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

Abstract

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.

Deconstructing the Complexities of Advance Care Planning Outcomes: What Do We Know and Where Do We Go? A Scoping Review

“…Patients, surrogates, and clinicians consistently rate ACP as important, especially by those who have experienced decision‐making for serious illness 2‐5 . In addition, ACP research has seen sustained growth (Figure 1), and prominent organizations have called for its implementation and reimbursement 6‐11 . Recent ACP studies have shown an overall benefit for patient, surrogate, and clinician outcomes; however, some results have been mixed, 12 leading some to question the utility of ACP 13 .…”

Treatment Decisions for Unrepresented Patients: American Thoracic Society/American Geriatrics Society Policy Statement Lacks Sufficient Guidance

“…The Journal recently published a joint statement of the American Thoracic Society and the American Geriatrics Society on medical decision-making for unrepresented patients in the critical care setting ( 1 ). This statement is an important contribution, but it neglects at least one significant aspect of the decision-making process for unrepresented patients, as follows: how to identify the point in an unrepresented patient’s treatment course at which an alternative decision-making process should be implemented.…”

Reply to Weber: Treatment Decisions for Unrepresented Patients: American Thoracic Society/American Geriatrics Society Policy Statement Lacks Sufficient Guidance

“…Similarly, this policy statement omits certain fine-grained details, noting that its six recommendations must be “tailored to the capabilities of the individual institution” and that “institutions should have flexibility” in how they implement the guidance. Indeed, at the heart of this policy statement is an explicit tradeoff between “excessive and insufficient procedural safeguards” ( 1 ). Although this policy statement sets some broad parameters, it is appropriate that various institutions will strike the balance between fairness and feasibility differently.…”

“…Second, whether a decision concerns major medical treatment or life-sustaining treatment, the decision-making process should promote the same five ethical goals ( 1 ). At least for the subset of consent-requiring procedures that involve significant risk, institutions should approximate the decision-making process that the policy statement provides for life-sustaining treatment.…”

“…Unrepresented patients are among the most vulnerable in the healthcare system ( 1 ). For decades, the dominant approach has prioritized efficiency over fairness and procedural due process.…”