A bioethical framework to guide the decision-making process in the care of seriously ill patients

Abstract

BackgroundOne of the biggest challenges of practicing medicine in the age of informational technology is how to conciliate the overwhelming amount of medical-scientific information with the multiple patients’ values of modern pluralistic societies. To organize and optimize the the Decision-Making Process (DMP) of seriously ill patient care, we present a framework to be used by Healthcare Providers. The objective is to align Bioethics, Evidence-based Practice and Person-centered Care.Main bodyThe framework divides the DMP into four steps, each with a different but complementary focus, goal and ethical principle. Step 1 focuses exclusively on the disease, having accuracy is its ethical principle. It aims at an accurate and probabilistic estimation of prognosis, absolute risk reduction, relative risk reduction and treatments’ burdens. Step 2 focuses on the person, using empathic communication to learn about patient values and what suffering means for the patient. Emphasis is given to learning and active listening, not taking action. Thus, instead beneficence, we trust comprehension and understanding with the suffering of others and respect for others as autonomous moral agents as the ethical principles of Step 2. Step 3 focuses on the healthcare team, having the ethics of situational awareness guiding this step. The goal is, through effective teamwork, to contextualize and link rates and probabilities related to the disease to the learned patient’s values, presenting a summary of which treatments the team considers as acceptable, recommended, potentially inappropriate and futile. Finally, Step 4 focuses on provider-patient relationship, seeking shared Goals of Care (GOC), for the best and worst scenario. Through an ethics of deliberation, it aims for a consensus that could ensure that the patient’s values will be respected as well as a scientifically acceptable medical practice will be provided. In summary: accuracy, comprehension, understanding, situational awareness and deliberation would be the ethical principles guiding each step.ConclusionHopefully, by highlighting and naming the different perspectives of knowledge needed in clinical practice, this framework will be valuable as a practical and educational tool, guiding modern medical professionals through the many challenges of providing high quality person-centered care that is both ethical and evidence based.

Focus on the frail and elderly: who should have a trial of ICU treatment?

“…VIPs are subject to different triage practices across ICUs [1,2,4]. This underscores the need to determine which VIP might benefit from ICU admission and how such decisions may be informed by patient preferences and societal preferences for elderly and ageing patients [1,2,5,6].…”

“…The prognosis for most elderly patients after cardiac arrest may be dismal. This dilemma has been discussed recently for the VIP, and more research and ethical debate is urgently needed on this topic [5,14].…”

When is it Worth Starting a Risky and Uncomfortable Treatment in Critically Ill Patients? Gender, Education and Professional Involvement in Critical Care Impact on the Opinion

“…[32] Taken together, our data support the notion of different viewpoint of different groups of health care professionals on treatment decisions in critical care and support the concept that especially in critical care, team discussions and team decisions are necessary and bene cial for team members and patients [9] as part of a bioethical framework to guide the decision-making process in critical care. [1] Interestingly, a proportion of respondents has different opinions on necessary survival chances and acceptable risks for themselves, relatives and patients. It is well documented, that for approximately onethird of ICU patients, there is disagreement between clinicians and patients/surrogates about the appropriateness of treatment.…”

“…Decisions on the appropriateness of intensive medical care should be based on fundamental ethical principles such as respect for the autonomy and dignity of the patient. [1][2][3] Interventions should aim for the well-being of the patient with avoidance of harm as the highest priority as well as fair use of available means. [4] Decisions on the appropriateness of therapies are a common practice in critical care medicine and recommended by practice guidelines.…”

Overcoming Challenges to Surrogate Decision Making for Young Adults at the End of Life

“…Cancer at any age is devastating, it has a much worse psychosocial impact on those in this age group due to affecting hopes and expectations for relationships, study, career, and goals for years of life. 3,4 In 2016, The American Academy of Pediatrics released a policy statement entitled Informed Consent in Decision Making in Pediatric Practice and the American Medical Association updated their Code of Medical Ethics to provide guidelines for the surrogate decision making process, but neither elaborate on how to provide this care for young adults, aged 18 to 39. 2,5,6 These individuals are old enough to have achieved full cognitive development and mental maturity to make EOL decisions regarding advanced care planning, besides knowing their SDM.…”