What are the ethical aspects surrounding the collegial decisional process in limiting and withdrawing treatment in intensive care?

Abstract

The decision to limit or withdraw life-support treatment is an integral part of the job of a physician working in the intensive care unit, and of the approach to care. However, this decision is influenced by a number of factors. It is widely accepted that a medical decision that will ultimate lead to end-of-life in the intensive care unit (ICU) must be shared between all those involved in the care process, and should give precedence to the patient's wishes (either directly expressed by the patient or in written form, such as advance directives), and taking into account the opinion of the patient's family, including the surrogate if the patient is no longer capable of expressing themselves. A number of questions still remain unanswered regarding how decisions to limit or withdraw treatment are taken in daily practice, especially when this decision can be anticipated. We discuss here the collegial procedure for decision-making, in particular in the context of recent French legislation on end-of-life issues. We describe how collegial decision-making procedures should be carried out, and what points are covered in shared discussions regarding decisions to limit or withdraw life-sustaining therapies.

Non-readmission decisions in the intensive care unit under French rules: A nationwide survey of practices

“…First is when the clinical course and prognosis seem to be unfavourable in the short term, and then the decision can be made at the end of the patient’s ICU stay in a collective and interdisciplinary approach [ 10 ]. This formal meeting should involve the patient where possible, either directly (if the patient is competent) or via the family and/or surrogate [ 39 ], in order to take account of the choices and preferences expressed by the patient [ 40 ].…”

“…general practitioner (GP), specialists…) in the framework of discussions between professionals [ 8 , 9 ]. While the ICU physician is likely the physician that best knows the potential benefits and adverse effects of intensive care techniques, he/she is rarely the one who knows the patient best, especially in the context of chronic disease [ 10 – 12 ].…”

Non-readmission decisions in the intensive care unit: A qualitative study of physicians’ experience in a multicentre French study

“…In our study, the physicians interviewed suggest that a collegial and multidisciplinary approach would be of significant value, in particular formalized meetings to decide specifically on non-readmission to the ICU [ 11 , 14 , 39 , 42 ]. Implementing daily collegial reflection for each patient about their goals of care has been shown to lead to shorter times to decision, and improved palliative care management [ 43 ].…”

Multidisciplinary approach to a septic COVID‐19 patient undergoing veno‐venous extracorporeal membrane oxygenation and receiving thoracic surgery

“…During the COVID‐19 pandemic, collegial decisional processes in limiting and withdrawing treatment have played a major role to allocate the scarce resources in priority to those patients with the highest probability of benefiting from intensive cares 30 . This holds true also before the pandemic: collegial and interdisciplinary meetings, together with several other factors, guide ICU physician in the decisions to limit or withdraw life support treatment in patients with limited intensive cares benefits 31 . Collegiality is more and more important in the decision‐making process to guide the best cares in the most severe and challenging cases.…”