapy, with donated organs being absolutely scarce resources. Efforts to both increase pediatric organ donation authorization by families of children declared dead by neurologic criteria and mitigate perception of conflicts of interest have resulted in frequent exclusion of physicians from this process. This article provides of focused review of pediatric organ donation in the setting of brain death, explores the breadth of consequences of physician exclusion in donation authorization requests, and provides an ethical framework defending physician involvement in the organ donation process for this patient population.

Health professionals' perceptions of complex feeding decision-making in school-aged children

AIM

Whilst prevalence of paediatric feeding disorders is high amongst children in specialist schools, there is little guidance for professionals supporting families with a child feeding orally with established risk of aspiration. We sought perceptions of the complex feeding decision-making process amongst health professionals supporting families in the specialist school setting in New Zealand.

METHODS

An observational, cross-sectional, national online survey of speech-language therapists was followed by in-depth interviews with seven health professionals associated with one specialist school.

RESULTS

Survey responses from 32 speech-language therapists showed inconsistency in assessment processes and how family, children and school staff are involved in feeding decisions, with 71% reporting a doctor had been involved. Respondents were not confident in their ability to predict aspiration risk, with 41% reporting that they could often determine risk, 41% sometimes and 16% never. Sixty-three percent of respondents indicated that level of risk was written in a report for a child and 50% reported that every child at high risk had a management plan. Speech-language therapists valued professional supervision, but it was not always available. Health professionals were broadly positive about the collaborative nature of decision-making in most but not all situations. They described communication, access/institutional and emotional barriers to timely, shared decision-making.

CONCLUSION

These findings demonstrate variability in how families are supported to make complex feeding decisions. Health professionals identified a need for clearer processes and strengthened communication between family, school and health professionals. Trusting relationships are critical if all families are to be well-supported.

Responding to Those Who Hope for a Miracle: Practices for Clinical Bioethicists

Significant challenges arise for clinical care teams when a patient or surrogate decision-maker hopes a miracle will occur. This article answers the question, "How should clinical bioethicists respond when a medical decision-maker uses the hope for a miracle to orient her medical decisions?" We argue the ethicist must first understand the complexity of the miracle-invocation. To this end, we provide a taxonomy of miracle-invocations that assist the ethicist in analyzing the invocator's conceptions of God, community, and self. After the ethicist appreciates how these concepts influence the invocator's worldview, she can begin responding to this hope with specific practices. We discuss these practices in detail and offer concrete recommendations for a justified response to the hope for a miracle.