A framework for resolving disagreement during end of life care in the critical care unit

Abstract

Background: End-of-life decisions regarding the administration, withdrawal or withholding of life-sustaining therapy in the critical care setting can be challenging. Disagreements between health care providers and family members occur, especially when families believe strongly in preserving life, and physicians are resistant to providing medically “futile” care. Such disagreements can cause tension and moral distress among families and clinicians. Purpose: To outline the roles and responsibilities of physicians, substitute decision makers, and the judicial system when decisions must be made on behalf of incapable persons, and to provide a framework for conflict resolution during end-of-life decision-making for physicians practicing in Canada. Source: We used a case-based example to illustrate our objectives. We employed a comprehensive approach to understanding end-of-life decision making that included: 1) a search for relevant literature; 2) a review of provincial college policies; 3) a review of provincial legislation on consent; 4) a consultation with two bioethicists and 5) a consultation with two legal experts in health law. Principal Findings: In Canada, laws about substitute decision-making for health care are primarily provincial or territorial. Thus, laws and policies from professional regulatory bodies on end-of-life care vary across the country. We tabulated the provincial college policies on end-of-life care and the provincial legislation on consent and advance directives, and constructed a 10-step approach to conflict resolution. Conclusion: Knowledge of underlying ethical principles, understanding of professional duties, and adoption of a process for mediation and conflict resolution are essential to ensuring that physicians and institutions act responsibly in maintaining a patients’ best interests in the context of family-centred care.

Conflict in a paediatric hospital: a prospective mixed-method study

“…4 Advances in interventions have led to longer term survival of preterm infants and children with complex conditions but possibly also greater morbidity. 26 The triadic dynamic of practitioner-parent-patient may increase the scope for conflict in decision-making, particularly around withholding or withdrawing life-sustaining treatment. 5 Difficulties in accurate prognostication further exacerbate the scope for conflict.…”

Checklist to Meet Ethical and Legal Obligations to Critically Ill Patients at the End of Life

“…If you believe that an SDM is not providing consent in line with prior expressed wishes or best interests of the patient, then an application can be made to the Consent and Capacity Board. The board process as a means of resolving end-of-life conflicts has been described in detail elsewhere (Chidwick and Sibbald 2011;Choong et al 2010;Parke and Handelman 2008).…”

“…When death is expected for a patient in the ICU or elsewhere, there are several types of error that we do not always consider (Table 1). Examples of "error" at the end of life Not acting on applicable wishes of patients made when they were capable Not identifying who the legal substitute decision-makers (SDMs) are Not explaining the consequences of the treatment alternatives, resulting in unrealistic expectations Allowing family members or SDMs to "direct" care, resulting in treatments that are not indicated Repercussions of these errors include moral distress and moral residue for the family and treatment team (Choong et al 2010;Kuhl 2003;Tulsky 2005); prolonged stays in the ICU; and confusion, misunderstanding and conflict between team members or between healthcare professionals and family members (Heyland et al 2006;Studdert et al 2003). These errors, when not identified, can also be the source of team-family conflict (Azoulay et al 2009;Breen et al 2001;Choong et al 2010;Luce 2010a).…”

“…Examples of "error" at the end of life Not acting on applicable wishes of patients made when they were capable Not identifying who the legal substitute decision-makers (SDMs) are Not explaining the consequences of the treatment alternatives, resulting in unrealistic expectations Allowing family members or SDMs to "direct" care, resulting in treatments that are not indicated Repercussions of these errors include moral distress and moral residue for the family and treatment team (Choong et al 2010;Kuhl 2003;Tulsky 2005); prolonged stays in the ICU; and confusion, misunderstanding and conflict between team members or between healthcare professionals and family members (Heyland et al 2006;Studdert et al 2003). These errors, when not identified, can also be the source of team-family conflict (Azoulay et al 2009;Breen et al 2001;Choong et al 2010;Luce 2010a). It has been suggested that conflict regarding the end of life should be addressed by creating policies and statements that guide healthcare professionals' behaviour (Brett and Jersild 2003;Choong et al 2010;College of Physicians and Surgeons of Manitoba 2007;College of Physicians and Surgeons of Ontario 2003) or defining notions of futility/inappropriateness (Schneiderman et al 1990;Sibbald et al 2007).…”

“…These errors, when not identified, can also be the source of team-family conflict (Azoulay et al 2009;Breen et al 2001;Choong et al 2010;Luce 2010a). It has been suggested that conflict regarding the end of life should be addressed by creating policies and statements that guide healthcare professionals' behaviour (Brett and Jersild 2003;Choong et al 2010;College of Physicians and Surgeons of Manitoba 2007;College of Physicians and Surgeons of Ontario 2003) or defining notions of futility/inappropriateness (Schneiderman et al 1990;Sibbald et al 2007). While formally established professional opinions have provided information about "end-of-life conflict" (Truog et al 2008), such documents have done little to prevent it (Luce and Alpers 2001).…”